DIAGNOSIS AND MANAGEMENT OF CHRONIC IDIOPATHIC CONSTIPATION: A NARRATIVE REVIEW FROM A BRAZILIAN EXPERT TASK FORCE.

BACKGROUND: Chronic idiopathic constipation (CIC) is a condition that widely affects the global population, represents relevant healthcare resource utilization and costs, and impacts the individual's well-being. OBJECTIVE: To review the consensus of expert societies and published guidelines on the diagnosis and treatment of CIC in adults, seeking to assist reasoning and decision-making for medical management of patients with CIC and provide a practical reference material. METHODS: A Brazilian medical task force searched the scientific literature in the following electronic databases: MEDLINE/PubMed, SciELO, EMBASE and Cochrane, using the following descriptors: chronic constipation, diagnosis, management of chronic constipation. In addition, a review of articles on the mechanism of action, safety, and efficacy of therapeutic options available in Brazil was carried out. RESULTS: The diagnostic approach and the understanding of the pathophysiology present in CIC are essential items to indicate the appropriate therapy and to understand the ecosystem of the patient's needs. CONCLUSION: CIC is a common condition in adults, occurring more frequently in the elderly and in women. Proper management is defined by detailed medical history and physical examination, together with appropriate therapeutics, regardless pharmacological or not, and depending on the best moment of indication. This way, the impact on quality of life is also optimized.

Diagnóstico e abordagem terapêutica da constipação idiopática crônica: uma revisão de especialistas brasileiros / Diagnosis and management of chronic idiopathic constipation: a narrative review from a brazilian expert task force

ABSTRACT Background Chronic idiopathic constipation (CIC) is a condition that widely affects the global population, represents relevant healthcare resource utilization and costs, and impacts the individual's well-being. Objective To review the consensus of expert societies and published guidelines on the diagnosis and treatment of CIC in adults, seeking to assist reasoning and decision-making for medical management of patients with CIC and provide a practical reference material. Methods A Brazilian medical task force searched the scientific literature in the following electronic databases: MEDLINE/PubMed, SciELO, EMBASE and Cochrane, using the following descriptors: chronic constipation, diagnosis, management of chronic constipation. In addition, a review of articles on the mechanism of action, safety, and efficacy of therapeutic options available in Brazil was carried out. Results The diagnostic approach and the understanding of the pathophysiology present in CIC are essential items to indicate the appropriate therapy and to understand the ecosystem of the patient's needs. Conclusion CIC is a common condition in adults, occurring more frequently in the elderly and in women. Proper management is defined by detailed medical history and physical examination, together with appropriate therapeutics, regardless pharmacological or not, and depending on the best moment of indication. This way, the impact on quality of life is also optimized.

RESUMO Contexto A constipação idiopática crônica (CIC) é uma condição que afeta amplamente a população global, representa um grande custo econômico, causa substancial utilização de recursos em saúde e impacta o bem-estar do indivíduo. Objetivo Revisar os consensos de Sociedades de especialistas e diretrizes publicados sobre o diagnóstico e tratamento da CIC em adultos, buscando auxiliar o raciocínio e a tomada de decisão para a conduta médica frente ao paciente e oferecer um material prático de referência. Métodos Uma força tarefa médica brasileira realizou uma busca na literatura científica nas bases de dados eletrônicos Medline/PubMed, SciELO, Embase e Cochrane, tendo sido utilizados os seguintes descritores: chronic constipation, diagnosis, management of chronic constipation. Adicionalmente, foi realizada uma revisão de artigos sobre o mecanismo de ação, segurança e eficácia das opções terapêuticas disponíveis no Brasil. Resultados A abordagem diagnóstica e o entendimento da fisiopatologia presente na CIC são itens fundamentais para que seja indicada a terapêutica apropriada e seja compreendido o ecossistema de necessidades do paciente. Conclusão A CIC é uma condição comum em adultos, ocorrendo com maior frequência em idosos e mulheres. O manejo correto é definido pela anamnese e exame físico detalhados, juntamente com a terapêutica apropriada, independentemente de ser farmacológica ou não, conforme o melhor momento de indicação. Desta forma, o impacto na qualidade de vida também é otimizado.

