Classificação endoscópica do megaesôfago / Endoscopic CLassification of megaesophagus

Apesar de apresentar diminuição em sua incidência, a doença de Chagas aina é a terceira doença tropical mais frequente. A endoscopia digestiva alta (EDA) cresce em importância como metódo auxiliar para eses pacientes, principalmente na avaliação da mucosa e diagnóstico de neoplasias. Até o presente momento, não se encontra na literatura uma classificação para padronizar a descrição das alterações endoscópicas nos pacientes com megaesôfago. Tal classisficação que tivesse boa correlação radiológica, poderia facilitar o tratamento desses pacientes, reduzindo o número de exames. Objetivos: Apresentar uma proposta de classificação endoscópica para pacientes com megaesôfago. Material e Método: Sessenta e cinco pacientes consecutivos com megaesôfago foram avaliados por dois endoscopistas experientes, cegos entre si, durante um único exame. A análise estatistica realizada pelo teste de Kappa, comparando os resultados obtidos com os achados radiológicos pela classificação de Rezende, além de análise da variaçãointerobservador. resultados: Os endoscopistas apresentaram indice de concordância excelenmte (K= 0,90) quando comparados entre si e concordâancia forte (K=0,67) quando comparados com a classificação radiológica. Conclusões: Esta classificação pode ser útil, já que parece haver boa concordância com os achados radiológicos e ser facilmente reproduzida. Novos estudos são necessários para comprovar os benefícios de sua utilização na prática clínica.

Pancreatic pseudocysts transpapillary and transmural drainage.

BACKGROUND: Pancreatic pseudocyst endoscopic drainage has been described as a good treatment option, with morbidity and mortality rates that are lower than surgery. The aim of our study is to describe the efficacy of different forms of endoscopic drainage and estimate pseudocyst recurrence rate after short follow up period. PATIENTS AND METHODS: We studied 30 patients with pancreatic pseudocyst that presented some indication for treatment: persistent abdominal pain, infection or cholestasis. Clinical evaluation was performed with a pain scale, 0 meaning absence of pain and 4 meaning continuous pain. Pseudocysts were first evaluated by abdominal CT scan, and after endoscopic retrograde pancreatography the patients were treated by transpapillary or transmural (cystduodenostomy or cystgastrostomy) drainage. Pseudocyst resolution was documented by serial CT scans. RESULTS: 25/30 patients could be treated. Drainage was successful in 21 (70% in an 'intention to treat' basis). After a mean follow-up of 42 +/- 35.82 weeks, there was only 1 (4.2%) recurrence. A total of 6 complications occurred in 37 procedures (16.2%), and all but 2 were managed clinically and/or endoscopically: there was no mortality related to the procedure. Patients submitted to combined drainage needed more procedures than the other groups. There was no difference in the efficacy when we compared the three different drainage methods. CONCLUSIONS: We concluded that pancreatic pseudocyst endoscopic drainage is possible in most patients, with high success rate and low morbidity.

Improvement of children's nutritional status after enteral feeding by PEG: an interim report.

BACKGROUND: Enteral feeding by percutaneous endoscopic gastrostomy is indicated as long-term nutritional support for children with neurologic impairment and dysphagia. We report our experience with percutaneous endoscopic gastrostomy and evaluate the age range of children with cerebral palsy who benefit most with weight and height gain. METHODS: In a prospective study, from August 1996 to August 1997, 20 endoscopic gastrostomies were performed in 20 children diagnosed with cerebral palsy (16), myopathy (2), and brain trauma (2). The mean age was 6.5 years and the mean follow-up 5.9 months. All patients had severe mental impairment and oropharyngeal dysphagia. They were followed up monthly on an outpatient basis by both the gastroenterologist and the dietitian, who assessed gastrostomy complications and performed anthropometric measurements. RESULTS: All 20 patients benefited from enteral nutrition with a statistically significant gain in weight (p < 0.01), and there was a trend toward improved weight/height ratio in children under 4 years of age according to Z-score and mid-arm muscle area (p < 0.01). Triceps skinfold thickness failed to reach statistical significance. There were no immediate complications related to the procedure. Perforations occurred with three (15%) tubes, and the plugs for introduction of food had to be replaced after 4 months of use. All complications, namely formation of granulation tissue at the stoma (7), stoma infection (4), gastroesophageal reflux pneumonia (3), and pneumoperitoneum (1) were managed clinically. CONCLUSIONS: Endoscopic gastrostomy is a safe procedure for children. Enteral feeding resulted in a trend toward a normalized weight/height ratio for children with cerebral palsy younger than 4 years and significant weight gain in those older than 12 years.

