Endoscopic Ultrasound-Guided Ethanol Injection Associated with Trans-arterial Embolization of a Giant Intra-abdominal Cavernous Hemangioma: Case Report and New Therapeutic Option.

BACKGROUND: Cavernous hemangiomas are congenital hamartomatous lesions that originate from mesodermal tissue composed of dilated blood vessels. Abdominal pain and palpable mass are the most common presenting symptoms. The different types of treatment for symptomatic patients remain controversial. However, surgical resection is always the most preferred method when possible. To date, there are no reports of endoscopic ultrasound-guided (EUS-guided) absolute ethanol injection as a treatment for such disease when surgery is not an option. CASE PRESENTATION: A 19-year-old girl with giant cavernous intra-abdominal hemangioma extending to the hepatic hilum, also affecting the gastric wall and occupying the entire supra-mesocolic cavity, initially presents with upper gastrointestinal bleeding and loss of 20 kg in 1 year (BMI = 18 kg/m2). Percutaneous angiography identified a mass with arterial blood supply by the left gastric artery that was embolized. After re-bleeding, an alternative treatment with EUS-guided injection of alcohol was proposed once resection was not feasible without major risks to a young patient. This procedure was repeated 15 and 45 days after the initial treatment, with the ethanol injection of 25 cc and 15 cc, respectively. On the second and third procedure dates, there was evident regression of the hemangioma. On the third procedure, it was possible to identify all anatomic structures that were not clear on the first EUS. After 45 days of last injection, abdominal CT and EUS showed notorious regression of the lesion. Eight months later, abdominal CT showed only a remnant lesion in the hepatogastric ligament with 129 cm3 on volumetry (87% lower in comparison to the initial image), and the patient remains asymptomatic with BMI of 26. In the most recent follow-up CT, 4 years and 2 months after first treatment, the patient presents with a slight increase in the hemangioma-now with 183 cm3 on volumetry. CONCLUSION: Transgastric EUS-guided ethanol injection in the treatment of giant intra-abdominal cavernous hemangioma can provide good outcomes without major complications and can be repeated if necessary.

Elevated Gastric Antrum Erosions in Portal Hypertension Patients: Peptic Disease or Mucosal Congestion?

BACKGROUND/AIMS: Portal hypertension (PH) is a syndrome characterized by chronic increase in the pressure gradient between the portal vein and inferior vena cava. Previous studies have suggested an increased frequency of antral elevated erosive gastritis in patients with PH, as well as an etiologic association; however, there has not been any histological evidence of this hypothesis to date. Our aim was to evaluate the histological features found in elevated antral erosions in patients with portal hypertension. METHODS: Sixty-nine patients were included; 28 with and 41 without PH. All patients underwent endoscopy, and areas with elevated antral erosion were biopsied. RESULTS: In the PH group, 24 patients had inflammatory infiltration with or without edema and vascular congestion, and 4 patients had no inflammation. In the group without PH, all patients showed inflammatory infiltration of variable intensity. There was no statistical significance between the two groups in the presence of Helicobacter pylori. There as a histological similarity between the two groups, if PH patients without inflammation were excluded; however, more edema and vascular congestion were observed in the PH group (p=0.002). CONCLUSIONS: The findings show that elevated antral erosions in patients with PH have more evident edema and vascular congestion in addition to lymphocytic infiltration.

EVALUATION OF UPPER GASTROINTESTINAL ENDOSCOPY IN PATIENTS UNDERGOING BARIATRIC SURGERY.

BACKGROUND: Obesity has become epidemic, and is associated with greater morbidity and mortality. Treatment is multidisciplinary. Surgical treatment is a consistent resource in severe obesity. The indication of preoperative upper gastrointestinal endoscopy in asymptomatic patients is controversial; however, most studies recommend its implementation in all patients. AIM: To analyze endoscopic performance in patients who were in preoperative for bariatric surgery and compare them with control group. METHOD: A series of 35 obese patients in preoperative period for bariatric surgery compared with a control group of 30 patients submitted to upper endoscopy. There were analyzed clinical and endoscopic data. RESULTS: The mean age of the group of patients was 43.54 years. Most individuals in the group of patients were female with median BMI of 47.26 kg/m2 and in control group 24.21 kg/m2. The majority of patients were asymptomatic. Upper endoscopy was altered in 81.25% of asymptomatic patients. Endoscopic findings in the patient group were 57.1% resulting from peptic ulcer disease and 34.3% associated with GERD. The analysis of endoscopic findings in patients showed no significant difference in relation of the control group. The prevalence of H. pylori infection was 60% in patients. CONCLUSION: It is recommended that the upper endoscopy should be made in all patients in the preoperative bariatric surgery period, although the degree of obesity is not related to a greater number of endoscopic findings. Obese patients do not have more endoscopic findings that non-obese individuals.

