Upper gastrointestinal Kaposi's sarcoma in HIV-infected patients: ten years of endoscopy observation at a single Brazilian center.

BACKGROUND: Kaposi's sarcoma (KS) is the most common neoplasm among HIV-infected individuals. The frequency of involvement of KS in the gastrointestinal (GI) tract and the associated epidemiological, immune, endoscopic, and histopathological features in HIV-infected patients, were evaluated in this study. METHODS: A review of the medical and endoscopy reports of 1428 HIV-infected patients, who had undergone upper GI endoscopy at the Endoscopy Service, Clinical Hospital, Faculty of Medicine of Ribeirão Preto between January 1999 and June 2009, was performed. Clinical, epidemiological, immunological, endoscopic, and histological data were collected. RESULTS: Twenty-seven (1.9%) patients were diagnosed with GI KS. Patients were predominantly male (81.5%). Sexual activity was the main route of HIV transmission (81.5%). Cutaneous involvement was noted in 21 patients (78%). Fifteen patients (55%) received highly active antiretroviral therapy for a mean duration of 12.6 weeks (range 2-52 weeks) before endoscopy. GI lesions were mainly found in the stomach (55%). Analysis of the immunohistochemical methods HHV8 LNA-1, CD31, and CD34 for the diagnosis of gastric KS indicated high agreement (kappa=0.63, 95% confidence interval 0.32-0.94). There was no relationship between CD4 levels (p=0.34) or HIV viral load (p=0.99) and HHV8 LNA-1 positivity in gastric KS. CONCLUSIONS: GI KS is an infrequent finding in patients with HIV infection. Among those with GI KS, 80% had concomitant skin lesions. Immunohistochemical methods for CD31, CD34, and LNA-1 were important tools in the diagnostic assessment of lesions suggestive of KS in the GI tract. Further studies are required to confirm these data, and the need for routine endoscopic investigation of the GI tract in HIV-infected patients with cutaneous KS should be assessed.

Esophageal ulcer in Brazilian patients with HIV: prevalence and comparative analysis among diagnostic methods.

Esophageal ulcer (EU) represents an important comorbidity in AIDS. We evaluated the prevalence of EU, the accuracy of the endoscopic and histologic methods used to investigate viral EU in HIV-positive Brazilian patients and the numerical relevance of tissue sampling. A total of 399 HIV-positive patients underwent upper gastrointestinal (UGI) endoscopy. HIV-positive patients with EU determined by UGI endoscopy followed by biopsies were analyzed by the hematoxylin-eosin (HE) and immunohistochemical (IH) methods. EU was detected in 41 patients (mean age, 39.2 years; 23 males), with a prevalence of 10.27%. The median CD4 count was 49 cells/mm(3) (range, 1-361 cells/mm(3)) and the viral load was 58,869 copies per milliliter (range, 50-77,3290 copies per milliliter). UGI endoscopy detected 29 of 41 EU suggestive of cytomegalovirus (CMV) infection and 7 of 41 indicating herpes simplex virus (HSV) infection. HE histology confirmed 4 of 29 ulcers induced by CMV, 2 of 7 induced by HSV, and 1 of 7 induced by HSV plus CMV. IH for CMV and HSV confirmed the HE findings and detected one additional CMV-induced case. UGI endoscopy showed 100% sensitivity and 15% specificity for the diagnosis of EU due to CMV or HSV compared to HE and IH. HE proved to be an adequate method for etiologic evaluation, with 87% sensitivity and 100% specificity compared to IH. The number of samples did not influence the etiologic evaluation. The data support the importance of IH as a complementary method for HE in the diagnosis of EU of viral etiology.

Pancreatite aguda sem etiologia aparente: a microlitíase deve ser pesquisada? [revisão] / Unexplained acute pancreatitis: the microlithiasis must be searched? [review]

In a large number of patients, with episodes of acute pancreatitis the etiology is not identified, even after initial clinical history, detailed physical examination, laboratory tests and biochemical exams and an transabdominal ultrasound. This patient are considered with a unexplained acute pancreatitis. In this cases the treatment is restricted to improvement of symptoms. These patients after treated tend to have new episodes with the risk of raising the rates of morbidity and mortality. Therefore, the identification of a cause and its prompt treatment prevent at recurrent episodes of pancreatitis. This review aims to draw attention to how best diagnostic approach when the light of evidence-based medicine, to search for causes of difficult identification with microlithiasis, occult stones, the anatomical variations of biliary and pancreatic duct and in addition to sphincter of Oddi dysfunction.

