Computed Tomography Colonography as a Sensible Option for Colorectal Cancer Screening: Evidence Based on Metanalysis / Colonografia por tomografia computadorizada como uma opção sensível para o rastreamento do câncer colorretal: Evidências baseadas em metanálise

Abstract Objective This metanalysis aimed to evaluate the sensitivity and specificity of computed tomography colonography in colorectal polyp detection. Methods A literature search was performed in the PubMed and Web of Science databases. Results A total of 1,872 patients (males 57.2%, females 42.8%) aged 49 to 82 years old (mean age 59.7 ± 5.3 years) were included in this metanalysis. The estimated sensitivity of computed tomography colonography was 88.4% (46.3-95.7%, coefficient of variation [CV]=28.5%) and the estimated specificity was 73.6% (47.4-100.0%, CV=37.5%). For lesions up to 9mm, the sensitivity was 82.5% (62.0-99.9%, CV =25.1%) and the specificity was 79.2% (32.0-98.0%, CV=22.9%). For lesions>9mm, the sensitivity was 90.2% (64.0-100.0%, CV=7.4%) and the specificity was 94.7% (80.0-100.0%, CV=6.2%). No statistically significant differences in sensitivity according to the size of the lesion were found (p=0.0958); however, the specificity was higher for lesions>9mm (p<0.0001). Conclusions Most of the studies analyzed in the present work were conducted before 2010, which is about a decade after computed tomography colonography started being indicated as a screening method by European and American guidelines. Therefore, more studies aimed at analyzing the technique after further technological advancements are necessary, which could lead to the development of more modern devices.

Resumo Objetivo Esta meta-análise teve como objetivo avaliar a sensibilidade e especificidade da colonografia por tomografia computadorizada na detecção de pólipos colorretais. Métodos Foi realizada uma pesquisa bibliográfica nas bases de dados da PubMed e da Web of Science. Resultados Um total de 1.872 pacientes, 57,2% homens e 42,8% mulheres, com idades entre 49 a 82 anos de idade (média de 59,7 ± 5,3 anos) foram incluídos nesta meta análise. A sensibilidade da colonografia por tomografia computadorizada foi estimada em 88,4% (46,3-95,7%; coeficiente de variância [CV]=28,5%) e a especificidade em 73,6% (47,4%-100,0%; CV=37,5%). Para lesões de até 9mm, a sensibilidade foi de 82,5% (62,0-99,9%; CV=25,1%) e a especificidade de 79,2% (32,0-98,0%; CV=22,9%). Para lesõesmaiores que 9mm, a sensibilidade foi de 90,2% (64,0-100,0%; CV=7,4%) e a especificidade de 94,7% (80,0-100,0%; CV=6,2%). Não houve diferença estatisticamente significante entre as sensibilidades por tamanho da lesão (p=0,0958), porém a especificidade foi maior em lesões acima de 9mm (p<0,0001). Conclusão A maioria dos estudos analisados no presente trabalho foi realizada antes de 2010, cerca de uma década depois que a colonografia por tomografia computadorizada passou a ser indicada como método de triagem pelas diretrizes europeias e americanas. Portanto, são necessários mais estudos com o objetivo de analisar a técnica apósmaiores avanços tecnológicos, o que poderia levar ao desenvolvimento de dispositivos mais modernos.

Dentin Thickness of Pulp Chamber Floor in Primary Molars: Evaluation by Cone-Beam Computed Tomography

ABSTRACT Objective: Use cone-beam computed tomography (CBCT) images to evaluate the dentin thickness of the pulp chamber floor in primary molars. Material and Methods: Cross-sectional study, conducted with CBCT images of teeth of children. Primary molars with preserved pulp chamber floor were included. The dentin thickness of the pulp chamber floor in the primary molars was measured linearly in CBCT cross-sections. Data were descriptively analyzed and the Mann-Whitney test was applied (p<0.05). Results: 27 CBCT exams and 123 primary molars of children aged 4 to 13 years were analyzed; the majority was female (52.0%). In maxillary molars, the median dentin thickness was 1.50 (0.6-2.2) mm in the first and 1.65 (0.6-2.3) mm in the second (p=0.049) molars. In mandibular molars, the median was 1.20 (0.3-1.7) mm in the first and 1.60 (1.0-2.2) mm in the second (p<0.001) molars. Children aged 4 to 8 years showed less dentin thickness (p<0.001). Conclusion: The median dentin thickness of the pulp chamber floor in primary molars was 1.50 mm, ranging from 0.3 to 2.3 mm. Less dentin thickness was associated with younger children, teeth in the mandibular arch, and first molars.

Retrospective analysis of the elective tests of rigid proctosigmoidoscopy performed in the service of medical residency in Coloproctology of Hospital Santa Marcelina / Análise retrospectiva de exames eletivos de retossigmoidoscopia rígida realizadas no serviço de residência médica de Coloproctologia no Hospital Santa Marcelina

Introduction: Proctologic examination is a deeply intimate procedure which deals with a body area in which prejudices, taboos and constraints prevail, and may also relate to previous trauma; yet this procedure is of paramount importance for the investigation of patients with symptoms that foretell pathologies associated with distal colon, rectum and anus. Objectives: This study aimed to analyze all cases scheduled of rigid proctosigmoidoscopy performed by the Coloproctology Service, Hospital Santa Marcelina, in 8 of its 10 years of residency in the specialty. Materials and methods: We analyzed mean age, gender distribution, device's height of reach in relation to the anal verge, the percentage of abnormal tests stratified to perform, or not perform, anoscopy and proctosigmoidoscopy, and major diseases detected. Results: 844 rigid proctosigmoidoscopy procedures scheduled and performed by the Coloproctology Service, Hospital Santa Marcelina, between September 2006 and August 2014, were analyzed. The distribution was similar between genders and the mean age was 51.2 years. With respect to the device's height of reach from the anal verge, these values were stratified as follows: distance reached >15 cm, 10-15 cm, and <10 cm from the anal verge. Distances >15 cm from the anal verge were attained in 692 (82% of RR) tests, between 10 and 15 cm in 94 (11.1%) tests, and <10 cm in 58 (6.9%) tests. Conclusion: In this study, it was found that proctology examination and rigid proctosigmoidoscopy are mandatory procedures in cases of symptoms depending on these practices.

