Incidence of opioid-induced esophageal dysfunction.

BACKGROUND: Retrospective studies have suggested that long-term use of opioids can cause esophageal motility dysfunction. A recent clinical entity known as opioid-induced esophageal dysfunction (OIED) has been postulated. There is no data from prospective studies assessing the incidence of opioid-induced effects on the esophagus. AIM: Evaluate the incidence of OIED during chronic opioid therapy. METHODS: From February 2017 to August 2018, all patients seen in the Pain Unit of the hospital, who started opioid treatment for chronic non-neoplastic pain and who did not present esophageal symptoms previously, were included. The presence of esophageal symptoms was assessed using the Eckardt score after 3 months and 1 year since the start of the study. In February 2021, the clinical records of all included patients were reviewed to assess whether esophageal symptoms were present and whether opioid therapy was continued. In patients presenting with esophageal symptoms, an endoscopy was performed and, if normal, a high-resolution esophageal manometry was performed. For a confidence level of 95%, a 4% margin of error and an estimated prevalence of 4%, a sample size of 92 patients was calculated. RESULTS: 100 patients were included and followed while taking opioids, for a median of 31 months with a range between 4 and 48 months. Three women presented with dysphagia during the first 3 months of treatment, being diagnosed with esophagogastric junction outflow obstruction; type II and type III achalasia. The cumulative incidence of OIED was 3%; 95%-CI: 0-6%. CONCLUSIONS: Chronic opioid therapy in patients with chronic non-neoplastic pain is associated with symptomatic esophageal dysfunction.

Dyspnea and dysphagia associated to hypopharyngeal fibrolipoma: A case report.

Fibrolipomas are benign lesions conformed by fat and connective tissue, classified as histologic variants of lipomas. They are rarely located in the head and neck and represent less than 0.6% of the benign tumors of the larynx and hypopharynx. Their clinical presentation depends on its location and size. We present the case of a 51-year-old male patient who reported progressive dyspnea, dysphagia and obstructive sleep symptoms with a duration of 3 months, without apparent cause. A pharyngolaryngeal fiberoptic endoscopy showed a smooth, rounded mass in the posterior wall of the hypopharynx, partially obstructing the laryngeal vestibule, creating a valve effect. Complete trans-cervical resection of the lesion was performed after the airway was secured by means of a tracheotomy. The final histopathology report was fibrolipoma. He is currently asymptomatic and without evidence of relapse one year after the procedure.

Decreased Esophageal Sensitivity to Acid in Morbidly Obese Patients: A Cause for Concern?

BACKGROUND/AIMS: To evaluate esophageal sensitivity to acid between morbidly obese (MO) patients and non-MO controls with abnormal esophageal acid exposure. METHODS: We conducted a cross-sectional study of 58 patients: 30 MO (cases) and 28 non-MO (controls). Esophageal symptoms and esophageal sensitivity to 0.1 M hydrochloric acid solution (Bernstein test) were compared between MO and non-MO patients with a prior diagnosis of abnormal esophageal acid exposure. RESULTS: MO patients were less symptomatic than non-MO controls (14% vs 96%; odds ratio [OR], 0.006; 95% confidence interval [CI], 0.001 to 0.075; p=0.000). MO patients were more likely to present with decreased esophageal sensitivity to the instillation of acid than non-MO controls (57% vs 14%; OR, 8; 95% CI, 1.79 to 35.74; p=0.009). Subgroup analysis revealed no differences in esophageal sensitivity in MO patients with and without abnormal esophageal acid exposure (43% vs 31%; p=0.707). CONCLUSIONS: Silent gastroesophageal reflux disease (GERD) is common among MO individuals, likely due to decreased esophageal sensitivity to acid. The absence of typical GERD symptoms in these patients may delay discovery of precancerous conditions, such as Barrett's esophagus. We believe that these patients may require a more aggressive diagnostic work-up to rule out the presence of silent GERD.