EVALUATION OF UPPER GASTROINTESTINAL ENDOSCOPY IN PATIENTS UNDERGOING BARIATRIC SURGERY / ANÁLISE DOS RESULTADOS DA ENDOSCOPIA DIGESTIVA ALTA NOS PACIENTES EM PRÉ-OPERATÓRIO DE CIRURGIA BARIÁTRICA

Background: Obesity has become epidemic, and is associated with greater morbidity and mortality. Treatment is multidisciplinary. Surgical treatment is a consistent resource in severe obesity. The indication of preoperative upper gastrointestinal endoscopy in asymptomatic patients is controversial; however, most studies recommend its implementation in all patients.Aim: To analyze endoscopic performance in patients who were in preoperative for bariatric surgery and compare them with control group.Method: A series of 35 obese patients in preoperative period for bariatric surgery compared with a control group of 30 patients submitted to upper endoscopy. There were analyzed clinical and endoscopic data.Results: The mean age of the group of patients was 43.54 years. Most individuals in the group of patients were female with median BMI of 47.26kg/m2and in control group 24.21 kg/m2. The majority of patients were asymptomatic. Upper endoscopy was altered in 81.25% of asymptomatic patients. Endoscopic findings in the patient group were 57.1% resulting from peptic ulcer disease and 34.3% associated with GERD. The analysis of endoscopic findings in patients showed no significant difference in relation of the control group. The prevalence of H. pylori infection was 60% in patients.Conclusion: It is recommended that the upper endoscopy should be made in all patients in the preoperative bariatric surgery period, although the degree of obesity is not related to a greater number of endoscopic findings. Obese patients do not have more endoscopic findings that non-obese individuals.

Racional: A obesidade tornou-se epidemia e está associada à maior morbimortalidade. Seu tratamento é multidisciplinar. O tratamento cirúrgico é recurso consistente nos casos de obesidade grave. A indicação da endoscopia digestiva alta pré-operatória em pacientes assintomáticos é controversa; no entanto, a maioria dos estudos recomenda sua realização em todos os pacientes.Objetivo: Analisar os resultados da endoscopia em pacientes que se encontravam em pré-operatório de cirurgia bariátrica, e compará-los aos achados do grupo controle.Método: Série de 35 pacientes obesos em pré-operatório de cirurgia bariátrica com um grupo controle de 30 pacientes submetidos à endoscopia no período de fevereiro a julho de 2014. Foram analisados dados clínicos e endoscópicos.Resultados:A média de idade do grupo de pacientes foi de 43,54 anos e a maioria deste grupo era do sexo feminino. A média do valor do IMC no grupo de pacientes foi de 47,26 kg/m2 e no grupo controle de 24,21 kg/m2. A maioria dos pacientes era assintomática. A endoscopia estava alterada em 81,25% dos pacientes assintomáticos. As alterações endoscópicas no grupo de pacientes foram 57,1% decorrentes da doença ulceropéptica e 34,3% associadas à DRGE. A análise do número de achados endoscópicos no grupo de pacientes em relação ao grupo controle não demonstrou diferença estatística significante. A prevalência da infecção do H. pylori foi de 60% no grupo de pacientes.Conclusão: Recomenda-se que a endoscopia digestiva alta deva ser realizada em todos pacientes em pré-operatório de cirurgia bariátrica, embora o grau de obesidade não tenha relação com maiores alterações endoscópicas. Os obesos não têm maior número de alterações endoscópicas que os não obesos.

Rectal cancer staging: Correlation between the evaluation with radial echoendoscope and rigid linear probe.