Introdução: O exame proctológico, apesar de profundamente íntimo e de lidar com área do corpo na qual imperam preconceitos, tabus e constrangimento, podendo inclusive relacionar-se a traumas prévios, é de suma importância para a investigação de pacientes com sintomas que predizem patologias associadas ao cólon distal, reto e ânus. Objetivos: Analisar todos os casos de retossigmoidoscopias rígidas realizadas de forma agendada pelo serviço de Coloproctologia do Hospital Santa Marcelina em 8 de seus 10 anos de residência médica na especialidade. Materiais e métodos: Analisou-se a média de idade, distribuição por sexo, altura de alcance do aparelho em relação à borda anal, percentagem de exames anormais com estratificação quando realizado ou não a anuscopia e retossigmoidoscopia e as principais doenças detectadas. Resultados: Foram avaliadas 844 retossigmoidoscopias rígidas realizadas pelo serviço de Coloproctologia do Hospital santa Marcelina, de forma agendada, entre setembro de 2006 e agosto de 2014. A distribuição foi semelhante entre os sexos e a média de idade foi de 51,2 anos. Com relação à altura em relação à borda anal, estratificou-se esses valores em maior que 15 cm, entre 10 e 15 cm da borda anal e alcance inferior a 10 cm da borda anal. Em 692 exames foi possível alcance superior a 15 cm da borda anal (82% das RR), em 94 (11,1%) entre 10 e 15 cm, e em 58 (6,9%) exames, abaixo de 10 cm. Conclusão Verificou-se em nosso estudo que o exame proctológico e a retossigmoidoscopia rígida são mandatório em casos de sintomatologia que assim o necessitem.

Diagnóstico de neoplasia colorrectal: descripción de hallazgos en colonoscopia virtual y convencional / Diagnosis of Colorectal Neoplasia: Description of Findings On Virtual Colonoscopy And Conventional Colonoscopy

Introducción: La colonoscopia virtual surge como método diagnóstico en las diferentes patologías del colon. Objetivos: Describir y comparar los hallazgos de la colonoscopia convencional y la virtual relacionados con la presencia de neoplasias y sus características morfológicas de tamaño y localización, en pacientes con sospecha de patología de colon. Métodos: Estudio descriptivo de registro de casos clínicos. Se incluyeron 23 pacientes remitidos al servicio de gastroenterología para realización de colonoscopia, durante septiembre de 2007 y mayo de 2008. Los pacientes fueron llevados a colonoscopia virtual y, posteriormente, a colonoscopia óptica; los hallazgos fueron clasificados por un radiólogo y un gastroenterólogo, respectivamente, según su localización en los diferentes segmentos del colon, así como el tamaño, el tipo de lesión en mucosa, submucosa, carcinomas y lesiones extrínsecas. Resultados: El grado de concordancia de los dos procedimientos para el diagnóstico de pólipos fue de 76 %. Se encontró que la colonoscopia virtual tiene una sensibilidad para el diagnóstico de pólipos de 85,7 % IC (52,6-100) y un valor predictivo negativo de 92,9 % IC (75,8-100), valores considerados importantes, pero con amplios intervalos de confianza atribuidos a la poca cantidad de pacientes. Conclusiones: En el presente estudio se encontró un alto valor predictivo negativo, lo que hace que la colonoscopia virtual pueda ser el método diagnóstico inicial de elección en el tamizaje de las patologías colorrectales. En caso de ser negativa, se descarta patología; si es positiva, el método diagnóstico a seguir para confirmar los hallazgos sería la colonoscopia directa.

Introduction: Virtual colonoscopy emerges as a new diagnostic method to study the pathology that affects the colon. Objectives: To describe and compare the findings of conventional colonoscopy and virtual colonoscopy related to the presence of a neoplasia according to its morphology, size and location in patients suspected of having colonic pathology. Material and Methods: Descriptive study of the review of clinical cases. 23 patients submitted to the gastroenterology service between September 2007 and May 2008 for a conventional colonoscopy were included. The patients were taken to virtual colonoscopy and, subsequently, to optical colonoscopy; the findings were classified by a radiologist and a gastroenterologist, respectively, according to its location in the different segments of the colon, as well as size, the type of lesion in the mucous and submucous membrane, carcinomas and extrinsic lesions. Results: The degree of concordance between the two procedures on the diagnosis of polyps was 76%. Virtual colonoscopy had 85.7% sensibility (IC 52.6-100) and a negative predictive value of 92.9% (IC 75.8-100) for the diagnosis of polyps. These are considered important findings, but with wide intervals of confidence due to the small quantity of patients. Conclusion: In this study we found a high negative predictive value, which means that virtual colonoscopy could be the initial diagnostic method of choice in the screening of colorectal pathologies. In case it is negative, pathology is ruled out. If it is positive, the diagnosis method to follow in order to confirm the findings would be direct colonoscopy.

Using computed tomography colonography in patients at high risk of colorectal cancer - a prospective study in a university hospital in South America

OBJECTIVES: The purpose of our study was to report the results of the implementation of computed tomography colonography in a university hospital setting serving a Brazilian population at high risk of colorectal cancer. METHODS: After creating a computed tomography colonography service in our institution, 85 patients at high risk of colorectal cancer underwent computed tomography colonography followed by a same-day optical colonoscopy from September 2010 to May 2012. The overall accuracy of computed tomography colonography in the detection of lesions ≥6 mm was compared to that of optical colonoscopy (direct comparison). All colonic segments were evaluated using quality imaging (amount of liquid and solid residual feces and luminal distension). To assess patient acceptance and preference, a questionnaire was completed before and after the computed tomography colonography and optical colonoscopy. Fisher's exact test was used to measure the correlations between colonic distension, discomfort during the exam, exam preference and interpretation confidence. RESULTS: Thirteen carcinomas and twenty-two lesions ≥6 mm were characterized. The sensitivity, specificity and accuracy of computed tomography colonography were 100%, 98.2% and 98.6%, respectively. Computed tomography colonography was the preferred method of investigation for 85% of patients. The preparation was reported to cause only mild discomfort for 97.6% of patients. According to the questionnaires, there was no significant relationship between colonic distension and discomfort (p>0.05). Most patients (89%) achieved excellent bowel preparation. There was a statistically significant correlation between the confidence perceived in reading the computed tomography colonography and the quality of the preparation in each colonic segment (p≤0.001). The average effective radiation dose per exam was 7.8 mSv. CONCLUSION: It was possible to institute an efficient computed ...