ASSESSMENT OF THE INTESTINAL MICROBIOTA IN ADULTS WITH EROSIVE ESOPHAGITIS.

BACKGROUND: The intestinal microbiota influences the appropriate function of the gastrointestinal tract. Intestinal dysbiosis may be associated with a higher risk of esophageal lesions, mainly due to changes in gastroesophageal motility patterns, elevation of intra-abdominal pressure, and increased frequency of transient relaxation of the lower esophageal sphincter. OBJECTIVE: The aim of this study was to evaluate the intestinal microbiota in individuals with erosive esophagitis and in healthy individuals using metagenomics. METHODS: A total of 22 fecal samples from adults aged between 18 and 60 years were included. Eleven individuals had esophagitis (eight men and three women) and 11 were healthy controls (10 men and one woman). The individuals were instructed to collect and store fecal material into a tube containing guanidine solution. The DNA of the microbiota was extracted from each fecal samples and PCR amplification was performed using primers for the V4 region of the 16S rRNA gene. The amplicons were sequenced using the Ion Torrent PGM platform and the data were analyzed using the QIIME™ software version 1.8. Statistical analyses were performed using the Mann-Whitney non-parametric test and the ANOSIM non-parametric method based on distance matrix. RESULTS: The alpha-diversity and beta-diversity indices were similar between the two groups, without statistically significant differences. There was no statistically significant difference in the phylum level. However, a statistically significant difference was observed in the abundance of the family Clostridiaceae (0.3% vs 2.0%, P=0.032) and in the genus Faecaliumbacterium (10.5% vs 4.5%, P=0.045) between healthy controls and esophagitis patients. CONCLUSION: The findings suggest that reduced abundance of the genus Faecaliumbacterium and greater abundance of the family Clostridiaceae may be risk factors for the development of erosive esophagitis. Intervention in the composition of the intestinal microbiota should be considered as an adjunct to current therapeutic strategies for this clinical condition.

Avaliação da microbiota intestinal em adultos com esofagite erosiva / Assessment of the intestinal microbiota in adults with erosive esophagitis

ABSTRACT BACKGROUND: The intestinal microbiota influences the appropriate function of the gastrointestinal tract. Intestinal dysbiosis may be associated with a higher risk of esophageal lesions, mainly due to changes in gastroesophageal motility patterns, elevation of intra-abdominal pressure, and increased frequency of transient relaxation of the lower esophageal sphincter. OBJECTIVE: The aim of this study was to evaluate the intestinal microbiota in individuals with erosive esophagitis and in healthy individuals using metagenomics. METHODS: A total of 22 fecal samples from adults aged between 18 and 60 years were included. Eleven individuals had esophagitis (eight men and three women) and 11 were healthy controls (10 men and one woman). The individuals were instructed to collect and store fecal material into a tube containing guanidine solution. The DNA of the microbiota was extracted from each fecal samples and PCR amplification was performed using primers for the V4 region of the 16S rRNA gene. The amplicons were sequenced using the Ion Torrent PGM platform and the data were analyzed using the QIIME™ software version 1.8. Statistical analyses were performed using the Mann-Whitney non-parametric test and the ANOSIM non-parametric method based on distance matrix. RESULTS: The alpha-diversity and beta-diversity indices were similar between the two groups, without statistically significant differences. There was no statistically significant difference in the phylum level. However, a statistically significant difference was observed in the abundance of the family Clostridiaceae (0.3% vs 2.0%, P=0.032) and in the genus Faecaliumbacterium (10.5% vs 4.5%, P=0.045) between healthy controls and esophagitis patients. CONCLUSION: The findings suggest that reduced abundance of the genus Faecaliumbacterium and greater abundance of the family Clostridiaceae may be risk factors for the development of erosive esophagitis. Intervention in the composition of the intestinal microbiota should be considered as an adjunct to current therapeutic strategies for this clinical condition.

