Performance of artificial intelligence in the characterization of colorectal lesions.

Background: Image-enhanced endoscopy (IEE) has been used in the differentiation between neoplastic and non-neoplastic colorectal lesions through microvasculature analysis. This study aimed to evaluate the computer-aided diagnosis (CADx) mode of the CAD EYE system for the optical diagnosis of colorectal lesions and compare it with the performance of an expert, in addition to evaluating the computer-aided detection (CADe) mode in terms of polyp detection rate (PDR) and adenoma detection rate (ADR). Methods: A prospective study was conducted to evaluate the performance of CAD EYE using blue light imaging (BLI), dichotomizing lesions into hyperplastic and neoplastic, and of an expert based on the Japan Narrow-Band Imaging Expert Team (JNET) classification for the characterization of lesions. After white light imaging (WLI) diagnosis, magnification was used on all lesions, which were removed and examined histologically. Diagnostic criteria were evaluated, and PDR and ADR were calculated. Results: A total of 110 lesions (80 (72.7%) dysplastic lesions and 30 (27.3%) nondysplastic lesions) were evaluated in 52 patients, with a mean lesion size of 4.3 mm. Artificial intelligence (AI) analysis showed 81.8% accuracy, 76.3% sensitivity, 96.7% specificity, 98.5% positive predictive value (PPV), and 60.4% negative predictive value (NPV). The kappa value was 0.61, and the area under the receiver operating characteristic curve (AUC) was 0.87. Expert analysis showed 93.6% accuracy, 92.5% sensitivity, 96.7% specificity, 98.7% PPV, and 82.9% NPV. The kappa value was 0.85, and the AUC was 0.95. Overall, PDR was 67.6% and ADR was 45.9%. Conclusions: The CADx mode showed good accuracy in characterizing colorectal lesions, but the expert assessment was superior in almost all diagnostic criteria. PDR and ADR were high.

Effect of Linked-color Imaging on the Detection of Adenomas in Screening Colonoscopies.

OBJECTIVES: Linked-color imaging (LCI) is a new image-enhancement option that emphasizes mucosal surface contrast, facilitating the differentiation between colorectal lesions and normal mucosa. This study aimed to evaluate the potential of LCI to increase the detection of colorectal adenomas in screening colonoscopies. METHODS: A prospective randomized study was conducted using white-light imaging (WLI), blue-laser imaging (BLI)-bright and LCI. The outcome measures were adenoma detection rate (ADR), mean number of adenomas per patient, and withdrawal time. Lesion characteristics such as size, morphology, location, and histology were also evaluated. RESULTS: A total of 205 patients were randomized, and 251 adenomas were detected. The overall ADR was 62%. The ADR was 52.9% for WLI, 62.1% for BLI-bright, and 71% for LCI, and was significantly higher in the LCI group than in the WLI group (P=0.04). No significant difference was observed between LCI and BLI-bright (P=0.28) or BLI-bright and WLI (P=0.30). The mean number of adenomas per patient was 1.01, 1.03, and 1.62 for WLI, BLI-bright, and LCI, respectively, with a significant difference (P=0.02). Withdrawal time did not differ among the groups. A total of 71 adenomas were detected by WLI, 68 by BLI-bright, and 112 by LCI. There was no difference in the size and morphology of the adenomas detected, nor in the diagnosis of sessile serrated adenomas/polyps. CONCLUSION: LCI significantly increased the detection of adenomas in screening colonoscopies.

Blue laser imaging: a new image-enhanced endoscopy for the diagnosis of colorectal lesions.

BACKGROUND: Image-enhanced endoscopy enables real-time differential diagnosis of colorectal lesions through the observation of microvascular architecture. PURPOSE: To evaluate the efficacy of using blue laser imaging (BLI) for capillary pattern analysis in the differential diagnosis of neoplastic and non-neoplastic lesions. PATIENTS AND METHODS: This prospective study included 920 consecutive superficial lesions diagnosed in 457 patients. The capillary pattern was analysed using BLI-bright magnification on the basis of the Teixeira classification. Histopathology was used as the reference standard. RESULTS: The adenoma detection rate was 42.3%, with a mean of 0.95 adenomas per patient. Neoplastic lesions were predominant (70.3%), of which 33 (5.1%) had advanced histology. Neoplastic progression was significantly increased in patients aged at least 50 years, in lesions at least 10 mm and in lesions located in the right colon (P<0.01). BLI-based capillary pattern analysis showed 95.5% accuracy, 95.7% sensitivity, 95.2% specificity, 97.9% positive predictive value and 90.3% negative predictive value in the diagnosis of neoplastic lesions. For 672 diminutive lesions (≤5 mm), BLI-based capillary pattern analysis showed 95.7% accuracy, 96.6% sensitivity, 93.6% specificity, 97.2% positive predictive value and 92.2% negative predictive value. Analysing only lesions up to 5 mm in the rectum and sigmoid colon, the values were 95.2, 93.9, 96.5, 95.8 and 94.8%, respectively. CONCLUSION: BLI associated with magnification yielded excellent results for the real-time predictive histological diagnosis of colorectal lesions.