Echoendoscopic evaluation of botulinum toxin intrasphincteric injections in Chagas' disease achalasia.

Botulinum toxin (BT) has recently been indicated as an alternative treatment of idiopathic achalasia with a success rate of 60-70%. One-third of BT-treated cases either fail to respond or fail to sustain the response beyond 6 months. An explanation for BT therapeutic failure would be that the lower esophageal sphincter muscular layer (LES) may be missed as injection is delivered 'blindly'. We aimed to evaluate the percentage of exact endoscopically 'blind' LES punctures using echoendoscopy after the injection of BT for the treatment of Chagas' achalasia (CA). Five patients with CA (mean age 53 years) were randomized to receive 1.2 ml of BT or the same amount of saline injected endoscopically. Echoendoscopy was performed immediately after puncture. Patients were evaluated by the clinical score of dysphagia, radiological examination, upper endoscopy and esophageal manometry and followed up for 6 months. All puncture sites were identified: 17 out of 20 (85%) in the muscle layer and 3 out of 20 (15%) in the submucosa. The three patients in the treatment group showed clinical improvement (average clinical score fell from 14 to 2 after 7 days, and remained at 4 after 6 months of follow-up). The mean pressure of the LES dropped by 29%. Neither patient in the placebo group showed clinical improvement, and the mean pressure of the LES increased by 35%. Endoscopic 'blind' injection of BT into the LES through endoscopy for the management of achalasia is a safe and reproducible technique and has a high percentage of exactness.

Botulinum toxin for oropharyngeal dysphagia: case report of flexible endoscope-guided injection.

Botulinum toxin (BT) has been used in neurology, ophthalmology, otorhinolaryngology and gastroenterology. Twenty-four patients with oropharyngeal dysphagia treated with BT injection into the cricopharyngeal muscle were reported, with good results in up to 79% of the patients. Different techniques were used to inject BT: percutaneous (guided by electromyography, computed tomography or videofluoroscopy) or direct injection during esophagoscopy (with a rigid esophagoscope). We report the first case of oropharyngeal dysphagia treated by BT injection into the cricopharyngeal muscle using a flexible scope, with clinical, radiological and manometric improvement. A reduction in the disability score 4 to 2 and sustained capacity to maintain adequate oral caloric intake were observed. The patient was also able to have the tracheotomy orifice closed and the gastrostomy tube removed after 3 months. Manometry showed a 38% reduction in the upper esophageal sphincter pressure with the presence of pharyngeal waves that were previously absent. After 1 year of follow-up, the patient was in good condition with mild dysphagia for solid foods. This is another case of complex dysphagia and relative hyperfunction of the cricopharyngeal muscle successfully treated with BT injection.

Nutritional status improvement in neurologically impaired patients by percutaneous endoscopic gastrostomy feeding.

With increased use of percutaneous endoscopic gastrostomy, it became clear that neurologically impaired patients might benefit from its use. From August 1996 to July 1997, we performed 19 percutaneous endoscopic gastrostomies in patients with neurological sequelae, who were incapable to maintain their nutritional status by oral ingestion or had repeated episodes of aspiration. Sixteen patients were followed prospectively, from 30 days to 11 months (median: 6.4 months). Average weight (38.2 kg to 44.8 kg), BMI (14.8 kg/m2 to 17.8 kg/m2), weight/height ratio (23.5 kg/cm to 28 kg/cm), mid-upper arm circumference (19.4 cm to 21.6 cm) and triceps skinfold thickness (10.3 mm to 12.6 mm) were significantly increased (P < 0.01). Before percutaneous endoscopic gastrostomy, there were 10 (10/16, 62.5%) patients with grade III thinness. In this group, 3/10 patients (30%) showed improvement to grade I (two individuals) and II (one patient). All but five patients (68.75%) were below the fifth percentile of normal distribution for mid-upper arm circumference. One patient (6.2%) showed improvement of her status (between 25th and 50th percentiles). Four patients (25%) started the follow-up below the fifth percentile for normal distribution of triceps skinfold thickness, and showed no improvement. There were no early complications secondary the procedure. Late complications included granulation tissue on ostomy site (18.8%) and ostomy infection (6.2%). Statistical analysis showed significant improvement of anthropometric data. Percutaneous endoscopic gastrostomy is a simple, highly successful and safe procedure, when performed in neurologically impaired patients. It is efficient as a long-term enteral feeding method.