[Prevalence of human papillomavirus infection in squamous cell carcinoma of the oral cavity, oropharynx and larynx]. / Prevalencia de infección por virus del papiloma humano en carcinoma espinocelular de cavidad oral, orofaringe y laringe.

BACKGROUND: Cancer of the head and neck comprises a group of neoplasms that share a similar anatomical origin. Most originate from the epithelium of the aerodigestive tract and 90% correspond to squamous cell carcinoma. In the last 15 years, an increase in the incidence of squamous cell carcinoma induced by human papillomavirus (HPV) has been seen, mainly types 16 and 18, which are the most frequent found in cancers of the oral cavity and oropharynx, and types 6 and 11 in laryngeal cancer. There are reports in the literature that show HPV as the leading cause of oropharyngeal squamous cell carcinoma. OBJECTIVE: Determine the prevalence of infection with high-risk HPV in patients diagnosed with squamous cell carcinoma of the oral cavity, oropharynx and larynx. MATERIAL AND METHODS: An observational, cross-sectional, descriptive, unblinded study was performed. Prevalence of HPV infection was determined by polymerase chain reaction (PCR) in DNA samples from tumour tissue of patients with squamous cell carcinoma of the oral cavity, oropharynx and larynx. Typing was subsequently performed in HPV positive samples in order to detect types 18, 16, 11 and 6, using custom primers. RESULTS: A total of 45 patients were included. The association between laryngeal squamous cell carcinoma and HPV was established in two patients, which represented an overall prevalence of 4.4% in our population, and 10% for laringeal tumours. CONCLUSIONS: There is a low prevalence of HPV infection in squamous cell carcinoma of the oral cavity, oropharynx and larynx, in our population. Prospective studies on younger patients could provide more information.

Small intestinal bacterial overgrowth in inactive Crohn's disease: influence of thiopurine and biological treatment.

AIM: To investigate the influence of thiopurines and biological drugs on the presence of small intestinal bacterial overgrowth (SIBO) in patients with inactive Crohn's disease (CD). METHODS: This was a prospective study in patients with CD in remission and without corticosteroid treatment, included consecutively from 2004 to 2010. SIBO was investigated using the hydrogen glucose breath test. RESULTS: One hundred and seven patients with CD in remission were included. Almost 58% of patients used maintenance immunosuppressant therapy and 19.6% used biological therapy. The prevalence of SIBO was 16.8%. No association was observed between SIBO and the use of thiopurine Immunosuppressant (12/62 patients), administration of biological drugs (2/21 patients), or with double treatment with an anti-tumor necrosis factor drugs plus thiopurine (1/13 patients). Half of the patients had symptoms that were suggestive of SIBO, though meteorism was the only symptom that was significantly associated with the presence of SIBO on univariate analysis (P < 0.05). Multivariate analysis revealed that the presence of meteorism and a fistulizing pattern were associated with the presence of SIBO (P < 0.05). CONCLUSION: Immunosuppressants and/or biological drugs do not induce SIBO in inactive CD. Fistulizing disease pattern and meteorism are associated with SIBO.

High prevalence of heartburn and low acid sensitivity in patients with idiopathic achalasia.