RESUMO CONTEXTO: A doença do refluxo gastroesofágico (DRGE) é uma das enfermidades mais comuns na prática clínica e possui fisiopatologia multifatorial. Disbiose da microbiota intestinal pode ter influência em mecanismos envolvidos nesta doença, como mudanças nos padrões motores gastrointestinais, elevação da pressão intra-abdominal e aumento da frequência de relaxamentos transitórios do esfíncter esofágico inferior. Contudo, a avaliação da microbiota intestinal, neste contexto, ainda é pouco documentada. OBJETIVO: Este estudo avaliou a microbiota bacteriana intestinal, em indivíduos com doença do refluxo gastroesofágico erosivo e em indivíduos saudáveis, utilizando técnicas de metagenômica. MÉTODOS: Estudo incluiu amostras fecais de 22 adultos, com idades entre 18 e 60 anos: 11 com esofagite erosiva (oito homens e três mulheres) e 11 controles saudáveis (dez homens e uma mulher). Os pacientes foram orientados a coletar e armazenar o material fecal em tubo contendo solução de guanidina. O DNA da microbiota foi extraído das amostras de fezes e amplificação por PCR foi realizada usando iniciadores para a região V4 do gene 16S rRNA. Os amplicons foram seqüenciados usando a plataforma Ion PGM Torrent e os dados foram analisados usando o software QIIME™ versão 1.8 (Quantitative Insights Into Microbial Ecology). Análise de estatística foi realizada utilizando-se o teste não paramétrico de Mann-Whitney e o teste ANOSIM, método não paramétrico baseado em matriz de distância. RESULTADOS: Os índices de alfa-diversidade e beta-diversidade foram semelhantes entre os dois grupos, sem diferença estatisticamente significante. Não houve diferença estatisticamente significante no nível de filo, classe e ordem. Entretanto, observou-se diferença estatisticamente significante na abundância da família Clostridiaceae (0,3% vs 2,0%, P=0,032) e no gênero Faecaliumbacterium (10,5% vs 4,5%, P=0,045) entre controles saudáveis e pacientes com DRGE erosiva, respectivamente. CONCLUSÃO: Os achados sugerem que menor abundância do gênero Faecaliumbacterium e maior abundância da família Clostridiaceae, nos pacientes com DRGE, podem influenciar na fisiopatologia desta doença.

TRANSCUTANEOUS MULTICHANNEL ELECTROGASTROGRAPHY: NORMAL PARAMETERS IN A BRAZILIAN POPULATION.

BACKGROUND: Electrogastrography (EGG) is a noninvasive technique for the assessment of gastric myoelectrical activity using electrodes placed on the abdominal surface. Changes in gastric myoelectrical activity may be associated with diseases such as gastroparesis, functional dyspepsia, nausea, and recurrent vomiting. In Brazil, no studies to date have assessed gastric myoelectrical activity using multichannel EGG in healthy individuals. OBJECTIVE: To establish normal values of transcutaneous multichannel EGG in healthy Brazilian individuals. METHODS: This was a prospective study including 20 healthy individuals who underwent EGG. Recording was performed during two periods: a preprandial recording was performed for 30 minutes, and a postprandial recording was performed for 30 minutes after a soft-solid meal of 400 kcal (20 grams of proteins, 60 grams of carbohydrates, and 9 grams of fat). RESULTS: We assessed dominant frequency (DF) parameters, %DF distribution, the instability coefficient, and the power ratio (PR). A total of 20 individuals (11 women and 9 men) with a mean age of 39.5±7.4 years were included. Mean DF (95%CI) ranged from 2.4 to 3.1 cpm in the resting phase and 2.6 to 3.2 cpm in the postprandial period. The %DF in normogastria range was >70% in all healthy individuals. We identified that only one individual did not present a positive response to the test meal, and the other 19 individuals showed a PR greater than 1. The instability coefficient did not change significantly with meal intake. CONCLUSION: Multichannel EGG may be applied in future studies to evaluate gastric motility disorders in the Brazilian population.