A prospective randomized trial of intralesional triamcinolone injections after endoscopic dilation for complex esophagogastric anastomotic strictures: steroid injection after endoscopic dilation.

BACKGROUND AND AIMS: Postoperative esophageal strictures frequently recur. We assessed the efficacy of injecting triamcinolone after bougie dilation in comparison to dilation alone. METHODS: In a double-blind randomized fashion, 19 patients (68% male with mean age of 53-years old) with non-dilated esophagogastric complex strictures after esophagectomy with gastric pull-up were assigned to receive dilation alone (control) or 40 mg of triamcinolone at the borders of the wall lacerations caused by the bougienage in each dilation session during the study follow-up. Dysphagia and complications were assessed at 1, 2, and 6 months. Primary end-point was to be dysphagia-free. RESULTS: After 1 month of the beginning of therapy, 4 patients in the steroid group were without dysphagia, in comparison to 0 patient in the control group (P = 0.021). Six months after endoscopic therapy, 62% of the cases in the triamcinolone group versus none in the control group were dysphagia-free (P = 0.009). There was no perforation nor hemorrhage. CONCLUSIONS: Injecting triamcinolone after every dilation session next to or at the borders of the lacerations caused by the dilators, results in a significant improvement or resolution of dysphagia.

Endoscopic classification of the capillary-vessel pattern of colorectal lesions by spectral estimation technology and magnifying zoom imaging.

BACKGROUND: Colonoscopy with spectral estimation technology and magnifying zoom imaging allows the characterization of the fine superficial capillary pattern of normal mucosa and of colorectal lesions. The endoscopic distinction of the capillary pattern of colorectal lesions might contribute to the differential diagnosis among normal, hyperplastic, and neoplastic lesions. OBJECTIVE: By means of these latest technologic advances, the objective is to define a classification of the capillary-vessel pattern of colorectal lesions diagnosed during routine colonoscopy. DESIGN: A total of 309 colorectal lesions endoscopically or surgically resected were prospectively examined. The capillary pattern was divided into 5 subtypes according to the number, morphology, and distribution of the fine blood vessels. Capillary patterns types I and II were characterized by a few short, straight, and sparsely distributed vessels; types III to V were of numerous, elongated, and tortuous capillaries irregularly distributed. RESULTS: The overall accuracy of the capillary-vessel classification in determining the neoplastic or non-neoplastic nature of the colorectal lesions was 98.3% (304/309 lesions). Among 59 non-neoplastic lesions, 56 (94.9%) that showed patterns I or II were diagnosed as normal, inflammatory, or hyperplastic polyps. Of the 250 neoplastic lesions, 248 (99.2%) that had capillary pattern types III, IV, and V were diagnosed as adenomatous or carcinoma. The sensitivity of the capillary pattern classification for distinguishing neoplasia was 99.2% (95% CI, 98.2%-100%), and the specificity was 94.9% (95% CI, 92.5%-97.4%). LIMITATION: A single-center study. CONCLUSION: The endoscopic classification of the superficial capillary-vessel pattern of colorectal lesions is an accurate method of predicting the histopathologic findings.

Repeated peribulbar injections of triamcinolone acetonide: a successful and safe treatment for moderate to severe Graves' ophthalmopathy.

PURPOSE: In this study, we aimed to evaluate the efficacy of peribulbar triamcinolone injections to treat inflammatory signs of Graves' ophthalmopathy (GO) in patients with moderate to severe GO and associated optic neuropathy (ON). METHODS: Twenty-one patients with active GO [clinical activity score (CAS) > or = 4] and systemic thyroid disease under control were enrolled in this prospective pilot study. Peribulbar triamcinolone acetonide was injected in each orbit (42 eyes), in four doses of 20 mg at 2-week intervals. Ophthalmological examination including CAS evaluation, visual field, computerized tomography (CT) scan and digital photography were performed before and after treatment. RESULTS: Twenty-one patients (11 with moderate disease, 10 with ON) were enrolled in this study and followed for at least 14 months. Initial mean CAS was 6.38 +/- 1.49, which dropped to 1.8 +/- 1.12 after 6 months of treatment (P = 0.01; mean difference of 4.57 +/- 1.56; range 1-8 score points). ON was diagnosed in 10 patients. Of these, 66% improved with peribulbar triamcinolone exclusively. A transitory increase in intraocular pressure in two patients was controlled with topic medication. CONCLUSION: Peribulbar triamcinolone injections reduce the inflammatory signs of moderate GO, as measured by the CAS, and could also be used as an alternative treatment for ON. Randomized clinical trials are needed to compare the results of triamcinolone peribulbar injections to those of other treatment modalities.

Endoscopic dilation of benign esophageal strictures without fluoroscopy: experience of 2750 procedures.

