The Comparative Anatomy of the Upper Digestive System in 26 Species of Zoophagous-Polyphagous Palearctic Birds / Anatomía Comparada del Sistema Digestivo Superior en 26 Especies de Aves Paleárticas Zoófagas-Polífagas

SUMMARY: Birds are the most diversified organisms on Earth, with species covering various niches in each major biome, being essential to understand the modern ecosystem. This study concentrates on the diversification of the anatomical structure of the upper digestive tract for 26 species of zoophage-polyphagous birds and the anatomical differences in the digestive system to reveal aspects related to their evolution and diversification. The trophic spectrum of the selected birds includes several categories of food, or, as in the case of strictly carnivorous birds, to a single food category. After performing the dissections, the digestive tract was separated from the carcass and each digestive segment was measured and analysed. In this study, it was demonstrated that the birds' feeding behaviour influence the macroscopic particularities of the digestive system, more visible in the cranial portion (oropharyngeal cavity, esophagus, proventriculus and gizzard), with little descriptive information in the literature. The tongue is poorly developed and immobile in piscivorous birds, while the tongue of insectivorous birds is long and moves considerably away from the tip of the bill. The esophagus was stretchable and presents longitudinal folds on its entire surface in piscivorous species and not extensible in insectivorous birds.

Las aves son los organismos más diversificados de la Tierra, con especies que cubren varios nichos en cada bioma principal, siendo esenciales para comprender el ecosistema moderno. Este estudio se concentra en la diversificación de la estructura anatómica del tracto digestivo superior para 26 especies de aves zoófago-polífagas y las diferencias anatómicas en el sistema digestivo para revelar aspectos relacionados con su evolución y diversificación. El espectro trófico de las aves seleccionadas incluye varias categorías de alimentos o, como en el caso de las aves estrictamente carnívoras, una sola categoría de alimentos. Después de realizar las disecciones, se separó el tracto digestivo de la canal y se midió y analizó cada segmento digestivo. En este estudio se demostró que el comportamiento alimentario de las aves influye en las particularidades macroscópicas del sistema digestivo, más visibles en la porción craneal (cavidad orofaríngea, esófago, proventrículo y molleja), con poca información descriptiva en la literatura. En las aves piscívoras, la lengua está poco desarrollada e inmóvil, mientras que la lengua de las aves insectívoras es larga y se aleja considerablemente de la punta del pico. El esófago era estirable y presentaba pliegues longitudinales en toda su superficie en especies piscívoras y no extensible en aves insectívoras.

Hemobilia, una causa infrecuente de hemorragia del tracto digestivo superior / Hemobilia, a rare cause of upper gastrointestinal bleeding

Resumen La hemobilia es una causa poco frecuente de hemorragia del tracto gastrointestinal superior. La principal etiología es de origen iatrogénico y la posibilidad de hemobilia debe considerarse en cualquier paciente con hemorragia gastrointestinal y un historial reciente de procedimientos hepatobiliares. Otras causas menos frecuentes incluyen el trauma de abdomen, la enfermedad oncológica de la vía biliar o las enfermedades inflamatorias del páncreas o la vía biliar. La presentación clínica varía según la gravedad del sangrado; generalmente se presenta con dolor abdominal, ictericia y melenas, aunque puede cursar al ingreso con rectorragia e hipotensión. Un alto porcentaje de estas presenta resolución espontánea, sin requerir procedimientos adicionales. La angiografía es el estándar de oro para el diagnóstico de la hemobilia, pero los avances en la angiotomografía permiten que esta sea una opción menos invasiva y con mayor disponibilidad. La angioembolización es el tratamiento principal para estos pacientes, pero existen otras alternativas como la colocación de stent vascular o de stent en el conducto biliar.

Abstract Hemobilia is a rare cause of upper gastrointestinal (GI) tract bleeding. Its main etiology is iatrogenic, and the possibility of hemobilia should be considered in any patient with GI bleeding and a recent history of hepatobiliary surgery. Other less frequent causes include abdominal trauma, oncologic disease of the biliary tract, or inflammatory diseases of the pancreas or bile duct. Its clinical presentation varies depending on the severity of the bleeding. It usually presents with abdominal pain, jaundice, and tarry stools, although patients may also present with rectorrhagia and hypotension on admission. A high percentage of these symptoms have a spontaneous resolution, without requiring additional procedures. Angiography is the gold standard for the diagnosis of hemobilia, but advances in computed tomography angiography make it a less invasive and more widely available option. Endovascular embolization is the main treatment for these patients, but there are other alternatives such as vascular or bile duct stent placement.

Aspectos clínicos y etiológicos de la hemorragia digestiva alta y sus escalas de evaluación / Clinical and etiological aspects of upper gastrointestinal bleeding and its evaluation scales

Resumen Introducción: La hemorragia digestiva alta es frecuente, con diversas etiologías, métodos de diagnóstico y tratamiento para el manejo de estos pacientes, además, cuenta con escalas de predicción clínica. Objetivo: Describir aspectos clave relacionados con la etiología, diagnóstico, factores de riesgo y escalas de evaluación que se han usado en pacientes con esta entidad. Metodología de búsqueda: Fueron incluídos artículos publicados en idiomas español e inglés, la mayoría entre 2013 y 2019 que tengan contenido relacionado con el objetivo del presente manuscrito. Conclusiones: La hemorragia digestiva alta es la principal emergencia gastroenterológica, con diferentes etiologías y métodos de diagnóstico y tratamiento orientados a mejorar la supervivencia de estos pacientes, actualmente se recomiendan diferentes escalas de evaluación para predecir desenlaces de estos pacientes, pero los estudios han tenido diferencias en los resultados encontrados, lo que sucita una oportunidad de investigación para beneficio de los pacientes y la práctica clínica. MÉD.UIS.2020;33(3):9-20