Colonografia por tomografia computadorizada versus colonoscopia óptica no rastreamento do câncer colorretal: uma revisão sistemática / Computed tomographic colonography versus optical colonoscopy in colorectal cancer screening: a systematic review

Objetivo: comparar, por meio de uma revisão sistematizada, a colonografia por tomografia (CTC) versus colonoscopia óptica (CO) em relação ao rastreamento e vigilância do câncer colorretal (CCR). Método: foram analisados estudos em inglês e português sobre CTC e CO realizados em humanos adultos de ambos os sexos, publicados no MedLine/PubMed (National Library of Medicine) e no Scielo (Scientific Eletronic Library Online) no período entre 1990 a 2013. A busca incluiu combinações de palavras-chave (Colonoscopy, Cólonoscopic surgery, virtual Colonoscopy, CT Colonography) com boolianos AND e OR. Os critérios de inclusão foram ensaios clínicos controlados e randomizados, estudo de revisão, revisões sistemáticas com ou sem metanálise, consenso, pacientes adultos, pacientes assintomáticos ou sintomáticos. Os critérios de exclusão foram pacientes inapropriados e somente em resumo. Resultados: foram selecionados 26 estudos com melhor abordagem dos desfechos selecionados para rastreamento e vigilância do câncer (CCR). O número global de pacientes submetidos às variáveis foi de 397.342 indivíduos. Os valores das variáveis de sensibilidade e especificidade para detecção de pólipos maior ou igual a 10mm e câncer colorretal apresentam percentagens semelhantes, sendo a taxa de sensibilidade da CTC diretamente proporcional ao tamanho do pólipo. A taxa de pacientes submetidos à CO após a CTC variou de 12% a 36,4%; destes, 3,8% apresentaram lesões significativas. A análise da taxa de CO incompleta obteve um padrão de variações entre 11% e 64,8%. A aceitação dos pacientes, tanto para o preparo intestinal como para o procedimento, foi maior para a CTC. Os achados extracólicos nos pacientes submetidos à CTC foram analisados e variaram de 58 a 69%. As complicações dos dois métodos foram baixas, maior na CO. Conclusão: as diferenças na sensibilidade e especificidade entre a CO e a CTC no rastreamento e vigilância do CCR não são relevantes. A indicação de CO após CTC deve seguir critérios consensuais para evitar aumento de custos e de riscos ao paciente. Pacientes com CO incompleta têm indicação de realizar CTC por se enquadrar no grupo de alto risco para desenvolver CCR. A aceitação dos pacientes na realização dos dois métodos é boa e não representa impedimento ao rastreamento e vigilância do CCR. Os achados extracólicos na CTC é um benefício adicional para o paciente. As complicações inerentes aos dois métodos não superam o impacto positivo dos mesmos na prevenção do CCR.

Objective: to compare in a systematic review the computed tomographic Colonography (CTC) and the optical Colonoscopy (OC) methods for the screening and monitoring of colorectal cancer (CRC). Method: english and portuguese studies on CTC and OC that were carried out on adult humans of both genders that had been published in MedLine/PubMed (National Library of Medicine) and SciELO (Scientific Electronic Library Online) between 1990 and 2013 were analyzed. The search included combinations of keywords (Colonoscopy, Cólonoscopic surgery, virtual Colonoscopy, CT Colonography, etc.) with the AND and OR Boolean operators. The inclusion criteria were as follows: controlled and randomized clinical trials, review studies, systematic reviews with or without meta-analysis, consensus, adult patients, and asymptomatic or symptomatic patients. The exclusion criteria were as follows: unsuitable patients and manuscripts only containing abstracts. Results: twenty-six studies that included the selected outcomes for screening for and monitoring CRC were selected. The overall number of patients analyzed was 397, 342 individuals. The sensitivity and specificity percentages for the detection of polyps greater than or equal to 10 mm and for colorectal cancer were similar between the two methods, and the CTC sensitivity rate was directly proportional to the size of the polyp. The rate of patients undergoing OC after CTC ranged from 12% to 36.4%, and of these patients, 3.8% had significant lesions. The analysis of the incomplete OC rate found variation ranging from 11 to 64.8%. The acceptance rates of the patients for both intestinal preparation and for the procedure were greater for CTC. The extracolic findings in patients undergoing CTC were analyzed and ranged from 58 to 69%. Complications were minimal for the patients undergoing both methods and higher for those in the OC group. Conclusion: the differences in the sensitivity and specificity of OC and CTC in screening and monitoring CRC are not significant. The indication of OC after CTC must follow agreed-upon criteria to avoid increased costs and risks to the patient. Patients with an incomplete OC should undergo CTC, as they fall within the high risk group for developing CRC. The acceptance of patients undergoing the two methods is good and does not represent an impediment to screening for and monitoring CRC. The extracolic findings, in the CTC group, is an additional benefit to the patient. The complications inherent in the two methods do not outweigh their positive impacts in the prevention of CRC.