Clinical, endoscopic and prognostic aspects of primary gastric non-hodgkin's lymphoma associated with acquired immunodeficiency syndrome.

Primary gastric non-Hodgkin's lymphoma (NHL) is a co-morbidity that can be observed during the clinical course of acquired immunodeficiency syndrome (AIDS). We evaluated the prevalence, clinical-evolutive aspects and form of endoscopic presentation of primary gastric NHL associated with AIDS. Two hundred and forty-three HIV patients were submitted to upper digestive endoscopy, with evaluation of clinical, endoscopic and histological data. A CD4 count was made by flow cytometry and viral load was determined in a branched-DNA assay. Six cases (five men; mean age: 37 years; range: 29-46 years) of primary gastric NHL were detected. The median CD4 count was 140 cells/mm(3) and the median viral load was 40,313 copies/mL. Upper digestive endoscopy revealed polypoid (in four patients) ulcero-infiltrative (two patients) and ulcerated (two patients) lesions and combined polypoid and ulcerated lesions (two patients). Histology of the gastric lesions demonstrated B cell NHL (four patients) and T cell NHL (two patients). Five of the six patients died of complications related to gastric NHL. We concluded that primary gastric NHL is an important cause of mortality associated with AIDS.

Case report: Esophageal histoplasmosis associated with disseminated tuberculosis in acquired immunodeficiency syndrome.

Bacterial and fungal infections are common in acquired immunodeficiency syndrome (AIDS). Histoplasmosis is a common fungal disease in severely immunocompromised patients infected with human immunodeficiency virus (HIV) in endemic areas. In this population the most frequent form of presentation of histoplasmosis is disseminated, with the clinical manifestations being similar to those of disseminated tuberculosis. Esophageal histoplasmosis and the association of histoplasmosis with tuberculosis are infrequent. We report here a rare case of esophageal histoplasmosis associated with disseminated tuberculosis in AIDS.

Clinical, endoscopic and prognostic aspects of primary gastric non-hodgkin's lymphoma associated with acquired immunodeficiency syndrome

Primary gastric non-Hodgkin's lymphoma (NHL) is a co-morbidity that can be observed during the clinical course of acquired immunodeficiency syndrome (AIDS). We evaluated the prevalence, clinical-evolutive aspects and form of endoscopic presentation of primary gastric NHL associated with AIDS. Two hundred and forty-three HIV patients were submitted to upper digestive endoscopy, with evaluation of clinical, endoscopic and histological data. A CD4 count was made by flow cytometry and viral load was determined in a branched-DNA assay. Six cases (five men; mean age: 37 years; range: 29-46 years) of primary gastric NHL were detected. The median CD4 count was 140 cells/mm³ and the median viral load was 40,313 copies/mL. Upper digestive endoscopy revealed polypoid (in four patients) ulcero-infiltrative (two patients) and ulcerated (two patients) lesions and combined polypoid and ulcerated lesions (two patients). Histology of the gastric lesions demonstrated B cell NHL (four patients) and T cell NHL (two patients). Five of the six patients died of complications related to gastric NHL. We concluded that primary gastric NHL is an important cause of mortality associated with AIDS.

[Unexplained acute pancreatitis: the microlithiasis must be searched?]. / Pancreatite aguda sem etiologia aparente: a microlitíase deve ser pesquisada?

In a large number of patients, with episodes of acute pancreatitis the etiology is not identified, even after initial clinical history, detailed physical examination, laboratory tests and biochemical exams and an transabdominal ultrasound. This patient are considered with a unexplained acute pancreatitis. In this cases the treatment is restricted to improvement of symptoms. These patients after treated tend to have new episodes with the risk of raising the rates of morbidity and mortality. Therefore, the identification of a cause and its prompt treatment prevent at recurrent episodes of pancreatitis. This review aims to draw attention to how best diagnostic approach when the light of evidence-based medicine, to search for causes of difficult identification with microlithiasis, occult stones, the anatomical variations of biliary and pancreatic duct and in addition to sphincter of Oddi dysfunction.

Assepsia e antissepsia: técnicas de esterilização / Asepsy and antisepsy: technics of sterilization

Por ser o hospital um ambiente insalubre, as técnicas de assepsia, anti-sepsia e de esterilização são de extrema importância para reduzir os riscos de infecção. São apresentados os principais anti-sépticos e técnicas de esterilização.