Abstract Introduction: Upper gastrointestinal bleeding it's a frequent clinical situation, has different etiologies, diagnostic methods and treatments for the management of these patients, in addition, has clinical scales to predict outcomes in those patients. Objective: To describe key points related to the etiology, diagnosis, risk factors, and evaluation scales that have been used in patients with this entity. Methodology: Articles published in spanish and english were included, the majority between 2013 and 2019 that have content related to the objective of this manuscript. Conclusions: Upper gastrointestinal bleeding is the main gastroenterological emergency, with different etiologies and methods of diagnosis and treatment aimed at improving the survival of these patients; currently, different evaluation scales are recommended to predict outcomes in these patients, but studies have differences in the results between them, which creates an opportunity of clinical research for patients and clinical practice benefit. MÉD.UIS.2020;33(3):9-20.

Hipertensión portal secundario a trombosis de la vena porta y várices esofágicas / Secondary portal hypertension to portal venous thrombosis and esophageal varices

Resumen La hipertensión portal se define como la alteración patológica en el gradiente de presión a nivel del sistema portal, es decir, la diferencia entre la presión de la vena porta y la vena cava inferior. El valor normal es entre 1-5 mm Hg y se considera hipertensión cuando es mayor de 10 mm Hg. En este artículo, se describe el caso de una paciente de 5 años con un cuadro de hipertensión portal secundario a várices esofágicas y trombosis de la vena porta, confirmado por endoscopia de vías digestivas alta y angioresonancia magnética. La paciente fue atendida en la Fundación Clínica Infantil Club Noel de la ciudad de Cali, Colombia, entre los meses de diciembre del 2018 y febrero del 2019.

Abstract Portal hypertension is defined as the pathological increase in the portal pressure gradient, which is the difference between the pressure of the portal vein and the inferior vena cava. Normally portal vein pressure ranges between 1-5 mmHg and is considered hypertension when it is higher than 10 mmHg. In this study the case of a 5-year-old patient that suffers from secondary portal hypertension to portal venous thrombosis and esophageal varices is presented. The diagnostic is confirmed by an endoscopy of the upper gastrointestinal tract and by a magnetic angioresonance. The patient was treated at the Fundacion Clinica Infantil Club Noel located in Cali, Colombia, between the months of December 2018 and February 2019.

Impact of the COVID-19 pandemic in the time to endoscopy in patients with upper gastrointestinal bleeding / Impacto de la pandemia de COVID-19 en el tiempo hasta la endoscopia en pacientes con hemorragia digestiva alta

ABSTRACT Introduction : During the COVID-19 pandemic, endoscopic procedures are associated with a high risk of SARS-CoV-2 infection. However, in cases of upper gastrointestinal bleeding (UGIB), priority should be given to an early endoscopy. Objective : The main objective was to compare the time since arrival at the hospital and the performance of the endoscopy between both groups. Materials and methods : We performed a retrospective study. Data contains information of patients who attended to the hospital with UGIB and underwent an endoscopy between October 19th, 2019 and June 6th, 2020. Patients were divided into 2 phases: pre-pandemic and pandemic. The time between arrival at the hospital and the performance of the endoscopy in both phases were compared as well as other indicators such hospital stay and in-hospital mortality. Results : With information from 219 patients, the median age was 69 years. 154 and 65 endoscopies were performed in pre-pandemic and pandemic phase, respectively. The time between arrival at the hospital and the performance of the endoscopy was significantly longer during the pandemic (10.00 vs. 13.08 hours, p-value = 0.019). Nevertheless, there were no significant differences in hospital stay or mortality. Conclusion : The management of patients with UGIB during the COVID-19 pandemic is complex and requires the application of clinical judgment to decide the best timing to perform an endoscopy without affecting patient care.

RESUMEN Introducción : Durante la pandemia de COVID-19, los procedimientos endoscópicos se asocian con un alto riesgo de infección por SARS-CoV-2. Sin embargo, en casos de hemorragia digestiva alta (HDA), se debe dar prioridad a una endoscopia precoz. Objetivo : El objetivo principal fue comparar el tiempo transcurrido desde la llegada al hospital y la realización de la endoscopia entre ambos grupos. Materiales y métodos : Realizamos un estudio retrospectivo. Los datos contienen información de pacientes que acudieron al hospital con HDA y fueron sometidos a endoscopia entre el 19 de octubre de 2019 y el 6 de junio de 2020. Los pacientes se dividieron en 2 fases: prepandémica y pandémica. Se comparó el tiempo transcurrido entre la llegada al hospital y la realización de la endoscopia en ambas fases, así como otros indicadores como la estancia hospitalaria y la mortalidad intrahospitalaria. Resultados : Con información de 219 pacientes, la mediana de edad fue de 69 años. Se realizaron 154 y 65 endoscopias en fase prepandémica y pandémica, respectivamente. El tiempo entre la llegada al hospital y la realización de la endoscopia fue significativamente mayor durante la pandemia (10,00 frente a 13,08 horas, valor de p = 0,019). Sin embargo, no hubo diferencias significativas en la estancia hospitalaria ni en la mortalidad. Conclusión : El manejo de pacientes con HDA durante la pandemia de COVID-19 es complejo y requiere la aplicación del juicio clínico para decidir el mejor momento para realizar una endoscopia sin afectar la atención del paciente.