Utilidad de la cromoscopia virtual computarizada en la detección de lesiones planas colorectales / Computerized virtual chromoscopy utility in flat colorectal lesions

Las lesiones planas están asociadas con mayor frecuencia a la presencia de carcinoma invasor superficial. La magnificación endoscópica permite el análisis detallado de la superficie mucosa de lesiones sospechosas y predecir, por sus características morfológicas, si son lesiones benignas o malignas, permitiendo decidir conducta terapéutica al momento del estudio. Los tumores de diseminación lateral de colon y recto, son lesiones >10mm con bajo eje vertical extendidas lateralmente a lo largo de la pared luminal. Okamoto describe dos grupos: tipo granular, endoscópicamente numerosos nódulos de color homogéneo en comparación con mucosa colónica circundante; tipo plano, lesiones con superficie plana en ausencia de formación de gránulos nodulares. Establecer utilidad de la cromoendoscopia virtual computarizada y magnificación (FICE) para la determinación de las lesiones detectadas en estudios de video colonoscopia; decidir en el momento del procedimiento, la conducta a seguir. Se utilizó el modelo de clasificación de Paris en las lesiones colorectales detectadas. Estudio retrospectivo y descriptivo en pacientes que acudieron a una consulta de centro privado, en el período Enero 2009-Marzo 2012, realizándoles video colonoscopia con FICE, con equipo Fujinon EPX-4400, por un mismo endoscopista. Se revisaron 1298 video colonoscopias, 269 casos con lesiones planas en colon de los cuales 17 (6.31%) fueron lesiones tipo II (diseminación lateral); 9 del sexo femenino (52.94%) y 8 masculino (47.05%); 7 fueron lesiones IIa no granular (41.17%), 7 IIa granular (41.17%), 2 IIc no granular (11.76%) y 1 IIc granular (5.88%). En relación a la ubicación 5 casos (29.41%), en transverso; 4 casos (23.52%) tuvieron resección endoscópica y 13 casos (76.47%) fueron referidos para resolución quirúrgica de los cuales, histológicamente: 7 fueron tubulovellosos (41,18%) y 1 de estos presentó displasia de alto grado y los 6 restantes de bajo grado....

The flat lesions are associated with a high incidence of invasive superficial carcinoma; the endoscopic magnification allows a more detailed evaluation of the superficial lesions and can predict if they will be or not malignant, allowing to take a therapeutic decision at the moment of the videocolonoscopy. These tumours are lesions no more than 10 mm, whit a low vertical axis wich extents laterally along the lumen of the colon. Okamoto describes two groups: Granular type Endoscopically are numerous nodules with the same color compared with the surrounding colonic mucosae; and the Flat type which are flat lesions without presence of nodules. To establish the utility of the virtual computerized chromoendoscopy and magnification (FICE)® in the evaluation of lesions detected in videocolonoscopies performed and in order to take a therapeutic decision. We used the Paris model for the classification of the colorectal lesions encountered at the time of the colonoscopy. We performed a retrospective and descriptive study in patients who evaluated in a private office between January 2009-March 2012, a videcolonoscopy with FICE® using a videocolonoscope Fujinon EPX 4400 ® all studies were performed by the same operator. 1298 videocolonoscopies were performed, 269 cases with flat lesions, 17 (6.31%) were lesions type II (lateral spread), 9 were females (52,94%) and 8 males (47,05%), 7 were lesions type IIa, non granular (41,17%), 7 IIa granular (41,17%), 2 IIc non granular (11,76%), and 1 IIc granular (5,88%), 5 cases (29,41%) were located in transverse colon, 4 (23,52%) were successfully removed endoscopically , and 13 (76,47) were referred for surgical treatment, in relation with the histopathology: 7 were tubulovillous (41,18%), and 1 associated with high degree dysplasia and 6 low degree dysplasia. Our study demonstrates, the usefulness of the FICE® in the detection of flat lesions and permits obtain samples for biopsy and make therapeutic decisions

Diagnóstico y tratamiento de las complicaciones biliares asociadas al trasplante hepático / Diagnosis and treatment of biliary complications associated with liver transplantation

Las complicaciones biliares se presentan en 10 - 25% de los pacientes que reciben un trasplante hepático y pueden causar una importante morbilidad e incluso la pérdida del injerto. Las complicaciones más comunes son la estenosis biliar (anastomótica y no anastomótica), fuga biliar y litiasis biliar. La gran mayoría de estas complicaciones puede tratarse con éxito mediante colangiopancreatografía retrógrada endoscópica. Esta revisión se centra en el diagnóstico, factores de riego y tratamiento endoscópico de las complicaciones biliares asociadas al trasplante hepático

Biliary complications ocurr in 10 - 25% of liver transplant recipients and are associated to a significant morbidity and the possibility of graft failure. The most common biliary complications are strictures (both anastomotic and non-anastomotic), bile leaks and stones. Most of these complications can be appropriately managed with endoscopic retrograde cholangiopancreatography. This article will review the diagnosis, risk factors, and endoscopic management of biliary complications related to liver transplantation

Plataforma colaborativa multimídia para apoio ao diagnóstico de lesões bucais em ambientes de teleodontologia / Collaborative multimedia platform to support oral diagnosis in teledentistry environments

Este artigo tem por objetivo apresentar uma solução tecnológica desenvolvida para permitir atividades colaborativas de diagnóstico de lesões bucais em ambientes de Teleodontologia. Trata-se de uma plataforma totalmente baseada na web e que permite o gerenciamento e compartilhamento de imagens clínicas, radiográficas e histopatológicas, dispensando a instalação de qualquer programa adicional no computador do usuário. Como suporte à colaboração através do navegador, as ações efetuadas por um usuário são replicadas e visíveis ao outro usuário conectado, sendo possível a discussão e troca de informações sobre o caso através de chat e/ou áudiovideoconferência. Ferramentas de Telessaúde podem ofereçe diferentes oportunidades para assistência e educação em Odontologia. Ao permitir a visualização de diferentes aspectos da doença do paciente, a solução aqui apresentada tem potencial para viabilizar: (1) a troca de informações entre profissionais de saúde atuantes em distintos níveis de assistência e (2) a tutoria, à distância, nos diferentes níveis de formação (graduação, pós-graduação e educação continuada) (AU).