The hospital is considered a virtual place for contamination. The technics of asepsis or antisepsis and sterilization are of extreme importance to reduce the risks of infection. In this work the main antiseptics and technics of sterilization are presented.

Cell block technique and cytological smears for the differential diagnosis of pancreatic neoplasms after endosonography-guided fine-needle aspiration.

Cytological smear is widely employed to analyse specimens obtained from endosonography-guided fine-needle aspiration (EUS-FNA), but false-negative or inconclusive results may occur. A better diagnostic yield can be obtained from processing cell blocks. We compared the effectiveness of the cell block technique and cytological smear in the diagnosis of pancreatic neoplasms. From January 1997 to December 2006, 611 patients with pancreatic tumors were evaluated by EUS-FNA. Surgery was performed in 356 cases, and the other 255 patients were followed clinically for an average of 12.8 months. In total, 282 (46.2%) patients were evaluated with cytological smears, and 329 (53.8%) were evaluated using only cell blocks. Malignant disease was detected in 352 (57.6%) cases, in which adenocarcinoma accounted for 236 (67%) cases. A benign disease was found in the other 259 cases, including 35.1% focal chronic pancreatitis and 32.4% pseudocysts. Aspiration samples were satisfactory in 595 (97.4%) patients after an average of 2.2 (1-4) passes of the needle. Regardless of the cytopathological examination technique, EUS-FNA confirmed malignancy in 269 of 352 (76.4%) cases, and a benign disease in 257 of 259 (99.2%) cases. For patients who received surgery with histologically confirmed lesions, the sensitivity specificity, positive and negative predictive values, and accuracy of the smears versus cell blocks in diagnosing pancreatic tumors were 61% versus 85.2% (P<0.001), 100% versus 93.1%, 100% versus 98.4%, 36% versus 55.1% (P=0.046) and 68% versus 86.5% (P<0.001), respectively The cell block technique demonstrated a hig her sensitivity, negative predictive value and accuracy than cytological smears.

Treatment of gastrogastric fistula after Roux-en-Y gastric bypass: surgery combined with gastroscopy.

A 53-year-old male who had previously undergone an open gastric bypass (Capella-Fobi) developed a gastrogastric fistula during the late postoperative course. Because he regained weight and had a stomal ulcer difficult to control, it was decided to submit him to revisional surgery. At laparotomy, a retrogastric approach plus gastroscopy permitted easy identification and closure of the fistula. The patient is doing well and losing weight after this reoperation.

Endoscopic ultrasound and fine needle aspiration in chronic pancreatitis: differential diagnosis between pseudotumoral masses and pancreatic cancer.

CONTEXT: Pseudotumoral chronic pancreatitis can be difficult to differentiate from pancreatic carcinoma. OBJECTIVE: To evaluate the role of endoscopic ultrasound and fine needle aspiration in differentiating between inflammatory masses and malignancies in chronic pancreatitis. DESIGN: Retrospective study. SETTING: Tertiary care endoscopy unit. PATIENTS AND INTERVENTIONS: Between February 1997 and December 2006, 69 pancreatic head masses from patients with alcoholic chronic pancreatitis underwent EUS-FNA using a linear echoendoscope and 22-gauge needles. Final diagnoses were obtained from surgery or clinical follow-up. The patients were subdivided into two groups: pseudotumoral chronic pancreatitis and pancreatic cancer. RESULTS: Pseudotumoral masses and adenocarcinoma were found in 58 and 11 patients, respectively. The size of the lesions and the clinical presentation were similar in both groups, but the cancer patients were older than the patients with pseudotumoral masses (P=0.020). Fourteen of the 58 (24.1%) pseudotumoral masses were misdiagnosed as cancers, and 4 of the 11 (36.4%) cancers were erroneously diagnosed as pseudotumoral masses when evaluated by EUS alone. EUS-FNA confirmed the final diagnosis in 66 of the 69 (95.7%) cases. Cytopathology correctly classified 8 of the 11 (72.7%) malignancies and all benign cases. Three of the 11 (27.3%) cancers were misdiagnosed as pseudotumoral masses, and no pseudotumoral mass was diagnosed as a cancer. In two cases, the specimens were inadequate for cytopathological assessment. The sensitivity, specificity, positive and negative predictive values, and the diagnostic accuracy of EUS-FNA were 72.7%, 100%, 100%, 95.1% and 95.7%, respectively. CONCLUSIONS: The diagnostic accuracy of endoscopic ultrasound alone for differentiating between pseudotumoral masses and pancreatic cancer arising from chronic pancreatitis is unsatisfactory. Fine needle aspiration of these tumors significantly improves diagnostic capability.