BACKGROUND AND OBJECTIVES: The National Cancer Institute estimated 40,340 new cases of rectal cancer in the United States in 2013. The correct staging of rectal cancer is fundamental for appropriate treatment of this disease. Transrectal ultrasound is considered one of the best methods for locoregional staging of rectal tumors, both radial echoendoscope and rigid linear probes are used to perform these procedures. The objective of this study is to evaluate the correlation between radial echoendoscopy and rigid linear endosonography for staging rectal cancer. PATIENTS AND METHODS: A prospective analysis of 48 patients who underwent both, radial echoendoscopy and rigid linear endosonography, between April 2009 and May 2011, was done. Patients were staged according to the degree of tumor invasion (T) and lymph node involvement (N), as classified by the American Joint Committee on Cancer. Anatomopathological staging of surgical specimen was the gold standard for discordant evaluations. The analysis of concordance was made using Kappa index. RESULTS: The general Kappa index for T staging was 0.827, with general P < 0.001 (confidence interval [CI]: 95% 0.627-1). The general Kappa index for N staging was 0.423, with general P < 0.001 (CI: 95% 0.214-0.632). CONCLUSION: The agreement between methods for T staging was almost perfect, with a worse outcome for T2, but still with substantial agreement. The findings may indicate equivalence in the diagnostic value of both flexible and rigid devices. For lymph node staging, there was moderate agreement between the methods.

Reliability in endoscopic diagnosis of portal hypertensive gastropathy.

AIM: To analyze reliability among endoscopists in diagnosing portal hypertensive gastropathy (PHG) and to determine which criteria from the most utilized classifications are the most suitable. METHODS: From January to July 2009, in an academic quaternary referral center at Santa Casa of São Paulo Endoscopy Service, Brazil, we performed this single-center prospective study. In this period, we included 100 patients, including 50 sequential patients who had portal hypertension of various etiologies; who were previously diagnosed based on clinical, laboratory and imaging exams; and who presented with esophageal varices. In addition, our study included 50 sequential patients who had dyspeptic symptoms and were referred for upper digestive endoscopy without portal hypertension. All subjects underwent upper digestive endoscopy, and the images of the exam were digitally recorded. Five endoscopists with more than 15 years of experience answered an electronic questionnaire, which included endoscopic criteria from the 3 most commonly used Portal Hypertensive Gastropathy classifications (McCormack, NIEC and Baveno) and the presence of elevated or flat antral erosive gastritis. All five endoscopists were blinded to the patients' clinical information, and all images of varices were deliberately excluded for the analysis. RESULTS: The three most common etiologies of portal hypertension were schistosomiasis (36%), alcoholic cirrhosis (20%) and viral cirrhosis (14%). Of the 50 patients with portal hypertension, 84% were Child A, 12% were Child B, 4% were Child C, 64% exhibited previous variceal bleeding and 66% were previously endoscopic treated. The endoscopic parameters, presence or absence of mosaic-like pattern, red point lesions and cherry-red spots were associated with high inter-observer reliability and high specificity for diagnosing Portal Hypertensive Gastropathy. Sensitivity, specificity and reliability for the diagnosis of PHG (%) were as follows: mosaic-like pattern (100; 92.21; High); fine pink speckling (56; 76.62; Unsatisfactory); superficial reddening (69.57; 66.23; Unsatisfactory); red-point lesions (47.83; 90.91; High); cherry-red spots (39.13; 96.10; High); isolated red marks (43.48; 88.31; High); and confluent red marks (21.74; 100; Unsatisfactory). Antral elevated erosive gastritis exhibited high reliability and high specificity with respect to the presence of portal hypertension (92%) and the diagnosis of portal hypertensive gastropathy (88.31%). CONCLUSION: The most suitable endoscopic criteria for the diagnosis of PHG were mosaic-like pattern, red-point lesions and cherry-red spots with no subdivisions, which were associated with a high rate of inter-observer reliability.

Adult Langerhans cell histiocytosis presenting as metachronous colonic polyps.

Langerhans cell histiocytosis (LCH) is a rare disease characterized by proliferation of Langerhans-type cells that express CD1a, Langerin (CD207) and S100 protein. Birbeck granules are a hallmark by ultrastructural examination. LCH presents with a wide clinical spectrum, ranging from solitary lesions of a single site (usually bone or skin) to multiple or disseminated multisystemic lesions, which can lead to severe organ dysfunction. Most cases occur in children. Gastrointestinal tract involvement is rare and has been associated with systemic illness and poor prognosis especially in children under the age of 2 years. Adult gastrointestinal LCH is very rare. We report a case of a previously healthy, nonsmoking 48-year-old male who was referred for routine screening colonoscopy. Two sessile, smooth, firm and yellowish LCH polyps measuring 0.2 cm and 0.3 cm were detected in the sigmoid colon. Fifteen months later a second colonoscopy found two histologically confirmed hyperplastic polyps at the sigmoid colon. No other LCH lesions were seen. A third colonoscopy after 28 months of follow-up found a submucosal 0.5 cm infiltrated and ulcerated LCH polyp in the cecum, close to the ostium of the appendix. The patient had been asymptomatic for all this period. Imaging investigation for systemic or multiorgan disease did not find any sign of extracolonic involvement. On histology all lesions showed typical LCH features and immunohistochemical analysis showed strong and diffuse staining for CD1a and CD207. This case illustrates two distinct clinicopathologic features not previously reported in this particular clinical setting: metachronous colonic involvement and positivity for CD207.