BACKGROUND/AIMS: To report a large series of patients with strictures from different etiologies who underwent dilation without fluoroscopy. METHODOLOGY: Between 1992 and 2005, 321 patients who underwent 2750 dilation sessions were entered in a database. Dysphagia score, cause and location of the stricture and diameter of the bougies were recorded in every session. RESULTS: The mean follow-up period was 18.8 months. Stricture was postsurgical in 204 patients, peptic in 60, caustic in 13, postradiotherapy in 13, and from other causes in 31. Clinical response was achieved in 92% of the postsurgical patients; 84% of the caustic injuries; 81% of the peptic patients; and 58% of the radiation injuries (p < 0.05). Absence of dysphagia was obtained in 68, 38, 67 and 27% of these, respectively (p < 0.05). All groups showed a significant improvement in dysphagia score, and 98% of patients in whom a 45F catheter was inserted, achieved clinical response. There were 6 perforations, with 2 deaths. CONCLUSIONS: Endoscopic dilation for benign esophageal strictures without fluoroscopy is safe and effective. Postsurgical patients show excellent results for dilation, and caustic and post-radiotherapy strictures have the worst response. A diameter of 45F is a satisfactory end-point for therapy in the majority of cases.

Redução da prevalência de úlcera duodenal: um estudo brasileiro (análise retrospectiva na última década: 1996-2005) / Prevalence reduction of duodenal ulcer: a Brazilian study. (retrospective analysis in tha last decade: 1996-2005)

RACIONAL: A úlcera duodenal sempre representou uma doença muito prevalente entre as enfermidades digestivas, em qualquer parte do mundo. A prevalência média era de aproximadamente 10 por cento da população mundial. A partir do início dos anos 90, a literatura, tanto européia como norte-americana, passou a demonstrar sua redução gradativa entre seus países. OBJETIVO: Demonstrar, através de análise retrospectiva, a prevalência anual da úlcera duodenal nos últimos 10 anos em um Serviço de Endoscopia Digestiva que é referência para o sistema público de saúde da cidade de Porto Alegre, municípios da Grande Porto Alegre e outras cidades vizinhas da mesma. Os dados analisados são de março de 1996 até dezembro de 2005. MÉTODOS: Estudo retrospectivo transversal, com análise documental de diagnósticos endoscópicos efetuados em endoscopia digestiva alta, no referido Serviço. Foi feita a análise retrospectiva de diagnósticos endoscópicos efetuados em 13.130 pacientes submetidos a endoscopia digestiva alta no período de março de 1996 a dezembro de 2005. A classificação de Sakita foi utilizada para o estádio do grau evolutivo da úlcera duodenal e foi considerado por ela acometido o paciente com a lesão no estágio A1, até o estágio S1, inclusive. Observou-se também a prevalência nos dois sexos, na raça, o percentual médio total nos 10 anos, além da prevalência anual. Para verificar se houve significância estatística dos resultados observados nos diferentes períodos, foi aplicado um teste de regressão linear ("linear regression model"). RESULTADOS: Observou-se decréscimo gradativo dos percentuais de prevalência da úlcera duodenal, ano após ano, iniciando-se em 1996 com 8,6 por cento e se encerrando no final de 2005, com 3,3 por cento. A exceção do período foi observada no ano de 2003 quando houve um acréscimo, comparando-se com o decréscimo gradativo dos 6 anos anteriores. Mas já, a partir do período seguinte (2004), a queda gradativa voltou a ser observada...

BACKGROUND: The duodenal ulcer always represented a very prevalent pathology among the gastrointestinal tract diseases worldwide. The average prevalence is approximately 10 percent of the world population. In the 90s the literature (both European and North American) begin to show a crescent reduction of this prevalence in many countries. AIM: To show through a retrospective analysis the annual prevalence of the duodenal ulcer in the last 10 years in a Digestive Endoscopy Service which is referred to public medical system in Porto Alegre and its suburban area and countryside of the State of Rio Grande do Sul, Brazil. The data analyzed is from March 1996 to December 2005. Specific data: transversal retrospective study with documented analysis of endoscopic diagnosis of upper gastrointestinal endoscopy. METHODS: A retrospective analysis of the diagnosis of the 13.130 procedures of upper gastrointestinal endoscopy between 1996 and 2005. The Sakita classification was used to verify the duodenal ulcer activity taking into consideration the patients who have lesions on A1 to S1 levels. To verify if there was a statistical significant results, a linear regression test was done (linear regression model). RESULTS: A gradate decrease of the prevalence percentuals was observed, year after year, it began with 8.3 percent of prevalence in 1996 and finished with 3.3 percent in the beginning of 2006. The average annual reduction of this prevalence was calculated following the regression test and it was placed in the 1.3 percent a year in the studied period of time. In 2003, in an isolated way, it was an exception in the decrease of the percentage because it presented a prevalence increase of (6.5 percent) comparing to the first 6 years of study. CONCLUSION: In this study it was observed a decrease of duodenal ulcer prevalence, 1.3 percent a year to be more accurate in 10 years of study, showing a statistical significance in the linear regression test.