Correlation between Helicobacter pylori infection, gastric diseases and life habits among patients treated at a university hospital in Southeast Brazil.

Helicobacter pylori is considered a significant agent in the development of various gastric diseases. However, the diseases caused by this bacterium are known as being multi-factorial, with the genotype, immune system and life habits of the host playing important roles in the establishment of the clinical outcome. Also, H. pylori exhibit a high degree of genetic variability, contributing to the complexity of the host-pathogen relationship. These observations, considered together with the widely-varying origins and social habits of the Brazilian population, lead us to speculate about the influence of these life habits on H. pylori infection and the clinical outcome. Therefore, in this study we evaluated the relationship between H. pylori infection and certain diseases in 172 patients treated at the Hospital das Clínicas of Ribeirão Preto (HCRP), Brazil, taking into account their different life habits, such as non-steroidal anti-inflammatory drugs and alcohol ingestion, and smoking habit. Our analysis indicated that H. pylori infection is not affected by any of the life habits evaluated but is associated with the development of peptic ulcers (gastric and duodenal ulcer) and inverse correlate with gastroesophageal reflux disease (GERD). No correlation was found between the infection with this bacterium and gastritis or intestinal metaplasia. However, gastritis and erosive gastritis were directly correlated with non-steroidal anti-inflammatory drugs (NSAID) ingestion. Moreover, ingestion of alcohol beverages exhibited a protective effect on gastritis development in men. Our data also indicated that to achieve reliable detection of this bacterium in biopsies, two or three detection methods should be used.

Diagnosis of pancreatic tumors by endoscopic ultrasound-guided fine-needle aspiration.

AIM: To evaluate the diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for pancreatic solid tumors larger or smaller than 3 cm, and cystic lesions. METHODS: From January/1997 to December/2006, 611 patients with pancreatic tumors were subjected to EUS-FNA. The final diagnosis was obtained either by surgery (356 cases) or after a mean clinical follow-up of 11.8 mo in the remaining patients. RESULTS: There were 405 solid tumors, 189 cystic lesions and 17 mixed. Pancreatic specimens for cytological assessment were successfully obtained by EUS-FNA in 595 (97.4%) cases. There were 352 (57.6%) malignancies and 259 (42.4%) benign tumors. Among the malignancies, pancreatic adenocarcinomas accounted for 67% of the lesions. Overall, the sensitivity, specificity, positive and negative predictive values, and accuracy of EUS-FNA were, respectively, 78.4%, 99.2%, 99.3%, 77.2% and 87.2%. Specifically for solid tumors, the same parameters for neoplasms larger and smaller than 3 cm were, respectively, 78.8% vs 82.4%, 100% vs 98.4%, 100% vs 99%, 54.8% vs 74.1% and 83.1% vs 87.8%. For cystic lesions, the values were, respectively, 72.2%, 99.3%, 97.5%, 91% and 92.2%. CONCLUSION: EUS-FNA can be used to sample pancreatic tumors in most patients. Even though the negative predictive value is inadequate for large solid tumors, the results are rather good for small solid tumors, especially concerning the sensitivity, negative predictive value and diagnostic accuracy. Among all pancreatic lesions, EUS-FNA for cystic lesions can reveal the best negative predictive value and diagnostic accuracy, both higher than 90%.

Association between Helicobacter pylori genotypes and gastric disorders in relation to the cag pathogenicity island.

Helicobacter pylori is a bacterium associated with upper gastrointestinal diseases in humans. However, only a small proportion of infected people become sick. Although several studies have tried to establish an association between known virulence markers and clinical outcomes, in many cases the results have been conflicting. The aim of this study was to investigate the importance of virulence markers to predict clinical outcome in Brazil. Mixed infections by genetically unrelated strains detected by vacA genotyping were found in 18% of the patients. The cagA and cagE genes and the vacAs1 genotype were associated with the development of peptic ulcer disease (PUD). The cagAvacAs1m1 genotype was associated with PUD and duodenal ulcer (DU). Conversely, jhp947 was not associated with DU or PUD, indicating that this gene is not a universal virulence marker. These results also show that a high proportion of the patients were simultaneously infected by cag-positive and cag-negative H. pylori types. This finding suggests the existence of a dynamic equilibrium between the loss and gain of the cag pathogenicity island, probably depending on the physiologic conditions of the patient's stomach. To the best of our knowledge, this is the first study that has documented this finding in Brazil.