Risk of Helicobacter pylori transmission by upper gastrointestinal endoscopy.

BACKGROUND: Upper gastrointestinal endoscopy has been reported as a risk factor for the transmission of Helicobacter pylori. The aim of this study was to evaluate the possibility of transmission of H. pylori infection by upper gastrointestinal endoscopy in patients who had previously had such procedures in a low disinfection level environment. METHODS: The study included 1082 patients. Patients that had undergone upper gastrointestinal endoscopy or were treated with antibiotics 15 days before the index endoscopy were excluded. H. pylori infection was diagnosed by ultra-rapid urease test. Variables analyzed were age, gender, type of dyspepsia (organic or functional), and the number of previous upper gastrointestinal endoscopies. RESULTS: Overall prevalence of H. pylori infection was 60%. Patients ranged in age from 13 to 94 years (mean = 45.8, SD = 15.7) and the number of previous upper gastrointestinal endoscopies ranged from 0 to 20 (mean = 1.5, SD = 2.4). In 53.3% of the patients, upper gastrointestinal endoscopy revealed some mucosal lesion (organic dyspepsia). Prevalence of H. pylori infection was higher in patients with organic rather than functional dyspepsia (71.1% vs. 47.1%, p < 0.001). There was no statistically significant difference in the mean number of upper gastrointestinal endoscopies in patients with and without H. pylori infection. CONCLUSIONS: We concluded that there was no association between history of upper gastrointestinal endoscopy and current H. pylori infection in this study population.

Prospective study of bacteremia rate after elastic band ligation and sclerotherapy of esophageal varices in patients with hepatosplenic schistosomiasis.

BACKGROUND: Esophageal band ligation is considered to be as efficient as endoscopic sclerotherapy, with a lower complication rate, including bacteremia. There are few studies comparing the two methods. The aim of this study was to compare the incidence of bacteremia after both treatments in patients with portal hypertension secondary to schistosomiasis. METHODS: Endoscopic sclerotherapy and band ligation were performed using standard techniques. Blood samples were obtained 5 and 30 minutes after endoscopic band ligation or sclerotherapy and cultured for aerobic and anaerobic organisms. RESULTS: In the sclerotherapy group 2 of 43 (4.6%) blood cultures were positive (Peptostreptococcus sp and Streptococcus mitis). A similar result was obtained in the band ligation group: 2 of 35 (5.7%) had positive cultures, both with Staphylococcus aureus. CONCLUSIONS: There is no difference in the frequency of bacteremia after treatment of esophageal varices with endoscopic sclerotherapy or endoscopic band ligation in patients with portal hypertension secondary to schistosomiasis.

[Comparison between invasive tests for the diagnosis of Helicobacter pylori infections]. / Comparação entre testes invasivos para o diagnóstico da infecção pelo Helicobacter pylori.

Helicobacter pylori is a Gram negative bacteria that colonizes gastric epithelial cells. It has been associated with several gastric disease including chronic gastritis and peptic ulcer. Helicobacter pylori infection diagnosis can be done with invasive and non-invasive methods. In invasive methods an endoscopic gastric mucosa biopsy specimen is used. In our study we compare the sensitivity, specificity, costs and applicability of four invasive diagnostic tests: culture, urease ultra-rapid test, histology (Giemsa and Hematoxilineosin stain) and fuchsin stained mucosal slides. Urease test was the easiest, fastest diagnostic test, with sensitivity of 86% and specificity of 100%, being also the cheapest test. We concluded that it should be the test of choice for Helicobacter pylori infection diagnosis.

Biliary and pancreatic stent blockage by bacterial biofilm: presentation of two cases.