Endoscopic laser lithotripsy for complicated bile duct stones: is cholangioscopic guidance necessary?

BACKGROUND: Endoscopic papillotomy is successful in more than 95% of the cases of choledocholithiasis. For patients with difficult bile duct stones not responding to mechanical lithotripsy, different methods for stone fragmentation have been developed. AIM: To compare the results of laser lithotripsy with a stone-tissue recognizing system, when guided by fluoroscopy only or by cholangioscopy. METHODS: Between 1992 and 2002 we have treated 89 patients with difficult bile duct stones by endoscopic retrograde cholangiopancreatography and laser lithotripsy. Unsuccessful extracorporeal shock-wave lithotripsy and electrohydraulic were also performed before laser in 35% and 26% of the cases, respectively. RESULTS: Laser was effective in 79.2% of 72 patients guided by cholangioscopy and in 82.4% of 17 cases steered by fluoroscopy. The median number of impulses in the latter was 4,335 and 1,800 with the former technique. Two parameters influenced the manner of laser guidance. In cases of stones situated above a stricture, cholangioscopic control was more effective (64.7% vs. 31.9%). When the stones were in the distal bile duct, fluoroscopic control was more successful. CONCLUSION: In cases of difficult stones in the distal bile duct, laser lithotripsy under fluoroscopic control is very effective and easily performed. Cholangioscopic guidance should be recommended just in cases of intrahepatic stones or in patients with stones situated proximal to a bile duct stenosis. In these cases, cholangioscopy should be performed either endoscopically or percutaneously.

Endoscopic laser lithotripsy for complicated bile duct stones: is cholangioscopic guidance necessary?

BACKGROUND: Endoscopic papillotomy is successful in more than 95 percent of the cases of choledocholithiasis. For patients with difficult bile duct stones not responding to mechanical lithotripsy, different methods for stone fragmentation have been developed. AIM: To compare the results of laser lithotripsy with a stone-tissue recognizing system, when guided by fluoroscopy only or by cholangioscopy. METHODS: Between 1992 and 2002 we have treated 89 patients with difficult bile duct stones by endoscopic retrograde cholangiopancreatography and laser lithotripsy. Unsuccessful extracorporeal shock-wave lithotripsy and electrohydraulic were also performed before laser in 35 percent and 26 percent of the cases, respectively. RESULTS: Laser was effective in 79.2 percent of 72 patients guided by cholangioscopy and in 82.4 percent of 17 cases steered by fluoroscopy. The median number of impulses in the latter was 4,335 and 1,800 with the former technique. Two parameters influenced the manner of laser guidance. In cases of stones situated above a stricture, cholangioscopic control was more effective (64.7 percent vs. 31.9 percent). When the stones were in the distal bile duct, fluoroscopic control was more successful. CONCLUSION: In cases of difficult stones in the distal bile duct, laser lithotripsy under fluoroscopic control is very effective and easily performed. Cholangioscopic guidance should be recommended just in cases of intrahepatic stones or in patients with stones situated proximal to a bile duct stenosis. In these cases, cholangioscopy should be performed either endoscopically or percutaneously.

RACIONAL: A papilotomia endoscópica é efetiva em mais de 95 por cento dos casos de coledocolitíase . Para pacientes com cálculos de difícil extração (gigantes ou proximais a uma estenose), que não respondem à litotripsia mecânica, diferentes métodos de fragmentação foram desenvolvidos. OBJETIVO: Comparar os resultados da litotripsia à laser com um sistema de reconhecimento cálculo-tecido, quando guiada por fluoroscopia somente ou por colangioscopia. MÉTODOS: Entre 1992 e 2002 foram tratados 89 pacientes com cálculos biliares de difícil extração pela colangiopancreatografia endoscópica retrógrada e litotripsia à laser. Litotripsia extracorpórea e eletro-hidráulica sem sucesso foram executados antes do laser em 35 por cento e 26 por cento dos casos, respectivamente. RESULTADOS: O laser foi efetivo em 79,2 por cento dos 72 pacientes guiados por colangioscopia e, em 82,4 por cento dos 17 casos guiados por fluoroscopia. A média de impulsos do último foi de 4 335 e da primeira técnica de 1 800. Dois parâmetros influenciaram o modo de orientação da litotripsia à laser. Nos casos de cálculos situados proximais a uma estenose, o controle colangioscópico foi mais efetivo (64,7 por cento vs 31,9 por cento). Quando os cálculos estavam na via biliar distal, o controle fluoroscópico era mais efetivo. CONCLUSÃO: Nos casos de cálculos biliares de difícil extração na via biliar distal, litotripsia à laser com controle fluoroscópico é muito efetiva e de fácil execução. A orientação colangioscópica deve ser recomendada somente nos casos de cálculos intra-hepáticos ou em pacientes com cálculos situados proximamente a uma estenose de via biliar. Nesses casos, colangioscopia pode ser executada tanto por via endoscópica quanto percutânea.