This paper presents a technological solution developed to enabling collaborative activities in Teledentistry environments. This is a platform composed by a set of tools for the management and sharing of clinical, radio graphic and histopathologic images. The proposed solution is fully web-based, requiring only a web browser installed; it's not necessary to install any other software on the user's computer. As collaboration support, the actions performed by a user with mouse and keyboard are replicated and visible to the other connected user. This toolkit allows the discussion of disease via chat and/or videoconferen ing. Telehealth's tools offer opportunities for assistance and education in Dentistry. By allowing realtime viewing and discussion of different aspects of a disease this technological solution has potential to facilitate: (1) exchange of information between health professionals at different levels of assistance and (2) distance tutoring at different levels of training (undergraduate, postgraduate and continuing education) (AU).

Utilidad del patrón capilar con NBI en el diagnóstico de las lesiones superficiales del colon: estudio prospectivo de validación en un centro endoscópico privado de Lima, Perú / Utility of the capilar pattern in the NBI diagnosis of superficial lesions of the colon: prospective validation in a private endoscopy center in Lima, Peru

INTRODUCCION: La detección y resección de los adenomas es importante para prevenir el cáncer colorrectal. La angiogénesis es un factor primordial en el crecimiento tumoral y la endoscopía con imagen de banda estrecha (NBI) permite una mejor evaluación del patrón capilar de la mucosa. OBJETIVO: Presentar nuestra experiencia en la diferenciación de las lesiones superficiales del colon, utilizando colonoscopía con NBI y la clasificación de Sano û Emura. MATERIAL & MÉTODOS: Estudio prospectivo realizado en Lima, Perú. Tres endoscopistas evalúan en tiempo real el patrón capilar de las lesiones, usando NBI con magnificación electrónica, y sus diagnósticos se correlacionan con el resultado histopatológico. RESULTADOS: se incluyen 380 pacientes con 739 lesiones; 473 adenomas, 241 pólipos no neoplásicos y 25 lesiones aserradas. Son divididas, por su patrón capilar al NBI, en dos grupos: Neoplásicas (Sano -Emura tipo II, IIIa y IIIb) y No Neoplásicas (Sano-Emura tipo I). Sensibilidad para adenomas: 84%, precisión diagnóstica: 77%, VPP: 82%, VPN: 67% y especificidad: 63%. La sensibilidad y la precisión diagnóstica aumentan a 94% y 84% en lesiones de 5 a 9 mm. En lesiones diminutas del recto-sigmoides, el VPN para adenomas mejora a 81%. Para las lesiones aserradas estos índices solo alcanzan el 50%. CONCLUSIONES: El NBI con magnificación electrónica resultó útil en la diferenciación de las lesiones de 5 mm o mayores, con resultados similares a estudios publicados. En lesiones menores de 5mm disminuyó la exactitud. Las lesiones aserradas no pudieron ser diferenciadas con NBI.

INTRODUCTION: It is important to detect and remove adenomas in order to prevent colon cancer. Angiogenesis is an early change in the pre malignant transformation sequence and narrow band imaging (NBI) allows for better visualization of the capillary pattern of the mucosa. OBJECTIVE: We present our data regarding the assessment of superficial lesions of the colon on colonoscopies using NBI as well as the Sano-Emura classification. MATERIALS & METHODS: Prospective study done in Lima Peru. Three endoscopists evaluate the capillary pattern of colonic lesions in real time using NBI and electronic magnification. These findings are then compared to the pathology report. RESULTS: 380 patients were evaluated with a total of 739 lesions; 473 adenomas, 241 non neoplastic lesions, and 25 serrated lesions. These were grouped depending on their NBI capillary pattern into two groups: Neoplastic (Sano-Emura types II, IIIa, and IIIb), and Non-Neoplastic (Sano-Emura type I). Sensitivity for adenomas 84%, diagnostic accuracy 77%, PPV 82%, NPV 67%, specificity 63%. Sensitivity and diagnostic accuracy improved to 94% and 84%, respectively when evaluating lesions of 5mm to 9mm. For diminutive rectosigmoid polyps, the NPV for adenomas was 81%. The serrated lesions showed both types of capillary pattern with equal frequency. CONCLUSIONS: Our results using NBI with electronic magnification showed that this method is useful for the differentiation of lesions 5 mm or bigger, as reported previously. Accuracy was diminished when evaluating lesions less than 5mm. NBI was not capable of aiding in the differential diagnosis of serrated lesions.

Enterotomografía en la enfermedad de Crohn / CT enterography in Crohn's disease

Objetivos de aprendizaje. Definir el aporte de la enterotomografía (ETC) para el diagnóstico, control y pronóstico de la enfermedad de Crohn (EC) y detallar su forma de adquisición. Compararlo con otros métodos de diagnóstico utilizados para el estudio del intestino delgado y establecer sus ventajas y desventajas. Revisión del tema. La EC es una enfermedad inflamatoria intestinal crónica, que afecta a todo el tubo digestivo de forma discontinua y transmural. Son objetivos a determinar el compromiso del intestino delgado, el diagnóstico de la etapa aguda de la enfermedad y su respuesta al tratamiento. El curso de la enfermedad,sus complicaciones (sangrado, obstrucción, estrangulamiento, abscesos y fístulas) y la severidad de los síntomas presentan una evolución variable. El diagnóstico inicial se basa en la combinación de la clínica, los hallazgos endoscópicos, bioquímicos y radiológicos. Hallazgos en imágenes. Los hallazgos característicos de la enfermedad estudiada con ETC son: aumento del realce mural e imágenes ganglionares con realce luego del contraste E.V. (ambos signos de actividad), incremento del espesor parietal y signo del halo (anillo hipodenso por depósito graso en la submucosa), proliferación de la grasa mesentérica, prominencia de los vasos rectos, áreas de estenosis, fístulas y abscesos.Conclusión. La ETC es un método accesible y fácil de emplear. Permite determinar la extensión y fase de progresión de la enfermedad, el compromiso extraintestinal y las eventuales complicaciones. La combinación de un tiempo corto de examen, una única respiración sostenida, la accesibilidad y disponibilidad del método le otorgan un rol importante en el diagnóstico y seguimiento de estos pacientes...