Hemorragia digestiva alta variceal y no variceal: mortalidad intrahospitalaria y características clínicas en un hospital universitario (2015-2017) / Variceal and non-variceal upper gastrointestinal bleeding. Analysis of 249 hospitalized patients

Background: Upper gastrointestinal bleeding (UGIB) is one of the main reasons of hospitalization due to gastrointestinal causes. Reported mortality rates range from 5 to 12%. Aim: To determine hospital mortality and associated risk factors in hospitalized patients with UGIB. To compare the clinical characteristics and outcomes of patients with variceal versus non-variceal UGIB. Material and Methods: Review of medical records of 249 patients (62% males) discharged with the diagnosis of UGIB at a clinical hospital between 2015 to 2017. Demographic and clinical characteristics and adverse clinical outcomes (surgery, length of hospital stay and in-hospital mortality) were recorded. A comparative analysis between patients with Variceal and Non-variceal UGIB was carried out. Results: Seventy two percent of UGIB were non-variceal (peptic ulcer in 44%). Two patients required surgery (both died). Median of length of hospital stay was seven days (interquartile range (IQR) 4-13). Overall hospital mortality was 13 and 4% in variceal and non-variceal UGIB, respectively (p = 0.024). The variables associated with mortality were: red blood cell transfusion (odds ratio (OR): 18.7, p < 0.01), elevated creatinine on admission (OR: 3.30, p = 0.03) and variceal bleeding (OR: 3.23, p = 0.02). Conclusions: Hospital mortality of UGIB remains high, especially in variceal UGIB. Elevated creatinine levels on admission, the need of transfusion of red blood cells and variceal etiology are risk factors for mortality.

Tratamiento quirúrgico de la hemorragia digestiva alta por enfermedad de Dieulafoy / Surgical treatment of upper gastrointestinal bleeding dueto Dieulafoy disease

La enfermedad de Dieulafoy constituye menos del 2 % de las causas de hemorragia digestiva alta. Corresponde a la presencia de un vaso sanguíneo arterial de trayecto tortuoso, que protruye a través de un defecto mucoso localizado, generalmente, proximal en el estómago. Se presenta como una hematemesis masiva, a veces recu-rrente, con inestabilidad hemodinámica. La endoscopia es el método diagnóstico y terapéutico de elección. Si esta fracasa, está indicado practicar una angiografía selectiva que permita identificar el punto sangrante y producir un embolismo. En algunas ocasiones, ninguna de estas dos técnicas consigue detener la hemorragia, en cuyo caso está indicada una cirugía urgente. Se deben practicar resecciones gástricas limitadas (gastrectomías en cuña o tubulares) a la zona sangrante localizada mediante las pruebas anteriores; así, se evitan grandes gastrectomías que implican la práctica de anastomosis por el gran riesgo de dehiscencia que estas últimas cuando hay inestabilidad hemodinámica.Se presenta el caso de un paciente con hemorragia digestiva alta secundaria a enfermedad de Dieulafoy, que precisó intervención quirúrgica urgente por la imposibilidad de resolver el sangrado mediante endoscopia. Se describen el diagnóstico y el tratamiento de la enfermedad de Dieulafoy como causa de hemorragia digestiva alta en el adulto, y se presenta una revisión de la literatura científica

Dieulafoy's disease constitutes less than 2% of the causes of upper gastrointestinal bleeding. It corresponds to the presence of a tortuous arterial blood vessel which protrudes through a localized mucosal defect, usually proximal in the stomach. It presents as a massive hematemesis, sometimes recurrent, with hemodynamic instability.Endoscopy is the diagnostic and therapeutic method of choice. If this fails, it is indicated to perform a selective angiography to identify the bleeding point and embolize it. In some cases, none of these two techniques manages to stop the bleeding, in which case urgent surgery is indicated. Limited gastric resections (wedge or tubular gastrectomies) should be performed to the bleeding area, thus avoiding large gastrectomies that involve anastomosis due to the high leak risk they have in hemodynamically unstable patients.We present the case of a patient with upper gastrointestinal bleeding secondary to Dieulafoy's disease, who required urgent surgical intervention due to the impossibility of resolving the bleeding endoscopically. The diagnosis and treatment of Dieulafoy's disease as a cause of upper gastrointestinal bleeding in adults are described and a review of the scientific literature is presented

Utilidad de la escala de Glasgow-Blatchford en pacientes con hemorragia digestiva alta no variceal, con alto y bajo riesgo de complicaciones atendidos en el Servicio de Urgencias del Hospital Santo Tomas, 2015-2016 / Glasgow-Blatchford usefulness in patients with non variceal upper gastrointestinal bleeding with low and high risk of complications seen at the Emergency Department of Santo Tomas Hospital, 2015-2016