[Prevalence reduction of duodenal ulcer: a Brazilian study. (retrospective analysis in the last decade: 1996-2005)]. / Redução da prevalência de úlcera duodenal: um estudo brasileiro (análise retrospectiva na última década: 1996-2005).

BACKGROUND: The duodenal ulcer always represented a very prevalent pathology among the gastrointestinal tract diseases worldwide. The average prevalence is approximately 10% of the world population. In the 90s the literature (both European and North American) begin to show a crescent reduction of this prevalence in many countries. AIM: To show through a retrospective analysis the annual prevalence of the duodenal ulcer in the last 10 years in a Digestive Endoscopy Service which is referred to public medical system in Porto Alegre and its suburban area and countryside of the State of Rio Grande do Sul, Brazil. The data analyzed is from March 1996 to December 2005. Specific data: transversal retrospective study with documented analysis of endoscopic diagnosis of upper gastrointestinal endoscopy. METHODS: A retrospective analysis of the diagnosis of the 13.130 procedures of upper gastrointestinal endoscopy between 1996 and 2005. The Sakita classification was used to verify the duodenal ulcer activity taking into consideration the patients who have lesions on A1 to S1 levels. To verify if there was a statistical significant results, a linear regression test was done (linear regression model). RESULTS: A graduate decrease of the prevalence percentuals was observed, year after year, it began with 8.3% of prevalence in 1996 and finished with 3.3% in the beginning of 2006. The average annual reduction of this prevalence was calculated following the regression test and it was placed in the 1.3% a year in the studied period of time. In 2003, in an isolated way, it was an exception in the decrease of the percentage because it presented a prevalence increase of (6.5%) comparing to the first 6 years of study. CONCLUSION: In this study it was observed a decrease of duodenal ulcer prevalence, 1.3% a year to be more accurate in 10 years of study, showing a statistical significance in the linear regression test.

O critério de positividade para a análise imunoistoquímica da p53 na confirmação da displasia do esôfago de Barrett faz diferença? / Does positive criterium for p53 immunohistochemical analysis in the confirmation of Barrett's dysplasia make difference?

RACIONAL: O esôfago de Barrett é uma complicação da doença do refluxo gastroesofágico com importante potencial de malignização. Relata-se que a expressão do marcador tumoral p53 se acentua com a progressão displasia-adenocarcinoma. OBJETIVO: Avaliar a expressão da p53 no epitélio de Barrett com presença ou não de displasia conforme dois critérios de positividade. MATERIAL E MÉTODOS: O material foi constituído por biopsias endoscópicas de 42 doentes com esôfago de Barrett. Cortes histológicos foram corados pela hematoxilina-eosina, pelo PAS-alcian blue e avaliados quanto à expressão imunoistoquímica da p53. O diagnóstico de displasia foi firmado pela concordância entre três patologistas. Foram utilizados dois critérios de positividade para a p53: 1. a coloração de, pelo menos, metade dos núcleos e 2. o encontro de qualquer núcleo corado. RESULTADOS: O número total de fragmentos foi de 229, com média de 5,4 por paciente. A displasia foi detectada em seis (14,3 por cento) casos. Para diferentes critérios de positividade, a p53 foi detectada, respectivamente, em 5 (13,9 por cento) e 14 (38,9 por cento) com epitélio metaplásico não-displásico. Especificamente nos seis casos displásicos, a p53 foi detectada, conforme o critério de positividade, em um (16,7 por cento) e quatro (66,7 por cento) casos, respectivamente. CONCLUSÕES: Nesta pequena série, a expressão imunoistoquímica da p53, independente do critério de positividade, não foi de auxílio para a confirmação de alterações displásicas no esôfago de Barrett.

[Does the criterium of positivity for the immunohistochemical analysis of p53 in the confirmation of Barrett's dysplasia make any difference?]. / O critério de positividade para a análise imunoistoquímica da p53 na confirmação da displasia do esôfago de Barrett faz diferença?

BACKGROUND: Barrett's esophagus is the most serious complication of the gastroesophageal reflux disease and presents a malignant potential. The expression of the tumoral marker p53 increases with the dysplasia-adenocarcinoma sequence. AIMS: To evaluate the p53 expression in Barrett's esophagus with or without dysplasia according to the two positive immunostaining criteria. MATERIALS AND METHODS: The material was constituted by endoscopic biopsy specimens from 42 patients with Barrett's esophagus. Section of formalin-fixed and paraffin-embedded biopsies were stained with hematoxylin-eosin, PAS-alcian blue and evaluated the p53 immunohistochemical expression. Two p53 immunostaining criteria were utilized: 1. The staining of, at least, half of the nuclei, and 2. The staining of any nucleus. The diagnosis of dysplasia was confirmed by the agreement between three pathologists. RESULTS: The total number of tissue specimens was 229, with an average of 5.4 specimens per patient. Dysplasia, with agreement for all pathologists examining the same set of slides, was detected in six (14.3%) cases. According to the two different p53 immunostaining criteria, the protein was detected in non-dysplastic Barrett's metaplasia, respectively, in 5 (13.9%) and 14 (38.9%) patients. Specifically in the six dysplastic cases, p53 was detected, according to the immunostaining criteria, in one (16.7%) and four (66.7%) cases, respectively. CONCLUSIONS: In this group, p53 immunohistochemical expression, regardless of positive criteria take into account, was not useful for detecting dysplasia in Barrett's esophagus.