Aspectos comuns e pseudolesões na colonografia por tomografia computadorizada: ensaio iconográfico / Common findings and pseudolesions at computed tomography colonography: pictorial essay

A colonografia por tomografia computadorizada é um método minimamente invasivo para rastreamento de pólipos e do câncer colorretal, com complicações extremamente incomuns, sendo cada vez mais utilizada na prática clínica. Na última década, a evolução no preparo intestinal, na aquisição das imagens e no treinamento dos examinadores determinou um aumento significativo na sensibilidade do método. A interpretação das imagens é realizada por meio da análise combinada das imagens fontes bidimensionais e de diversos tipos de reconstruções tridimensionais, com sensibilidade ao redor de 96% na detecção de lesões com dimensões iguais ou maiores que 10 mm, quando analisadas por radiologistas experientes. Neste ensaio pictórico selecionamos exemplos ilustrativos das doenças e pseudolesões mais frequentemente observadas neste tipo de exame. Apresentamos exemplos de lesões polipoides e planas, benignas e malignas, moléstia diverticular dos cólons, entre outras afecções, bem como pseudolesões, entre as quais aquelas relacionadas a preparo inadequado e interpretação equivocada.

Computed tomography colonography is a minimally invasive method for screening for polyps and colorectal cancer, with extremely unusual complications, increasingly used in the clinical practice. In the last decade, developments in bowel preparation, imaging, and in the training of investigators have determined a significant increase in the method sensitivity. Images interpretation is accomplished through a combined analysis of two-dimensional source images and several types of three-dimensional renderings, with sensitivity around 96% in the detection of lesions with dimensions equal or greater than 10 mm in size, when analyzed by experienced radiologists. The present pictorial essay includes examples of diseases and pseudolesions most frequently observed in this type of imaging study. The authors present examples of flat and polypoid lesions, benign and malignant lesions, diverticular disease of the colon, among other conditions, as well as pseudolesions, including those related to inappropriate bowel preparation and misinterpretation.

Colonoscopia virtual: papel en el screening del cáncer colorrectal / Virtual colonoscopy: role in colorectal cancer screening

La colonoscopia virtual (CV) desempeña dos papeles en el screening del cáncer colorrectal (CCR): uno indiscutidoy otro que plantea un debate, aun entre las diferentes sociedades gastroenterológicas, radiológicasy de cáncer más representativas del mundo.El papel que no genera discusión es la clara superioridad (avalada por numerosa evidencia en la literatura) de la CV sobre el estudio colon por enema (CXE) en la detección de CCR y pólipos. Tampoco plantea debate su integración en programas de screening, como reemplazo del CXE en el caso de una colonoscopia convencional (CC) incompleta. El papel que sí es discutido es el avalado por la American Cancer Society (ACS), la US Multi-Society TaskForce on Colorectal Cancer y el American College of Radiology (ACR) que incluye la CV en el grupo deestudios (junto con la CC, la sigmoidoscopia y el CXE) como método diagnóstico en el screening del CCR enpacientes de riesgo promedio, para ser realizado cada 5 años a partir de los 50 años. Algunas sociedades, como el American College of Gastroenterology o el Asia Pacific Working Group onColorectal Cancer, consideran la CV como un método de segunda línea para aquellos pacientes reacios a realizaruna CC o con CC incompletas.Ya sea con un papel discutido u otro más cuestionado, lo cierto es que la CV se viene utilizando y se utiliza cada vez más y no podemos dejar de conocer cómo se realiza, cuáles son sus ventajas, limitaciones y eficaciadiagnóstica. Desde el año 2007 se vienen realizando en el Servicio de Diagnóstico por Imágenes del Hospital Italiano de Buenos Aires un promedio de 950 estudios por año. Y es importante recalcar que la CV no compite con laCC sino que la complementa. El objetivo del presente artículo es: explicar y dar a conocer en qué consiste el métodoy cómo se realiza e interpreta, mostrar sus ventajas, limitaciones y eficaciadiagnóstica.

Preferência do paciente no rastreamento do câncer colorretal: uma comparação entre colonografia por tomografia computadorizada e colonoscopia / Patient preferences toward colon cancer screening: a comparison between computed tomography colonography and conventional colonoscopy

OBJETIVO: Avaliar o grau de aceitação do paciente submetido a colonografia por tomografia computadorizada (CTC) em comparação com a colonoscopia, quando realizadas para rastreamento de doença colorretal. MATERIAIS E MÉTODOS: Cinquenta pacientes com suspeita de doença colorretal foram submetidos a CTC e colonoscopia. Questionários foram aplicados antes e após a realização da CTC e após a colonoscopia. Graduou-se o desconforto esperado e experimentado antes e após a realização da CTC e da colonoscopia, bem como a preferência do paciente por exame. RESULTADOS: Em relação à CTC, antes de iniciar o exame 18 por cento dos pacientes afirmaram esperar pouco desconforto, 78 por cento, desconforto moderado e 4 por cento, muito desconforto. Após a realização do exame, 72 por cento dos pacientes relataram pouco desconforto, 26 por cento, desconforto moderado e apenas um (2 por cento) dos pacientes referiu muito desconforto. Após a realização da colonoscopia, 86 por cento dos pacientes relataram preferência pela CTC. O grau de distensão colônica e a quantidade de fluido residual não influenciaram na preferência dos pacientes. CONCLUSÃO: Os pacientes preferiram a CTC à colonoscopia, não havendo relação estatística com o grau de distensão colônica na CTC e a eficiência do preparo intestinal.