Introducción: La escala de Glasgow-Blatchford (GBS) nos permite clasificar al paciente como riesgo alto o bajo de presentar complicaciones. En los pacientes identificados como "bajo riesgo", la realización de una endoscopia temprana, podría disminuir los días intrahospitalarios y en el coste global. En nuestro medio, desconocemos la utilidad de la escala de GBS. Objetivo: Describir la utilidad de la escala de Glasgow-Blatchford (GBS) en la estratificación del riesgo en los pacientes con hemorragia digestiva alta (HDA) no variceal atendidos en el servicio de urgencias en un hospital de tercer nivel. Materiales y métodos: Se incluyeron prospectivamente 218 pacientes, y se les realizó en las primeras 24-48 h endoscopia urgente. Éstos se estratificaron, según la escala de GBS, en bajo riesgo (GBS ≤ 2), y alto riesgo (GBS ≥ 3). Se calculó la sensibilidad, especificidad, valor predictivo positivo (VPP) y negativo (VPN) de la escala de GBS en nuestro medio basándonos en el requerimiento de tratamiento endoscópico, radiológico (embolización arterial), transfusión de hemoderivados y/o cirugía, como estándar de oro para clasificar a los pacientes en alto riesgo. Resultados: Se incluyó un total de 218 pacientes, con edad media de 56 ± 18 años, de los cuales 121/218 (55%) fueron varones. 156/218 precisaron intervención por lo que fueron clasificados como "alto riesgo" mientras 62/218 no precisaron y se clasificaron como "bajo riesgo". Un valor de corte de GBS ≤ 2 mostró una sensibilidad del 98% con un VPN de 100%. La utilidad de la escala de GBS mostró un área bajo la curva ROC 0,83 (IC 95% 0,75-0,90). Conclusión: La escala de GBS utilizada pacientes con HDA no variceal atendidos en el servicio de urgencias posee una validez diagnóstica adecuada para predecir la necesidad de intervención.

Introduction: The Glasgow-Blatchford (GBS) scale allows us to classify the patient as a high or low risk of presenting complications. In the patients identified as "low risk", the performance of an early endoscopy could reduce the intrahospital days and the overall cost. In our environment, we do not know the usefulness of the GBS scale. Objective: To describe the utility of the Glasgow-Blatchford scale (GBS) in the stratification of risk in patients with non-variceal upper gastrointestinal bleeding (HDA) seen in the emergency department of a tertiary hospital. Materials and methods: 218 patients were prospectively included, and they were performed in the first 24-48 hr an urgent endoscopy. These were stratified, according to the GBS scale, at low risk (GBS ≤ 2), and high risk (GBS ≥ 3). We calculated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the GBS scale in our setting based on the requirement of endoscopic, radiological treatment (arterial embolization), transfusion of blood products and / or surgery, as our gold standar to classify patients as "high risk". Results: A total of 218 patients were included, with a mean age of 56 ± 18 years, of which 121/218 (55%) were male. 156/218 required intervention for what were classified as "high risk" while 62/218 did not specify and classified as "low risk". A cut-off value of GBS ≤ 2 showed a sensitivity of 98% with a NPV of 100%. The utility of the GBS scale showed an area under the ROC curve 0.83 (95% CI 0.75-0.90). Conclusion: The GBS scale used in patients with non-variceal UGB attended in the emergency department has adequate diagnostic validity to predict the need for intervention.

Distribución Topográfica y Manejo de Tumores Neuroendocrinos del Tubo Digestivo / Topographic Distribution and Management of Neuroendocrine Tumors of the Digestive Tube

Introducción: Los tumores neuroendocrinos (TNE) son un grupo de neoplasias que se originan a partir de células enterocromafínicas, especialmente ubicadas en el tubo digestivo. El objetivo del presente estudio es escribir la distribución topográfica, el manejo multidisciplinario y diagnóstico patológico según la OMS de los tumores neuroendocrinos del tubo digestivo. Métodos: El presente es un estudio descriptivo, retrospectivo de los casos con diagnóstico anatomopatológico confirmado de tumor neuroendocrino localizados en el tubo digestivo entre enero del 2011 a diciembre del 2018 en el Instituto Oncológico Nacional del Ecuador- SOLCA de Guayaquil. Se describe topografía y tipo de tratamiento establecido con frecuencias y porcentajes. Resultados: Ingresaron al estudio 21 casos. La localización más frecuente fue el apéndice cecal n = 8 (38 %), en estómago n=4 (19 %), intestino delgado n=3 (14 %). El diagnóstico patológico en estadio G1 (65 %); G2 (24%) y G3 (12%). La primera línea de tratamiento fue la cirugía con intención curativa n=19 (90.5 %) y tratamiento endoscópico n=2 (9.5 %). Los pacientes sometidos a cirugía, n=16/19; (84 %) obtuvieron niveles de resección 0 (R0) y permanecieron en observación clínica, los demás sujetos en el estudio recibieron tratamiento adyuvante con somatostatina sola n=1 (4.8 %) o combinación de somatostatina y radioterapia n=2 (9.5 %). Conclusión: El diagnóstico de tumor neuroendocrino de tubo digestivo es una etiología oncológica poco frecuente. El tratamiento quirúrgico en esta serie de casos está enfocada en una acción curativa de tipo quirúrgico.

Introduction: Neuroendocrine tumors (NETs) are a group of neoplasms that originate from enterochromaffin cells, especially located in the digestive tract. The objective of the present study is to write the topographic distribution, the multidisciplinary management and pathological diagnosis according to the WHO of the neuroendocrine tumors of the digestive tract. Methods: This is a descriptive, retrospective study of the cases with a confirmed anatomopathological diagnosis of neuroendocrine tumor located in the digestive tract between January 2011 to December 2018 at the National Oncology Institute of Ecuador- SOLCA of Guayaquil. The topography and type of treatment established with frequencies and percentages are described. Results: 21 cases were entered into the study. The most frequent location was the cecal appendix n = 8 (38%), stomach n = 4 (19%), small intestine n = 3 (14%). The pathological diagnosis in stage G1 (65%); G2 (24%) and G3 (12%). The first line of treatment was surgery with curative intent n = 19 (90.5%) and endoscopic treatment n = 2 (9.5%). Patients undergoing surgery, n = 16/19; (84%) obtained resection levels 0 (R0) and remained under clinical observation, the other subjects in the study received adjuvant treatment with somatostatin alone n = 1 (4.8%) or combination of somatostatin and radiotherapy n = 2 (9.5%). Conclusion: The diagnosis of neuroendocrine tumor of the digestive tract is a rare oncological etiology. The surgical treatment in this series of cases is focused on a surgical action of a surgical type.