[Dysplasia in Barrett's esophagus--intra- and interobserver variability in histopathological diagnosis]. / Displasia no esôfago de Barrett--concordância intra e interobservador no diagnóstico histopatológico.

BACKGROUND: Barrett's esophagus is a well-known pre-malignant condition. Pathologic interpretation of biopsy specimens guides endoscopic surveillance as well as the therapeutic approach that will be carried out. However, the predictive value of histopathologic diagnosis can be questioned due to its poor intra- and interobserver reproducibility. AIMS: To assess intra- and interobserver variability in the diagnosis of Barrett's dysplasia. MATERIAL AND METHODS: Three-micrometer thick sections from biopsy specimens from 42 patients with Barrett's esophagus were stained with hematoxylin-eosin and PAS-alcian blue. The reading of the slides was carried out blindly in a light microscope. Intra and interobserver variability in the interpretation of the slides was determined by kappa statistics. RESULTS: The number of tissue specimens was 229, with average of 5.45 (1 to 18) fragments for patient. Low grade dysplasia was diagnosed by pathologists in 21.4% to 52.4% of the cases. The intra-observer agreement for the diagnosis of low grade dysplasia was slight (kappa = 0.30). The interobserver agreement for the diagnosis of low grade dysplasia was poor, with kappa scores between 0.05 and 0.16. The diagnosis of dysplasia, with agreement for all pathologists examining the same set of slides, was 14.3%. CONCLUSIONS: Pathologic interpretation of Barrett's dysplasia may be subject to marked intra- and interobserver variabiliaty. Interpretation of low grade dysplasia, as high grade dysplasia, should also be considered for review by two or more pathologists.

The role of cagA Helicobacter pylori strains in gastro-oesophageal reflux disease.

BACKGROUND AND AIMS: The role of Helicobacter pylori infection in gastro-oesophageal reflux disease is controversial. The aim of this study was to evaluate the prevalence of colonization by cagA-positive and cagA-negative H. pylori strains in the spectrum of gastro-oesophageal reflux disease. METHODS: A total of 108 patients (50 male/58 female; mean age, 50.3 years) with dyspepsia and peptic ulcer or erosive gastritis/duodenitis were categorized into patients without reflux and patients with reflux oesophagitis graded from I to IV. All patients underwent upper endoscopy with biopsies of the antrum. H. pylori was detected by histology, urease test and polymerase chain reaction. The cagA status was diagnosed in the gastric biopsy by polymerase chain reaction. RESULTS: The overall prevalence of H. pylori colonization in patients with reflux was 68.6% and was 70.2% in those without oesophageal disease (P = 0.862). Colonization by cagA-positive strains was also not statistically different between the two groups (31.4% versus 40.4%, P = 0.332). However, patients with grades II-IV reflux oesophagitis were less colonized by the bacterium (36.4%) than patients with grade I oesophagitis (77.5%) (P = 0.009). H. pylori cagA-positive strains were also less likely to colonize the stomach of patients with grades II-IV oesophagitis (0%), than grade I reflux oesophagitis (40%) patients and controls (40.4%). CONCLUSIONS: Infection of the stomach by H. pylori and especially by H. pylori cagA strains may play a protective role against the development of the most severe forms of gastro-oesophageal reflux disease.

Displasia no esôfago de Barrett - concordância intra e interobservador no diagnóstico histopatológico / Dysplasia in Barrett's esophagus - intra- and interobserver variability in histopathological diagnosis

RACIONAL: O potencial maligno do esôfago de Barrett é bem reconhecido. A vigilância endoscópica e a abordagem terapêutica se baseiam na presença e graduação da displasia. Contudo, a validade do diagnóstico histopatológico pode ser questionada devido à precária reprodutibilidade tanto intra como interobservador. OBJETIVO: Avaliar a concordância intra e interobservador no diagnóstico de displasia no esôfago de Barrett. MATERIAL E MÉTODOS: O material foi constituído por 42 blocos de parafina contendo fragmentos de esôfago provenientes de biopsias endoscópicas de portadores de esôfago de Barrett. Cortes de 3 micrômetros foram corados pela hematoxilina-eosina e pelo PAS-alcian blue. A leitura das lâminas foi realizada de maneira cega, em microscópio óptico. A reprodutibilidade intra e interobservador utilizou o teste kappa. RESULTADOS: O número total de fragmentos foi de 229, com média de 5,45 (1 a 18) fragmentos por paciente. O diagnóstico de displasia de baixo grau firmado pelos diferentes patologistas variou de 21,4 por cento a 52,4 por cento. A concordância intra-observador para o diagnóstico de displasia de baixo grau foi fraca (kappa = 0,30). A concordância interobservador para o diagnóstico de displasia de baixo grau foi pobre, com escore kappa oscilando entre 0,05 e 0,16. O diagnóstico de displasia, firmado pela concordância entre todos os patologistas, foi de 14,3 por cento. CONCLUSÕES: A concordância no diagnóstico histopatológico de displasia de baixo grau no esôfago de Barrett, tanto intra quanto interobservador, é ruim. Idealmente, à semelhança da displasia de alto grau, o diagnóstico de displasia de baixo grau no esôfago de Barrett também deveria ser confirmado por mais de um patologista.