Biliary and pancreatic stents are effective tools in the management of obstructive jaundice (both malignant and benign), pancreatic pseudocyst drainage, and as treatment for biliary and pancreatic fistulae. Unfortunately, stents may become blocked and require replacement in a number of patients. In the present study a blocked stent from a patient with transpapillary drainage of pancreatic pseudocyst and another from a patient with obstructive jaundice resulting from cancer of the head of the pancreas associated with Mirizzi syndrome were characterized by electron microscopy. Stent blockage was diagnosed by a pressure test and stent cultures were performed. Electron microscopy of the blocked stents revealed the sludge to consist of microcolonies of bacteria mixed with amorphous material, and cultures of both stents were positive for Klebsiella sp and E. coli.

Biliary and pancreatic stent blockage by bacterial biofilm: presentation of two cases

Biliary and pancreatic stents are effective tools in the management of obstructive jaundice (both malignant and benign), pancreatic pseudocyst drainage, and as treatment for biliary and pancreatic fistulae. Unfortunately, stents may become blocked and require replacement in a number of patients. In the present study a blocked stent from a patient with transpapillary drainage of pancreatic pseudocyst and another from a patient with obstructive jaundice resulting from cancer of the head of the pancreas associated with Mirizzi syndrome were characterized by electron microscopy. Stent blockage was diagnosed by a pressure test and stent cultures were performed. Electron microscopy of the blocked stents revealed the sludge to consist of microcolonies of bacteria mixed with amorphous material, and cultures of both stents were positive for Klebsiella sp and E. coli.

The value of adenosine deaminase (ADA) determination in the diagnosis of tuberculous ascites.

In order to evaluate the role of the determination of adenosine deaminase activity (ADA) in ascitic fluid for the diagnosis of tuberculosis, 44 patients were studied. Based on biochemical, cytological, histopathological and microbiological tests, the patients were divided into 5 groups: G1-tuberculous ascites (n = 8); G2-malignant ascites (n = 13); G3-spontaneous bacterial peritonitis (n = 6); G4-pancreatic ascites (n = 2); G5-miscelaneous ascites (n = 15). ADA concentration were significantly higher in G1 (133.50 +/- 24.74 U/l) compared to the other groups (G2 = 41.85 +/- 52.07 U/l; G3 = 10.63 +/- 5.87 U/l; G4 = 18.00 +/- 7.07 U/l; G5 = 11.23 +/- 7.66 U/l). At a cut-off value of > 31 U/l, the sensitivity, specificity and positive and negative predictive values were 100%, 92%, 72% and 100%, respectively. ADA concentrations as high as in tuberculous ascites were only found in two malignant ascites caused by lymphoma. We conclude that ADA determination in ascitic fluid is a useful and reliable screening test for diagnosing tuberculous ascites. Values of ADA higher than 31 U/l indicate more invasive methods to confirm the diagnosis of tuberculosis.

[Endoscopic therapy of pancreatic pseudocyst]. / Terapêutica endoscópica do pseudocisto de pâncreas.

Endoscopy therapy of pancreatic pseudocyst has been described as an efficient method. We report six cases of pancreatic pseudocyst treated by pancreatic stenting (three cases), cystogastrostomy (three cases) and cystoduodenostomy (one case). Rapid symptomatic improvement and pseudocyst regression were noted in all cases, except one. Such patient needed pancreatic stenting even after cystogastrostomy due to main pancreatic duct stenosis. There were three complications: hemorrhage (one case) and pseudocyst infection (two cases), and all were treated clinically. Two patients had pseudocyst infection previous to endoscopic manipulation, and they were treated only with antibiotics and endoscopic drainage, without surgery (treatment suggested by most of the authors). We concluded that endoscopic therapy of pancreatic pseudocyst is efficient and safe, being responsible for rapid relief of symptoms in most of patients.

[Peutz-Jeghers syndrome and adenocarcinoma. Report of a case]. / Síndrome de Peutz-Jeghers e adenocarcinoma. Relato de caso.

Peutz-Jeghers syndrome is a rare disease, characterized by autosomic inheritance, presenting skin stain and hamartomatous polyps. We report one case of Peutz-Jeghers syndrome and duodenal adenocarcinoma in a young male who presented with liver metastasis and pancreatic invasion. Such association is reported to be presented in 5% of patients with the syndrome. The reasons of such association are unknown, being possible that: 1) there is malignant degeneration of a adenomatous polyp; 2) malignant degeneration of a hamartomatous polyp, or 3) adenomatous portion of a hamartomatous polyp could undergo malignant transformation.