Enfrentamiento de la ingesta de cuerpo extraño en un Hospital Regional del sur de Chile / Management of foreign body ingestion at a Regional Hospital in southern Chile

Introducción: La ingesta de cuerpos extraños (ICE) es frecuente en pediatría y puede llevar a complicaciones. Nuestro objetivo es revisar la experiencia de nuestro centro en el manejo de estos pacientes y proponer un protocolo de tratamiento. Material y Método: Estudio transversal retrospectivo, observacional y descriptivo, en el cual se revisaron los informes endoscópicos y fichas de pacientes con diagnóstico de ICE manejados por la Unidad de Endoscopia Pediátrica del Hospital Clínico Regional de Concepción entre enero de 2013 y junio de 2017 (53 meses), totalizando 40 casos. El registro y análisis de los datos se realizó con Microsoft® Excel 2016® para MacOS®. Resultados: El promedio de edad fue de 3,96 ± 3,24 años. La moda estadística fue de 2 años. A todos los pacientes se les realizó una endoscopia digestiva alta. El CE más frecuente fue la moneda (61,9%). En 6 casos (14,2%) fue una pila de botón. La retención de CE fue en tercio proximal del esófago (30,9%), el cuerpo gástrico (26,2%) y el tercio distal del esófago (14,2%), extrayéndose principalmente con pinza de cuerpo extraño (90,4%). El 57,5% evidenció alguna lesión relacionada a la ubicación del CE, siendo la más grave la producida por pila de botón. Conclusión: La ICE en niños es una entidad potencialmente peligrosa, por lo que se hace necesario disponer de una unidad de endoscopia pediátrica y protocolos de manejo para evitar complicaciones, sobre todo con objetos de alto riesgo.

Introduction: Foreign body ingestion (FBI) is common in pediatrics and can lead to complications. The aim of the present study is to review the experience of our center in the management of these patients and to propose a treatment protocol. Material and Method: Retrospective, observational and descriptive cross-sectional study, in which the endoscopic reports and records of patients diagnosed with IFB managed by the Pediatric Endoscopy Unit of the Regional Clinical Hospital of Concepción between January 2013 and June 2017 (53 months) were reviewed, with a total of 40 cases. Data recording and analysis was performed with Microsoft® Excel 2016® for MacOS®. Results: The average age was 3,96 ± 3,24 years. The statistical fashion was 2 years. All patients underwent a upper gastrointestinal endoscopy. The most frequent FB was the coin (61,9%). In 6 opportunities (14,2%) was a button batery. FB retention was in the proximal third of the esophagus (30,9%), the gastric body (26,2%) and the distal third of the esophagus (14,2%), being extracted mainly with foreign body clamp (90,4%). The 57,5% showed some injury related to the location of the FB, being the most serious the produced by button batery. Conclusion: FBI in children is a potentially dangerous entity, so it becomes necessary to have a pediatric endoscopy unit and treatment protocols to avoid complications, especially with high-risk objects.

Functionality of upper gastrointestinal cancer patients which have undertaken surgery in hospital phase / Funcionalidade de pacientes com neoplasia gastrointestinal alta submetidos ao tratamento cirúrgico em fase hospitalar

ABSTRACT Background: Cancer patients present various physiological, metabolic, social and emotional changes as a consequence of the disease's own catabolism, and may be potentiated in the gastrointestinal tract cancer by their interference with food intake, digestion and absorption. Aim: T o evaluate the functionality of upper gastrointestinal cancer patients which have undertaken surgery and analyze the factors associated with changes in strength and functionality during hospitalization time. Methods: Prospective analytical study in patients with cancer of the upper gastrointestinal tract which have undertaken surgery. Was evaluated the handgrip strength using a hand dynamometer and functionality through the functional independence measure and Functional Status Scale for Intensive Care Unit in the preoperative period, 2nd and 7th postoperative day. Results: Were included 12 patients, 75% men, and mean age was 58.17 years old. The most prevalent tumor site was stomach (66.7%). There was a progressive reduction from the pre-operative palmar grip strength to the 2nd and 7th postoperative day, respectively. There was a decrease in functional performance from the preoperative period to the 2nd and a gain from the 2nd to the 7th postoperative day (p<0.001). Conclusion: An important reduction in the handgrip strength and functionality was evidenced during the postoperative period in relation to the basal value in the pre-operative period.