Tratamento endoscópico de lesões sangrantes do trato gastrointestinal por meio de eletrocoagulação com argônio / Endoscopic treatment of bleeding lesions of the gastrointestinal tract by argon plasma coagulation

Introdução e objetivos: A eletrocoagulação com argônio (APC) é um método térmico de não-contato que pode ser utilizado como alternativa ao laser em endoscopia. Um amplo espectro de indicações têm sido propostas para tratamento através de APC, desde a introdução do uso em endoscopia, em 1991. O objetivo deste estudo é avaliar a eficácia do uso do APC na hemostasia endoscópica de lesões sangrantes do esôfago, estômago, duodeno, cólon e reto. Metodologia: Um total de 22 pacientes consecutivos (14M/8F, média de idade 66,7 anos) foram submetidos ao tratamento com APC entre 1998 e fevereiro de 2002. As causas de sangramento incluíam retite actínica (12 pacientes), ectasia vascular do antro gástrico (GAVE) ­ watermelon stomach (6 pacientes), angiodisplasias de esôfago, estômago e cólon (2 pacientes), gastrite actínica (1 paciente) e síndrome de Osler-Weber-Rendu (1 paciente). Resultados: Um total de 49 sessões foram realizadas (média de 2,2 sessões por paciente). Sucesso no tratamento endoscópico foi obtido em 18 pacientes (85,8%). Complicações foram observadas em 3 pacientes: 2 apresentaram dor local após as sessões de APC e um paciente desenvolveu estenose retal tratada com sucesso em uma sessão de dilatação endoscópica. Não houve mortalidade relacionada ao método. Conclusões: APC é um método seguro, efetivo, de relativo baixo custo e boa aceitação pelos pacientes para o tratamento de lesões sangrantes do trato gastrointestinal. Deve, portanto, ser considerado método de primeira escolha no tratamento dessas afecções (AU)

Background and aims: Argon plasma coagulation (APC) is an innovative non-touch electrocoagulation technique. A broad spectrum of indications has been proposed for APC since its introduction into endoscopy in 1991. The aim of this study is to evaluate the efficacy of utilizing APC in the endoscopic hemostasis of bleeding lesions of the esophagus, stomach, duodenun, colon and rectum. Methodology: A total of 22 consecutive patients (14M/ 8 F, mean age 66.7 years) underwent APC treatment between 1998 and february 2002. Causes of bleeding included radiation colitis (12 patients), gastric antral vascular ectasia ­ watermelon stomach (6 patients), esophagus,stomach and colon angiodysplasia (2 patients), radiation gastritis (1 patient) and Osler-Weber-Rendu Syndrome (1 patient). Results: A total of 49 sessions were performed (mean 2.2 sessions / patient). Succesful endoscopic APC treatment was achieved in 18 patients (85,8%). Complications were observed in 2 patients that referred local pain after therapy and 1 patient that developed a rectal stenosis succesfully reversed in one session of endoscopic dilation. No mortality related to APC was observed. Conclusions: APC is a safe, effective, and relative low-cost hemostatic modality for bleeding vascular lesions of the gastrointestinal tract. Therefore, APC should be considered as a first-line therapy for these conditions (AU)

The efficacy of endoscopic ligation for the prevention of variceal rebleeding in cirrhotic patients according to the hepatocellular function.