BACKGROUND: Heartburn is frequently reported by patients with achalasia before treatment. However, the esophageal sensitivity to acid as a possible mediator of this symptom has not been previously evaluated. AIM: To evaluate the prevalence of gastroesophageal reflux symptoms and the esophageal sensitivity to acid perfusion in patients with untreated achalasia. METHODS: Forty patients with achalasia were prospectively evaluated. Forty-three patients with gastroesophageal reflux disease comprised the control group (ten of them with Barrett's esophagus). Symptoms were evaluated by a structured clinical questionnaire. Objective assessment was performed by ambulatory 24-h esophageal pH monitoring and endoscopy. Esophageal sensitivity to acid was evaluated by esophageal perfusion of ClH 0.1 N. RESULTS: Fifteen (37%) of the 40 patients with achalasia presented heartburn, but only four of them had esophagitis and/or abnormal esophageal pH recording. Eight patients had abnormal pH recording. Three patients had esophagitis. The esophagus was sensitive to acid in seven (17%) patients with achalasia, three of them with heartburn and one with abnormal pH recording. In the control group, 40 of 43 (93%) presented heartburn. Acid perfusion was positive in 32 (74%). Sensitivity to acid was lower in patients with achalasia than in those with gastroesophageal reflux disease with or without Barrett's esophagus. CONCLUSIONS: The prevalence of heartburn in patients with achalasia is high, although its association with objective indicators of gastroesophageal reflux disease is weak. Patients with achalasia have lower esophageal sensitivity to acid than patients with GERD, suggesting that heartburn is does not arise from this condition.

Description of the third-instar of Anastrepha leptozona Hendel (Diptera: Tephritidae) / Descrição do terceiro ínstar de Anastrepha leptozona Hendel (Diptera: Tephritidae)

The morphology of the third-instar larva of Anastrepha leptozona Hendel is characterized using optical and scanning electron microscopy. The antennomaxillary complex, oral ridges, labium, stomal sensory organ, cephalopharyngeal skeleton, anterior and posterior spiracles and caudal segment are described and illustrated. Mature larvae of A. leptozona present a "ventral sclerite" below the pharyngeal sclerite which is characterized for the first time in Anastrepha species.

A morfologia da larva do terceiro ínstar de Anastrepha leptozona Hendel é descrita. São analisados, em microscopia de luz e de varredura, o complexo antenomaxilar, as margens da abertura oral, o bordo, o órgão oral, o esqueleto cefalofaríngeo, os espiráculos anterior e posterior e o segmento caudal. As larvas do terceiro ínstar de A. leptozona têm um "esclerito ventral" abaixo do esclerito faríngeo, o qual é caracterizado pela primeira vez em espécies de Anastrepha.

Impact of gastroesophageal reflux disease on the quality of life of Spanish patients: the relevance of the biometric factors and the severity of symptoms.

BACKGROUND: Gastroesophageal reflux disease (GERD) has a negative impact on health-related quality of life (HRQoL). AIM: (i) To evaluate HRQoL in the general Spanish population with GERD. (ii) To analyze the influence of biometric factors and symptoms profile on HRQoL. MATERIALS AND METHODS: A multicenter and population-based evaluation was performed. Surveys were sent out to the general population and 335 responders (16%) fulfilled symptomatic criteria of GERD. They filled out two HRQoL questionnaires [Short Form-36 (SF-36) and Quality of Life in Reflux and Dyspepsia]. Biometric factors and symptoms profile were collected. The SF-36 physical and mental component summary scores were calculated. RESULTS: Two hundred and fifty-two individuals (75.2%) participated. SF-36 and Quality of Life in Reflux and Dyspepsia (QoLRAD) punctuations were lower compared with the general population. Female sex, severity of symptoms, and nocturnal symptoms were associated with a greater deterioration of HRQoL. Obese participants had a negative impact on the physical component summary score, but mental component summary score was better than in participants with normal weight. Adjusted by age, punctuations of smokers, exsmokers, and nonsmokers were similar. No differences in HRQoL with regard to alcohol consumption were observed. CONCLUSION: In participants who fulfill symptomatic criteria of GERD, the HRQoL is very deteriorated. The factors that worsen the QoL are being female, increase in BMI, and nocturnal symptoms.

Angiosarcoma of the nasal cavity: a case report.