RESUMO Racional: Os pacientes com câncer apresentam diversas alterações fisiológicas, metabólicas, sociais e emocionais como consequências do próprio catabolismo provocado pela doença, podendo ser potencializadas nos canceres gastrointestinais pela sua interferência na ingestão, digestão e absorção dos alimentos. Objetivo: Avaliar o comportamento funcional de pacientes com neoplasia gastrointestinal alta submetidos ao tratamento cirúrgico e analisar os fatores associados às alterações da força e funcionalidade durante o tempo de internação. Métodos: Estudo prospectivo analítico de pacientes com câncer do trato gastrointestinal alto submetidos ao tratamento cirúrgico. Foram avaliadas a força de preensão palmar por meio do dinamômetro manual e funcionalidade por meio da Medida de Independência Funcional e Functional Status Scale for Intensive Care Unit no pré-operatório, no 2º e 7º dias do pós-operatório . Resultados: Foram incluídos 12 pacientes, 75% homens, com idade média de 58,17 anos. O sítio tumoral mais prevalente foi o estômago (66,7%). Houve redução progressiva da força de preensão palmar das fases pré-operatória em relação ao 2º e 7º dias do pós-operatório, respectivamente. Ocorreu diminuição do desempenho funcional do pré-operatório para o 2º dia e um ganho do 2º dia pós-operatório para o 7º dia (p<0,001). Conclusão: Houve importante redução na força de preensão palmar e funcionalidade durante o período pós-operatório em relação ao valor basal no pré-operatório.

Early oral feeding post-upper gastrointestinal tract resection and primary anastomosis in oncology / Realimentação oral precoce após ressecções e anastomose primária do trato gastrointestinal alto em oncologia

ABSTRACT Background: The practice of starving patients in the immediate period after upper gastrointestinal surgery is widespread. Early oral intake has been shown to be feasible and may result in faster recovery and decrease length of hospital. Aim: To evaluate the feasibility and safety of oral nutrition on postoperative early feeding after upper gastrointestinal surgeries. Methods: Observational cohort design study with convenience retrospective data in both genders, over 18 years, undergoing to total gastrectomy and/or elective esophagectomy. They have received oral or enteral nutrition in less than 48 h after surgery, and among those who started with enteral nutrition, the oral feeding up to seven days. Results: The study was performed in 161 patients, 24 (14.9%) submitted to esophagectomy, 132 (82%) to total gastrectomy and five (3.1%) to esophagogastrectomy. Was observed good dietary acceptance and low percentage (29%) of gastrointestinal intolerances, more pronounced among those with enteral diet. Most of the patients did not present postoperative complications, 11 (6.8%) were reopened, five (3.1%) had fistulas, three (1.9%) wound dehiscence, three (1.9%) fistula more wound dehiscence and six (3.7%) other non-infectious complications. Conclusion: Early oral diet is safe and viable for patients undergoing upper gastrointestinal surgery.

RESUMO Racional: Os níveis do antígeno carcinoembriônico no lavado peritoneal têm sido demonstrados como possível fator prognóstico de recidiva e mortalidade em pacientes com câncer gástrico. Objetivos: Medir seus níveis em lavado peritoneal durante operação de ressecção de câncer gástrico e ver se eles aumentados estão relacionados com mortalidade, recorrência, recidiva e outros fatores prognósticos. Métodos: Foi realizado lavado peritoneal durante ressecções de câncer gástrico; os níveis do antígeno carcinoembriônico nesse lavado maiores ou iguais a 210 ng/g foram considerados aumentados ou positivos. Resultados: Foram estudados 30 pacientes, destes, 33,33 % apresentaram níveis aumentados, os quais foram fator de risco para mortalidade em seis meses OR: 8,5 (1,458-49,539) IC 95%, mortalidade geral RR: 2,111 (1,314-3,391) IC 95%, mortalidade devido à doença OR: 12 (1,885-76,376) IC 95%, recorrência peritoneal OR: 9 (1,325-61,138) IC 95%, e recidiva ou progressão da doença OR: 27 (2,705-269,460) IC 95%. Conclusões: Os níveis aumentados do antígeno carcinoembriônico no lavado peritoneal foram fatores de risco para mortalidade, recorrência peritoneal, recidiva e progressão da doença em pacientes com câncer gástrico.

Lesão de Dieulafoy do fundo gástrico / Dieulafoys lesion of the gastric fundus

Hemorragia digestiva alta (HDA) é uma emergência clínica exteriorizada através de melena, hematêmese, além de alterações hemodinâmicas decorrentes de perda volêmica. Existem vários diagnósticos etiológicos causadores de hemorragias digestivas altas; dentre eles, uma causa rara é lesão de Dieulafoy, sendo relacionada acerca de 2% dos casos de HDA. Neste relato, descreveremos um caso de lesão de Dieulafoy, evidenciando a relevância desta lesão como um importante diagnóstico diferencial nas causas de hemorragia digestiva alta. O procedimento diagnóstico e o manejo atual são fundamentados pela endoscopia digestiva alta. A hemostasia endoscópica é realizada, utilizando técnicas como eletrocoagulação, injeções com adrenalina e hemoclips.

Upper gastrointestinal bleeding (UGBI) is a clinical emergency externalized through melena, hematemesis and hemodynamic changes due to volume loss. There are a lot of etiological diagnosis of gastroduodenal hemorrhages, including Dieulafoy which is a rare cause related about 2% of the UGBI cases. In this report we describe a case of Dieulafoy lesion highlighting the importance of this lesion as a rare and important differential diagnosis in cases of upper gastrointestinal bleeding. The current diagnostic and management is justified by endoscopy. Endoscopic hemostasis is performed using techniques such as electrocoagulation, injections of adrenaline and hemo-clips.