OBJECTIVE: To assess the degree of acceptance of patients undergoing computed tomography colonography (CTC) in comparison with colonoscopy in the screening of colorectal disease. MATERIALS AND METHODS: Fifty patients with suspected colorectal disease underwent CTC and colonoscopy. Questionnaires were administered before and after the performance of the CTC and after the colonoscopy. The discomfort expected and experienced before and after the performance of both procedures as well as the patients' preference for each method were evaluated. RESULTS: As regards CTC, before the procedure, 18 percent of the patients reported expecting little discomfort, 78 percent, mild discomfort, and 4 percent, a lot of discomfort. After the procedure, 72 percent of the patients reported little discomfort, 26 percent, mild discomfort, and only one (2 percent) of the patients reported a lot of discomfort. Upon completion of the colonoscopy, 86 percent of the patients reported their preference for CTC. The degree of colonic distention and residual amount of fluid had no influence on the patients' preference. CONCLUSION: CTC was preferred to colonoscopy, with no statistical relationship with the degree of colonic distention at CTC and efficiency of bowel preparation.

Manejo conservador de las perforaciones post videocolonoscopías / Conservative management of colon perforations after videocolonoscopy

Introducción: La videocolonoscopía (VCC) es un procedimiento que permite examinar visualmente el interior del intestino. Se trata de un excelente método de diagnostico, pero al ser un estudio invasivo no esta exento de complicaciones. Es de vital importancia identificar precozmente aquellos pacientes con síntomas sugestivos de complicaciones. Debemos conocer los múltiples factores que predisponen a este tipo de eventos.Objetivos: Destacar la importancia del reconocimiento de los síntomas de perforaciones post VCC y la evaluación para el control y manejo conservador de esta entidad.Material y Métodos: Revisión de historias clínicas y bibliografía de pacientes con complicaciones post VCC.Resultados: Se registraron 265 videocolonoscopías, de las cuales se constataron 2 casos (0.7%) con complicaciones asociadas al procedimiento.Discusión: La conducta a seguir esta relacionada con el estado general de los pacientes. Ambos fueron procedimientos realizados de manera programada, con preparación satisfactoria y buen estado previo al procedimiento.

Introduction: Colonoscopy is a procedure that allows visual examination of the intestine. It’s an excellent method of diagnosis, but as an invasive study it is not free of complications.It’s important to identify precociously those patients with symptoms suggestive of complications. We must recognize multiple factors that lead to these complications.Objectives: To emphasize the importance of recognition of post colonoscopy perforations symptoms and the evaluation of conservative management of this entity.Material and Methods: Clinical cases and bibliographic review of colonoscopy complications.Results: There were registered 265 videocolonoscopies, of which 2 patients (0.7%) underwent procedure-related complications. Discussion: Management of these complications is related with patients general condition. Both of them were scheduled with satisfactory preparation and good general condition previously to procedure.

Experiencia con cromoendoscopia virtual computarizada (FICE) para la descripción y caracterización de lesiones colorectales / Experience with computed virtual chromoendoscopy (FICE) for description and characterization of colorectal lesions

La cromoendoscopia virtual computarizada es la técnica de estimación espectral basada en el procesamiento aritmética de imágenes capturadas por el video endoscopio. Este estudio incluye 247 pacientes a quienes se le realizó Colonoscopia en el período comprendido entre Abril 2007 y Mayo 2009 (83/33,5 % hombres, 164/66,5 % mujeres). La comparación fue realizada entre la visualización endoscópica con FICE, las imágenes grabadas y el diagnóstico histológico final realizado mediante biopsias, polipectomia o mucosectomia evaluados por dos patólogos expertas en patología gastrointestinal. La aplicación de esta nueva técnica combinada con magnificación constituye un área prometedora en la descripción de cambios patológicos mínimos de la mucosa y microvasculares. Permite incrementar la correlación entre las imágenes endoscópicas y los resultados histopatologicos.

The computed virtual chromoendoscopy imaging technique is based on narrowing the bandwidth of the conventional endoscopic image arithmetically, using spectral estimation technology. This study includes 247 consecutive patients (83/33.5% males, 164/66.5% females) who had a colonoscopy performed between April 2007 and May 2009. A comparison was made between direct visualization with FICE and recorded images and the fi nal diagnosis made by biopsy, polipectomy or endoscopic mucosal resection. The sampling was evaluated by two experts’ GI pathologist. The application of this new technology combined with high resolution endoscopy has promising areas of development in the description of pathologic mucosal changes and microvessels. This advanced technology allows an increased correlation between the images processed and the histological results.

Performance of computed tomographic colonography for the screening of colorectal polyp in acromegalic patients: a prospective study / Desempenho da colonografia tomográfica computadorizada para o rastreamento de pólipo colorretal em pacientes acromegálicos: um estudo prospectivo

CONTEXT: Acromegalic patients have better chances to develop colorectal polyps and cancer and, considered a high-risk group, need to undergo frequent screening examinations. Moreover, in acromegalia, the increased bowel length and the intestinal loop complexity can lead to higher levels of technical difficulties and increase the risks of complications at conventional colonoscopy. Computed tomographic colonography, also known as virtual colonoscopy, is an innovative and secure technology which is revolutionizing the diagnosis of colon and rectum neoplasias. OBJECTIVE: To analyze computed tomographic colonography performance for the screening of colorectal polyps in acromegalic patients. METHODS: A prospective study of 21 asymptomatic acromegalic patients, 12 male and 9 female, average age 49, who underwent computed tomographic colonography and conventional colonoscopy. Computed tomographic colonography was performed with a GE Helical Multislice Computed Tomography Apparatus. Conventional colonoscopy was performed in the same day, without previous knowledge of the computed tomographic colonography diagnostics. The study evaluated the capacity of computed tomographic colonography to detect patients with colorectal polyps and identify each colorectal lesion described by the colonoscopy. RESULTS: In two patients (2/21), conventional colonoscopy was incomplete. However, in all patients computed tomographic colonography was complete. In Phase I ("per patient"), computed tomographic colonography diagnosed eight of the nine patients with colorectal polyps and showed 88 percent sensitivity, 75 percent specificity and 81 percent accuracy. In Phase II ("per polyp"), out of the 21 acromegalic patients included in this study, 12 presented normal findings at conventional colonoscopy. A total of 19 polyps were identified in 9 patients. Ten of the 19 polyps were smaller than 10 mm, and 9 were equal to or larger than 10 mm. Computed tomographic colonography...