Angiosarcomas are malignant neoplasias of rapid growth that develop from endothelial cells. They represent 2% of all sarcomas and only 1-4% are located in the aerodigestive tract. Since 1977, only 16 cases have been reported.We present a 33-year-old male with spontaneous epistaxis that was refractory to cauterization. During physical examination, a smooth purplish tumor of 1.5 cm x 1.5 cm was identified. A CT scan showed a nonenhanced tumor in the left nostril on the uncinate process. A biopsy revealed an intermediate-grade angiosarcoma. Surgical removal followed by radiation therapy was performed with good result. Aerodigestive angiosarcomas have a better prognosis than angiosarcomas of other locations due to better cell differentiation and the presence of early symptoms. Recurrence can occur because of tumor tissue left during resection. Our patient continues tumor free after three years.

Second-line rescue therapy with levofloxacin after H. pylori treatment failure: a Spanish multicenter study of 300 patients.

AIM: Quadruple therapy is generally recommended as second-line therapy after Helicobacter pylori (H. pylori) eradication failure. However, this regimen requires the administration of four drugs with a complex scheme, is associated with a relatively high incidence of adverse effects, and bismuth salts are not available worldwide anymore. Our aim was to evaluate the efficacy and tolerability of a triple second-line levofloxacin-based regimen in patients with H. pylori eradication failure. DESIGN: Prospective multicenter study. PATIENTS: in whom a first treatment with proton pump inhibitor-clarithromycin-amoxicillin had failed. INTERVENTION: A second eradication regimen with levofloxacin (500 mg b.i.d.), amoxicillin (1 g b.i.d.), and omeprazole (20 mg b.i.d.) was prescribed for 10 days. OUTCOME: Eradication was confirmed with (13)C-urea breath test 4-8 wk after therapy. Compliance with therapy was determined from the interview and the recovery of empty envelopes of medications. Incidence of adverse effects was evaluated by means of a specific questionnaire. RESULTS: Three hundred consecutive patients were included. Mean age was 48 yr, 47% were male, 38% had peptic ulcer, and 62% functional dyspepsia. Almost all (97%) patients took all the medications correctly. Per-protocol and intention-to-treat eradication rates were 81% (95% CI 77-86%) and 77% (73-82%). Adverse effects were reported in 22% of the patients, mainly including nausea (8%), metallic taste (5%), abdominal pain (3%), and myalgias (3%); none of them were severe. CONCLUSION: Ten-day levofloxacin-based rescue therapy constitutes an encouraging second-line strategy, representing an alternative to quadruple therapy in patients with previous proton pump inhibitor-clarithromycin-amoxicillin failure, being simple and safe.

Gastroesophageal reflux, quality of life, and satisfaction in patients with achalasia treated with open cardiomyotomy and partial fundoplication.

BACKGROUND: Cardiomyotomy, often associated with an antireflux technique, is effective in the management of achalasia, although gastroesophageal reflux (GER) may occur after the procedure. Patient-centered measures, ie, health-related quality of life (HRQoL) and satisfaction, should be included in the evaluation of the patients. METHODS: A study was made of the incidence of GER (symptoms, upper endoscopy and 24-hour pH monitoring), HRQoL (Short Form-36 Health Survey), and satisfaction after open-access cardiomyotomy and 180-degree anterior fundoplication in 28 consecutive patients, with a minimum postoperative follow-up of 12 months. RESULTS: Mean age was 45 years (range 15 to 80) and 68% were female. In 8 subjects (all with heartburn) GER morbidity was present (4 with esophagitis and 4 with positive pH study), and 6 patients required proton pump inhibitors. Short Form-36 scores after surgery were similar to those found in the general population. Patient satisfaction was high and was more related to the absence of dysphagia than to the presence of GER symptoms. CONCLUSIONS: Gastroesophageal reflux is relatively frequent after cardiomyotomy and partial fundoplication, although the efficacy of proton pump inhibitor treatment minimizes its clinical significance.

Congenital oesophageal stenosis: an atypical presentation in a young woman.

Congenital oesophageal stenosis is a very rare disease that commonly occurs in infancy with male predominance. This report describes a highly unusual case of congenital oesophageal stenosis extended throughout the length of the oesophagus, without webs or tracheobronchial remnants in the oesophageal wall, with normal oesophageal motility and normal endosonography in an adult female.