Manifestações do trato gastrointestinal superior em pacientes com doença inflamatória intestinal atendidos em serviço de referência em Salvador - BA / Upper gastrointestinal tract manifestations in inflammatory bowel disease patients from one reference service in Salvador - BA

Introdução: a Doença Inflamatória Intestinal (DII) se manifesta em duas principais formas: doença de Crohn (DC) e retocolite ulcerativa (RCU). O quadro clínico clássico da DII compreende dor abdominal, diarreia e perda ponderal. Além da apresentação habitual, os pacientes podem apresentar, no decorrer da doença, manifestações do trato gastrointestinal superior (TGS) como: dispepsia, dor epigástrica, plenitude pós-prandial, pirose, náuseas, regurgitação, aftas orais, vômitos, disfagia, odinofagia e hematêmese. Objetivo: descrever as manifestações do TGS em pacientes com DII em um centro de referência da Bahia. Métodos: estudo transversal realizado no período de julho de 2015 a agosto de 2016 no ambulatório de DII do Hospital Geral Roberto Santos (HGRS). A coleta de dados foi por um questionário objetivo e revisão de prontuários. Foram avaliadas variáveis do ponto de vista epidemiológico e clínico. O estudo foi aprovado pelo Comitê de Ética em Pesquisa do Hospital Geral Roberto Santos. As variáveis foram analisadas utilizando o pacote estatístico SPSS versão 21.0. Resultados: foram incluídos 306 pacientes. O sexo feminino foi mais prevalente tanto na DC (63,1%) quanto na RCU (60,6%). Dos 306 pacientes analisados, 141 tinham diagnóstico de DC e 165 tinham diagnóstico de RCU. Da amostra total, 58,5% apresentaram alguma manifestação do TGS, sendo a frequência semelhante entre DC e RCU. Conclusões: mais da metade dos pacientes com DII apresentou pelo menos uma manifestação do TGS, sendo que as manifestações mais frequentes foram: pirose, dor epigástrica, dispepsia e plenitude pós-prandial. DC e RCU apresentaram frequências semelhantes dessas manifestações. Estes sintomas devem ser atentamente questionados, pois é fundamental o seu reconhecimento precoce para o manejo adequado.

Introduction: inflammatory Bowel Disease (IBD) manifests itself in two main forms: Crohns disease (CD) and ulcerative colitis (UC). The classic clinical presentation of IBD includes abdominal pain, diarrhea and weight loss. In addition to the usual presentation, patients may presente upper gastrointestinal tract (UGT) manifestations such as: dyspepsia, epigastric pain, postprandial fullness, heartburn, nausea, regurgitation, oral thrush, vomiting, dysphagia, odynophagia and hematemesis. Objective: to describe the manifestations of the UGT in patients with IBD at a reference center in Bahia. Methods: a cross-sectional study conducted from July 2015 to August 2016 at the Hospital Geral Roberto Santos (HGRS) - IBD unit. Data collection was made by an objective questionnaire and review of medical records. Variables from epidemiological and clinical point of view were evaluated. The study was approved by the Research Ethics Committee of the HGRS (Salvador - BA). Variables were analyzed using the statistical package SPSS version 21.0. Results: we evaluated 306 patients. Female gender was more prevalent in both CD (63.1%) and UC (60.6%). Of the 306 patients analyzed, 141 had been diagnosed with CD and 167 with UC. Of the total sample, 58.5% had some manifestation of the UGT, being similar between CD and UC. Conclusion: more than half of patients with IBD presented at least one manifestation of the UGT, and the most frequent were: heartburn, epigastric pain, dyspepsia and postprandial fullness. CD and UC presented similar frequencies of these manifestations. These symptoms should be carefully questioned, as it is fundamental their early recognition for the adequate management of these patients.

Pharmacological and toxicological investigations of etodolac loaded gum katira microspheres prepared by W1/O/W2 emulsion solvent evaporation technique in rats

ABSTRACT Etodolac is a non-steroidal anti-inflammatory drug (NSAID) and approved by USFDA as a COX2 inhibitor. Although etodolac therapy provides clinical benefits, it is associated with upper gastrointestinal (GI) tract complications also. Etodolac loaded gum Katira microsphere (ELGKM) was prepared by W1/O/W2 emulsion solvent evaporation technique. The gastric irritation properties of orally administered pure etodolac, ELGKM and blank microspheres (without etodolac) were evaluated in experimental rats treated for 6 days. The stomach examination and biochemical investigation of stomach tissue of treated rats indicated that ELGKM formulation remarkably reduced ulcerogenecity as compared to pure etodolac. The anti-inflammatory activities of pure etodolac and ELGKMs were ascertained by the implantation of cotton pellets in rats for 6 days. Based on the results, ELGKMs showed significant anti-inflammatory activities (P<0.01) as compared to control group. The cotton pellets test suggested that ELGKM formulation retained more anti-inflammatory properties among the groups. The hematological changes, biochemical analysis and histopathological studies of subacute toxicity in rats revealed that ELGKM were the effective sustained release formulation in the treatment of chronic pain and inflammation. In conclusion, the physicochemical characterization, pharmacological and toxicological studies suggest that ELGKMs may represent as a potential candidate for sustained drug delivery (10-12 hours) in chronic joint pain related diseases with remarkably diminished gastrointestinal side effects.