BACKGROUND/AIMS: Endoscopic variceal ligation is considered the leading therapy for the prevention of variceal rebleeding in cirrhotic patients. However, the efficacy of this method in cirrhotic patients with poor hepatocellular function is not well-known yet. The aim of this study is to compare the efficacy of endoscopic variceal ligation for the eradication of esophageal varices, rebleeding and mortality rates, based on hepatocellular function, as graded by Child-Pugh. METHODOLOGY: Between June 1996 and December 2001, 163 consecutive cirrhotic patients were submitted to band ligation at our Department. Of these cases, 128 patients with previous variceal bleeding (mean age = 50.7 years; 90 males and 38 females) were followed-up. 55 patients were graded as Child A, 49 as Child B and 24 as Child C. RESULTS: The mean follow-up period for all groups was 17.3 months. Varices were eradicated in 82.7% (86 of 104 cases) of Child A/B cirrhotic patients and in 54.2% (13 of 24 cases) of Child C cases (p=0.0061). Eradication was achieved after a mean of 3.7 sessions, and no difference was observed among the groups. Varices recurred in 38.4% (38 of 99 cases) of the patients, presenting no difference among the different Child classes. However, there was a trend to a higher rebleeding rate among patients with variceal recurrence (21% vs. 8.2%, p=0.075). Rebleeding occurred in 20.2% (21 of 104 cases) of Child A/B cirrhotics and in 41.7% (10 of 24 cases) of Child C patients (p=0.001 log-rank test). The mortality rate was 13.5% (14 of 104 cases) among Child A/B patients and 37.5% (9 of 24 cases) among Child C cases (p=0.0135). CONCLUSIONS: Endoscopic variceal ligation is an effective method for the prevention of rebleeding in patients with better liver function. Child C patients had a poor response to treatment. These patients, in a statistically significant fashion, had a worse eradication rate and greater rebleeding and mortality rates than Child A/B patients.

The influence of endoscopic variceal ligation on the portal pressure gradient in cirrhotics.

BACKGROUND/AIMS: After variceal eradication by endoscopic ligation, fundal varices and worsening of portal hypertensive gastropathy can occur. The aim of this study is to verify the impact of the eradication of esophageal varices by endoscopic ligation on the portal pressure gradient, worsening of portal hypertensive gastropathy and development of fundal varices. METHODOLOGY: Twenty-two (15M/7F, mean age: 54.5 years) cirrhotics with previous variceal bleeding were submitted to measurement of hepatic venous pressure gradient before and after variceal eradication by endoscopic ligation. RESULTS: The mean hepatic venous pressure gradient in the first measurement was 14.1 mmHg and after eradication, 13.5 mmHg (p = 0.403). After eradication, 12 patients experienced a reduction in portal pressure and 10, an elevation. Three patients developed fundal varices. Their mean gradient before treatment was 22 mmHg and 18.8 mmHg after therapy (p = 0.368). The gastropathy worsened in 9 patients (mean gradient before therapy of 15.2 mmHg; and 16.1 mmHg after treatment) (p = 0.303). The initial pressure gradient of these patients was not different from the other 13 cases (p = 0.463). CONCLUSIONS: The esophageal variceal eradication by endoscopic band ligation does not alter the hepatic venous pressure gradient. There is no significant variation in the portal pressure of patients in whom there was a worsening of portal hypertensive gastropathy or fundal varices development.

Dilatação endoscópica de esôfago sem o auxílio de fluoroscopia: experiência en 1.358 sessões / Endoscopic dilation of esophagus without fluoroscopy: report on 1.358 procedures

Introdução e objetivos: A dilatação esofágica é considerada a terapêutica de escolha para a maioria dos casos de estenose benigna de esôfago; contudo permanece controversa a utilização da fluoroscipia neste procedimento, bem como qua a etiologia de estenose que melhor responde a esse tratamento. Neste estudo, os autores pretendem expor sua experiência coletada prospectivamente, em 1.358 sessões de dilatação endoscópica esofágica (DEE) sem auxílio fluoroscópico, e comparar os resultados deste método em pacientes de diferentes etiologias de estenose e graus de disfagia. Métodos: Entre 1992 e 2000, 241 pacientes foram submetidos à DEE sem auxílio fluoroscópico. O grau de disfagia dessses pacientes foi graduado de 0, sem disfagia a 4, quando não opto a ingerir líquidos em quantidade suficiente. A resposta de tratamento endoscópica era considerada ótima se fosse inserido um dilatador maior ou igual a 45Fr pela estemose e houvesse leve disfagia ou desaparecimento desta ( graus 0 e 1), e ruim mesmo que fosse inserido um dilatador maior ou igual a 45Fr pela estemose e houvesse disfagia (graus 2, 3 e 4). Resultados: obteve-se seguimento médio de 18,1 meses (1-82) em 207 pacientes (131 M, 76 F, idade média de 55,8 anos) que foram submetidos a 1.358 sessões de dilatação (mediana= 4, elastério de 1-75). A etiologia da estenose era pós-operatória em 125 pacientes, péptica em 46, cáustica em 16 e 20 por outras causas. O grau médio de disfagia antes do tratamento foi de 3,4 e 0,8 após a terapêutica (p=0,001). Resposta ótima ao tratamento foi obtida em 82por cento dos pacientes com estenoses pós-operatórias, em85porm cento dos casos de estenose péptica e em 61por cento dos pacientes com estenose cáustica (p= 0,08). Pacientes com estenose cáustica necessitaram de um número significante maior de sesões (mediana = 5,5) em relação aos casos de estenose pós-operatória (mediana =4) e péptica(mediana=3). Resposta ótima foi obtida em 84por cento dos pacientes que apresentavam disfagia a sólidos em em 41por cento dos casos com disfagia a líquidos à apresentação clínica (p= 0,0001)