Contribution of obesity to hepatitis C-related fibrosis progression.

OBJECTIVE: Hepatitis C virus (HCV) disease progression is variable. Identification of factors predictive of rapid progression is an important goal for improving patient management. The aim of this study was to evaluate the predictive role of several variables, including some that are etiologically related to the nonalcoholic steatohepatitis (NASH) syndrome such us obesity, in fibrosis progression in both patients with elevated and normal transaminase levels. METHODS: A total of 114 chronic HCV-infected (HCV-RNA positive) patients were recruited prospectively between 2000 and 2001. All patients had at least one liver biopsy. The annual change in fibrosis stage (fibrosis progression rate) was assessed from the time of presumed infection (fibrosis = 0) among those who had only one biopsy (n = 97) or between two biopsies if these were available (n = 17). Based on published data, we arbitrarily defined a patient as a rapid progressor when the fibrosis progression rate was > 0.2 U/yr. Potential predictors of rapid progression were: age at infection and biopsy, sex, significant alcohol intake (> 50 g/day), risk factor of HCV acquisition (based on answers to a questionnaire), obesity (based on body mass index [BMI]), autoantibodies, iron overload (ferritin, transferrin saturation), diabetes, hyperlipidemia, anti-HBcore IgG, genotype, and viral load. RESULTS: The median fibrosis progression rate was 0.05 U/yr (range 0-1.58 yr). In all, 22 patients (19%) were rapid progressors. Variables associated with progression by multivariate analysis included: advanced age at infection (p = 0.0001), BMI > or = 25 (p = 0.01), and ALT > 1.5 times upper limit of normal (p = 0.01). Among patients with ALT > 1.5 times upper limit of normal, these variables were advanced age at infection, BMI > or = 25, diabetes and transferrin saturation > 45. Among those with normal ALT levels, only BMI > or = 30 was predictive of progression. CONCLUSIONS: Obesity, advanced age at infection, and elevated ALT levels predict rapid disease progression, suggesting that measures aimed at weight reduction may play a significant role in hepatitis C management. The natural history of hepatitis C is independent of the presence of autoimmunity markers.

Gammagrafía mediante 99m Tc-sestamibi en el cáncer de tiroides / Gammagrafía by means of 99m Tc-sestamibi in the cancer of tiroides

Presenta el resultado del estudio, mediante gammagrafía con 99mc-sestamibi, de un grupo de 22 pacientes con cáncer de la tiroides en el período de control clínico post-operatorio, y 6 casos con lesiones tumorales y otras patologías tiroideas, antes de cualquier intervención terapeútica. Todos los pacientes fueron estudiados mediante gammagrafía con 99m Tc-sestamibi adquiriéndose imágenes de cuello y tórax en la proyección anterior, y de todo el cuerpo, a los 10 minutos y la hora después de la administración del radiofármaco. En todos los casos también se realizó gammagrafía mediante iodo-131. Los resultados de ambas gammagrafías fueron comparados. En el grupo de 22 casos de cáncer de tiroides estudiados durante el control clínico evolutivo del proceso tumoral, se encontraron coincidencias entre ambas gammagrafías en 18 de ellos. En 11 de estos últimos casos ambas imágenes mostraron igual forma, tamaño y características de las zonas "calientes" anormales, mientras en 5 casos de lesiones gammagráficas con 99mc-sestambi mostraron mayor o menor captación que las de iodo-131. El pequeño grupo de 6 pacientes con patología tiroidea no tratada aún, mostró gammagrafías con 99mTc-sestamibi superiores a las de iodo-131 para evaluar el tamaño de la lesión estudiada. Se concluye que la gammagrafía mediante 99m Tc-sestamibi podría tener gran valor en el estudio sistemático de pacientes con lesiones tumorales de tiroides antes del tratamiento quirúrgico o durante el período de control clínico evolutivo...