Utilidad del estudio contrastado precoz del tracto digestivo superior después de cirugía bariátrica: ¿se justifica su uso rutinario? / Usefulness of upper gastrointestinal series to detect leaks in the early postoperative period of bariatric surgery

Background: Postoperative leaks are the most undesirable complication of bariatric surgery and upper gastrointestinal (GI) series are routinely ordered to rule them out. Despite the published literature recommending against its routine use, it is still being customarily used in Chile. Aim: To examine the usefulness of routine upper GI series using water-soluble iodinated contrast media for the detection of early postoperative leaks in patients undergoing bariatric surgery. Material and Methods: A cohort of 328 patients subjected to bariatric surgery was followed from October 2012 to October 2013. Most of them underwent sleeve gastrectomy. Results: Upper GI series on the first postoperative day were ordered to 308 (94%) patients. Postoperative leaks were observed in two patients, with an incidence of 0.6%. The sensitivity for upper GI series detection of leak was 0% and the negative predictive value was 99%. Conclusions: Routine upper GI series after bariatric surgery is not useful for the diagnosis of postoperative leak, given the low incidence of this complication and the low sensitivity of the technique.

Estenosis pilórica del adulto, a propósito del primer caso registrado en Colombia / Adult Pyloric Stenosis, Regarding the First Reported Case in Colombia

La estenosis pilórica hipertrófica primaria en adultos es una enfermedad poco frecuente, de etiología desconocida, en la cual el diagnóstico solo puede establecerse después de la exclusión de las causas más comunes de obstrucción de la salida gástrica. El abordaje terapéutico, aunque muy diverso, puede estar encaminado a la dilatación o apertura pilórica. Se presenta el caso de una paciente de 62 años de edad que ingresó al Hospital San Rafael de Tunja con síntomas de obstrucción gástrica. En esta paciente solo fue posible dar un diagnóstico correcto de estenosis pilórica hipertrófica primaria por medio de estudios imaginológicos, para ofrecer finalmente un tratamiento adecuado.

Primary pyloric stenosis in adults is a rare disease, with an unknown etiology in which the diagnosis can only be established after excluding the most common obstruction causes of gastric transit. The treatment, although very diverse, can be geared towards dilatation or pyloric opening. In this article, we present the case of a 62-year old patient who entered the Hospital San Rafael in Tunja with symptoms of gastric obstruction. In this patient, it was only possible to give a correct diagnosis of primary hypertrophic pyloric stenosis through imaging studies, in order to finally provide adequate treatment.

La recuperación posoperatoria acelerada (fast track) disminuye la estancia hospitalaria en cirugía gastrointestinal alta: revisión sistemática de la literatura / Fast track surgery protocols diminish hospital length of stay in upper gastrointestinal surgery: systematic review of literature

Introducción. Los protocolos de la cirugía con recuperación acelerada (fast-track surgery) han demostrado disminución de la estancia hospitalaria y los costos médicos en cirugía colorrectal. La evidencia sobre su aplicación en cirugía general es escasa si se compara con otras especialidades quirúrgicas. En este estudio se revisa la evidencia científica sobre la estrategia fast-track en cirugía gastrointestinal alta. Métodos. Se revisaron PubMed y Medline con el término "fast track surgery" y "ERAS surgery". Se incluyeron estudios clínicos controlados de asignación aleatoria que contaran con un grupo de control de pacientes con cuidado convencional. Se excluyeron trabajos no relacionados con cirugía gastrointestinal alta. Se analizaron las diferencias de medias sopesadas, tomando como puntos finales la estancia hospitalaria, la morbilidad, la mortalidad y la rehospitalización. Resultados. Cinco estudios clínicos de asignación aleatoria cumplieron con los criterios de inclusión. Cuatro estudios de gastrectomías y uno de perforación de úlcera duodenal. De un total de 385 pacientes, se compararon 197 (51 %) en el grupo con cuidado convencional y 188 (49 %) en grupo con fast-track. Al comparar el cuidado convencional con el fast-track, la estancia hospitalaria fue de 7,5 Vs. 5,7 días, (p=0,019), y la morbilidad, de 22 % Vs. 14 % (p=0,017), respectivamente. No se obtuvieron diferencias significativas en la mortalidad (p=0.347) ni en las rehospitalizaciones (p=0.954) entre los dos grupos. Conclusión. La estrategia fast-track disminuye la estancia hospitalaria, y puede implementarse en forma segura en pacientes que requieren cirugía gastrointestinal alta, sin incrementar la morbilidad, la mortalidad ni las rehospitalizaciones.

Introduction: Fast-track surgery protocols (FT) have demonstrated reduction in hospital length of stay (LOS) and medical costs in colorectal surgery. The evidence on FT applied to general surgery is sparse. This study reviews the scientific evidence of FT strategy in upper gastrointestinal surgery (UGIS). Methods: PubMed and Medline databases were reviewed with the term "Fast Track surgery" and "ERAS surgery". Randomized clinical trials (RCT) regarding FT strategies in UGIS were included only if a control group with conventional care (CC) was compared. Studies not related to UGIS were excluded. The differences in weighted means were analyzed using as end points the LOS, morbility, mortality, and hospital readmission. Results: Five RCT met the inclusion criteria: four randomized clinical studies on gastrectomies, and one on perforated duodenal ulcer From a total of 385 patients, 197 (51%) included the CC group and 188 (49%) in FT group were compared. The LOS of CC vs. FT groups was 7.5 and 5.7 days, respectively (p=0.019), and morbidity of 22% vs. 14%. Respectively (p=0.019). No significance differences were obtained on mortality (p=0.347) or hospital readmission (p=0.954) between the two groups. Conclusion: Fast-Track strategy decreases length of hospital stay, and could be safely implemented in patients undergoing upper gastrointestinal surgery, without increasing morbidity, mortality or readmission rates.