CONTEXTO: Pacientes com acromegalia apresentam maiores chances de desenvolver pólipo e câncer colorretal e, sendo considerados integrantes do grupo de risco, necessitam serem submetidos aos exames de rastreamento. Por sua vez, na acromegalia, o maior comprimento do cólon e a formação de alças intestinais complexas podem prever maiores dificuldades técnicas e aumentar o risco em potencial de complicações durante o exame de colonoscopia convencional. A colonografia tomográfica computadorizada, também denominada colonoscopia virtual, é uma tecnologia inovadora e segura, que está revolucionando o diagnóstico das neoplasias do cólon e do reto. OBJETIVO: Analisar o desempenho da colonografia tomográfica computadorizada no rastreamento de pólipos colorretais em pacientes com acromegalia. Métodos - Estudo prospectivo com 21 pacientes acromegálicos, 12 do sexo masculino e 9 do sexo feminino, idade média de 49 anos, assintomáticos, submetidos a colonografia tomográfica computadorizada e colonoscopia convencional. A colonografia tomográfica computadorizada foi realizada com aparelho de tomografia computadorizada helicoidal multislice da marca GE. A colonoscopia convencional foi realizada, no mesmo dia, sem prévio conhecimento do diagnóstico da colonografia tomográfica computadorizada. O estudo avaliou a capacidade da colonografia tomográfica computadorizada para detectar pacientes acromegálicos com pólipos colorretais e a identificação de cada lesão colorretal descrita pela colonoscopia. RESULTADOS: Em dois pacientes (2/21) a colonoscopia convencional foi incompleta. Entretanto, em todos os pacientes a colonografia tomográfica computadorizada foi completa na avaliação colorretal. Na primeira fase ("por paciente"), a colonografia tomográfica computadorizada diagnosticou oito de nove pacientes com pólipos colorretais e mostrou 88 por cento de sensibilidade, 75 por cento de especificidade e 81 por cento de precisão. Na segunda fase ("por pólipo")...

Avaliação do desempenho da colonografia tomográfica computadorizada (colonoscopia virtual) no diagnóstico de pólipos colorretais / Evaluation of computed tomographic colonography for detection of colorectal polyps

RACIONAL: A colonografia tomográfica computadorizada tem sido proposta como teste substituto da colonoscopia para o diagnóstico de pólipos colorretais em programas de rastreamento de câncer de intestino grosso. OBJETIVO: Avaliar o desempenho da colonografia tomográfica computadorizada na detecção de pólipos colorretais, considerando a colonoscopia como padrão-ouro. MÉTODOS: Foram estudados 20 pacientes com alto risco para neoplasia colorretal (14 homens e 6 mulheres com idades médias de 55 e 59 anos, respectivamente). A colonografia tomográfica computadorizada foi realizada até 3 horas antes da colonoscopia. Um cateter com balão foi introduzido no reto com insuflação dos cólons e do reto com ar ambiente até que fosse obtida distensão satisfatória dos mesmos. Para otimizar a distensão colônica, minimizar artefatos decorrentes da peristalse e diminuir o espasmo, foram administrados 20 mg de hioscina intravenosa imediatamente antes do exame radiológico. RESULTADOS: A imagem radiológica do cólon foi considerada de qualidade satisfatória em todos os casos. A colonoscopia detectou o total de 85 pólipos em 19 dos 20 pacientes (95 por cento). Todos os pólipos observados foram removidos e encaminhados para exame anatomopatológico. A colonografia tomográfica computadorizada identificou 8 dos 10 pólipos com diâmetros > 10 mm (80 por cento), 2 dos 19 com diâmetro entre 5 e 9 mm (18,2 por cento), e apenas 1 dos 53 <5 mm (9,1 por cento). Dos 43 pólipos adenomatosos, 17 eram > 5 mm. Destes, 8 (47 por cento) foram corretamente identificados pela colonografia tomográfica computadorizada. Nenhuma das neoplasias com diâmetros <5mm foi observada no exame radiológico. Dezenove dos 20 pacientes (95 por cento) submetidos a ambos os testes prefeririam submeter-se a nova colonoscopia, ao invés de uma colonografia tomográfica computadorizada, na eventualidade hipotética de ser necessário repetir um dos dois testes. CONCLUSÃO: Para pacientes com risco aumentado...

BACKGROUND: Computed tomographic colonography has been proposed for detection of colorectal polyps instead of colonoscopy in colorectal cancer screening programs. AIM: To evaluate the performance of computed tomographic colonography in the detection of colorectal polyps with colonoscopy used as the gold standard. METHODS: We prospectively studied 20 patients at high risk for colorectal neoplasia (14 men and 6 women; mean age, 55 years and 59 years). Computed tomographic colonography was performed immediately before colonoscopy. We inserted a rectal balloon catheter and insufflated the colon with room air to the level that a good distension was observed. Twenty milligrams of hioscin was given immediately before computed tomographic imaging of the abdomen and pelvis in order to minimize the degree of smooth-muscle spasm and peristalsis and to reduce the patient's discomfort. RESULTS: Computed tomographic colonography images were considered satisfactory in all cases. Colonoscopy detected 85 polyps in 19 of 20 patients (95 percent). All the observed polyps were successfully removed and examined histologically. The radiological examination correctly identified 8 of 10 polyps 10 mm or more in diameter, 2 of 19 (18,2 percent) with 5-9 mm, and just 1 of 53 <5mm (9,1 percent). Seventeen of the 43 adenomatous polyps were > 5 mm. Eight (47 percent) were correctly identified on computed tomographic colonography. None of the neoplasias <5 mm were identified on colonography. Nineteen patients preferred colonoscopy in the event of having to repeat on of the two examinations. CONCLUSION: For the detection of colorectal polyps, computed tomographic colonography seems to be useful only when the result is positive, as the negative results of this examination cannot eliminate the presence of these lesions.