Heterotopic pancreas complicated by pseudocyst in the gastric wall diagnosed by endoscopic ultrasound-guided fine needle aspiration.

Heterotopic pancreas is usually asymptomatic and does not change throughout the patient's life, but sometimes it can present symp-toms and complications, which are rarely discrete in the literature. We present here a case of heterotopic pancreas in the gastric wall complicated with pseudocyst, and suggest that heterotopic pancreatic pseudocyst should be included in the differential diagnosis of gastric wall cysts.

Endoscopia digestiva alta: perfil dos exames eletivos e emergenciais realizados em um hospital terciário / Upper digestive endoscopy: results of electives and emergency procedures performed in a tertiary hospital

A gastroenterologia sofreu uma verdadeira revolução com a introdução da endoscopia digestiva, principalmente a partir da década de 1960, com o desenvolvimento de novas técnicas e o aprimoramento do conhecimento científico. A endoscopia digestiva alta (EDA) ocupa um papel muito importante no arsenal diagnóstico e terapêutico na prática médica, em especial graças ao extraordinário avanço tecnológico ocorrido nos últimos anos. Atualmente, é possível avaliar e conduzir de maneira mais precisa as patologias gastrointestinais, entre elas as diversas formas de esofagites, gastrites, lesões pépticas, neoplásicas, vasculares e corpos estranhos, com melhor acurácia diagnóstica e menores complicações. A EDA é o principal e o mais importante método disponível na abordagem da hemorragia digestiva alta (HDA), tanto para o diagnóstico como para a terapêutica, com consequente influência no prognóstico dos pacientes. Além disso, exerce papel fundamental na avaliação e retirada dos corpos estranhos no trato digestivo, reduzindo de forma importante a morbimortalidade dos indivíduos acometidos por essa comorbidade. Com base nisso, o objetivo desse estudo é mostrar os resultados encontrados nos exames de EDA, realizados em âmbito ambulatorial ou emergencial, em um centro de treinamento em endoscopia digestiva.

Gastroenterology underwent a revolution with the introduction of endoscopy, mainly from the 1960, with the development of new techniques and the improvement of scientific knowledge. Upper endoscopy (EGD) occupies a very important role in diagnosis and therapeutics in medical practice, mainly due to the extraordinary technological advances of recent years. Currently, it is possible to evaluate and conduct more accurately the gastrointestinal disorders, including various forms of esophagitis, gastritis, peptic lesions, neoplastic, vascular, and foreign bodies, most accurate diagnoses and fewer complications. The EDA is the main and most important method available in the approach to upper gastrointestinal bleeding (UGIB), both for diagnosis and for therapy, with consequent influence on the prognosis of patients. Furthermore, plays a fundamental role in the evaluation and removal of foreign bodies in the digestive tract, greatly reducing the morbidity and mortality of individuals affected by this comorbidity. Based on this, the objective of this study is to show the results of EDA exams performed in outpatient or emergency context, a training center for endoscopy.

Diagnostic management of pancreatic cancer.

Pancreatic cancer is one of the most deadly solid tumors, with an overall 5-year survival rate of less than 5%. Due to a non-specific clinical presentation, it is often diagnosed at an advanced stage and is rarely amenable for curative treatment. Therefore early diagnosis and appropriate staging are still essential to define the best care and to improve patient survival. Several imaging modalities are currently available for the evaluation of pancreatic cancer. This review focuses on different techniques and discusses the diagnostic management of patients with pancreatic cancer. This review was conducted utilizing Pubmed and was limited to papers published within the last 5 years. The search key words pancreatic cancer, pancreatic adenocarcinoma, pancreatic tumors, diagnosis, radiology, imaging, nuclear imaging, endoscopy, endoscopic ultrasound and biochemical markers were used.