Correlation between Helicobacter pylori infection, gastric diseases and life habits among patients treated at a university hospital in Southeast Brazil

Helicobacter pylori is considered a significant agent in the development of various gastric diseases. However, the diseases caused by this bacterium are known as being multi-factorial, with the genotype, immune system and life habits of the host playing important roles in the establishment of the clinical outcome. Also, H. pylori exhibit a high degree of genetic variability, contributing to the complexity of the host-pathogen relationship. These observations, considered together with the widely-varying origins and social habits of the Brazilian population, lead us to speculate about the influence of these life habits on H. pylori infection and the clinical outcome. Therefore, in this study we evaluated the relationship between H. pylori infection and certain diseases in 172 patients treated at the Hospital das Clínicas of Ribeirão Preto (HCRP), Brazil, taking into account their different life habits, such as non-steroidal anti-inflammatory drugs and alcohol ingestion, and smoking habit. Our analysis indicated that H. pylori infection is not affected by any of the life habits evaluated but is associated with the development of peptic ulcers (gastric and duodenal ulcer) and inverse correlate with gastroesophageal reflux disease (GERD). No correlation was found between the infection with this bacterium and gastritis or intestinal metaplasia. However, gastritis and erosive gastritis were directly correlated with non-steroidal anti-inflammatory drugs (NSAID) ingestion. Moreover, ingestion of alcohol beverages exhibited a protective effect on gastritis development in men. Our data also indicated that to achieve reliable detection of this bacterium in biopsies, two or three detection methods should be used.

Prevalence of Helicobacter pylori cagA, iceA and babA2 alleles in Brazilian patients with upper gastrointestinal diseases.

Helicobacter pylori is an important human pathogen associated with gastrointestinal diseases such as gastritis, gastric and duodenal ulcer (peptic ulcer disease, PUD), and gastric cancer. A number of pathogenic factors have been described for this bacterium, and some of them have been proposed as markers for the prediction of the clinical outcome. However, with the exception of the cag and vacA status, there is no universal consensus regarding the importance of the other virulence factors. Therefore, the aim of this study was to investigate the status of H. pylori strains regarding the babA and iceA alleles, as well as the cagA genotype, to reveal any association between these genotypes and clinical outcomes in Brazilian patients. The great majority (92.6%) of the strains were typed as iceA1, while 40.4% were found to possess the babA2 allele. The cagA gene was detected in 73.4% of the strains. The iceA2 and cagA genotypes were associated with PUD, while iceA1 was negatively correlated with PUD. However, considering the high percentage of strains typed as iceA1, these associations must be treated with caution. No clinical entity was associated with the babA2 allele. These results suggest that iceA1 is not a good marker for the diseases associated with H. pylori infection in Brazil. Further studies are needed in order to elucidate the relevance of the babA status, because other studies performed in Brazil have associated the babA2 allele with clinical outcomes. These results also indicate the existence of regional differences in the H. pylori genotypes and their association with clinical outcomes.

Liver disease associated with intestinal failure in the small bowel syndrome.

The introduction of the Total Parenteral Nutrition (TPN) has given rise to a new hope in the treatment of intestinal failure (LF) associated with the Short Bowel Syndrome (SBS). However, together with the TPN and the increase of survival of these patients, new problems and questions have emerged, as well as new therapeutical procedures. Taking into consideration this emerging reality, this paper has the purpose to undertake a review of current concepts and available treatments for patients with IF associated-liver disease. Although TPN provides an increase of survival of patients with intestinal failure, it is a potential source of complication such as: septicemia, hyperglycemia, venous thrombosis and liver disease. There are several hypothesis conceived to explain the liver disease associated to intestinal failure, however the only definite treatment as a potential to reverse the non-cirrhotic liver disease is the small intestine transplantation. Despite indications for intestine transplantation are not entirely defined in literature, the trend is its early indication in high-risk patients, preserving the liver integrity and preventing the eventual need of both liver and intestine transplantations altogether.