GUT MICROBIOTA, PREBIOTICS, PROBIOTICS, AND SYNBIOTICS IN GASTROINTESTINAL AND LIVER DISEASES: PROCEEDINGS OF A JOINT MEETING OF THE BRAZILIAN SOCIETY OF HEPATOLOGY (SBH), BRAZILIAN NUCLEUS FOR THE STUDY OF HELICOBACTER PYLORI AND MICROBIOTA (NBEHPM), AND BRAZILIAN FEDERATION OF GASTROENTEROLOGY (FBG).

Over the last years, there is growing evidence that microorganisms are involved in the maintenance of our health and are related to various diseases, both intestinal and extraintestinal. Changes in the gut microbiota appears to be a key element in the pathogenesis of hepatic and gastrointestinal disorders, including non-alcoholic fatty liver disease, alcoholic liver disease, liver cirrhosis, inflammatory bowel disease, irritable bowel syndrome, and Clostridium difficile - associated diarrhea. In 2019, the Brazilian Society of Hepatology (SBH) in cooperation with the Brazilian Nucleus for the Study of Helicobacter Pylori and Microbiota (NBEHPM), and Brazilian Federation of Gastroenterology (FBG) sponsored a joint meeting on gut microbiota and the use of prebiotics, probiotics, and synbiotics in gastrointestinal and liver diseases. This paper summarizes the proceedings of the aforementioned meeting. It is intended to provide practical information about this topic, addressing the latest discoveries and indicating areas for future studies.

Eletrogastrografia multicanal transcutânea: parâmetros normais em uma população brasileira / Transcutaneous multichannel electrogastrography: normal parameters in a brazilian population

ABSTRACT BACKGROUND: Electrogastrography (EGG) is a noninvasive technique for the assessment of gastric myoelectrical activity using electrodes placed on the abdominal surface. Changes in gastric myoelectrical activity may be associated with diseases such as gastroparesis, functional dyspepsia, nausea, and recurrent vomiting. In Brazil, no studies to date have assessed gastric myoelectrical activity using multichannel EGG in healthy individuals. OBJECTIVE: To establish normal values of transcutaneous multichannel EGG in healthy Brazilian individuals. METHODS: This was a prospective study including 20 healthy individuals who underwent EGG. Recording was performed during two periods: a preprandial recording was performed for 30 minutes, and a postprandial recording was performed for 30 minutes after a soft-solid meal of 400 kcal (20 grams of proteins, 60 grams of carbohydrates, and 9 grams of fat). RESULTS: We assessed dominant frequency (DF) parameters, %DF distribution, the instability coefficient, and the power ratio (PR). A total of 20 individuals (11 women and 9 men) with a mean age of 39.5±7.4 years were included. Mean DF (95%CI) ranged from 2.4 to 3.1 cpm in the resting phase and 2.6 to 3.2 cpm in the postprandial period. The %DF in normogastria range was >70% in all healthy individuals. We identified that only one individual did not present a positive response to the test meal, and the other 19 individuals showed a PR greater than 1. The instability coefficient did not change significantly with meal intake. CONCLUSION: Multichannel EGG may be applied in future studies to evaluate gastric motility disorders in the Brazilian population.

RESUMO CONTEXTO: Eletrogastrografia (EGG) é técnica não invasiva que avalia a atividade miolétrica gástrica utilizando eletrodos localizados na superfície abdominal. Alterações na atividade miolétrica gástrica podem estar associadas a distúrbios como gastroparesia, dispepsia funcional, náuseas e vômitos recorrentes. No Brasil, não há estudos até o momento que tenham avaliado a atividade miolétrica gástrica pela EGG multicanal transcutânea em indivíduos saudáveis. OBJETIVO: Estabelecer valores de normalidade da EGG multicanal transcutânea em indivíduos brasileiros saudáveis. MÉTODOS: Este foi um estudo prospectivo, incluindo 20 indivíduos saudáveis submetidos a EGG. O registro foi realizado em dois períodos: um período pré-prandial foi registrado por 30 minutos, e um período pós-prandial por 30 minutos após a ingesta de uma dieta de prova com consistência sólida e pastosa de 400 kcal (20 gramas de proteínas, 60 gramas de carboidratos e 9 gramas de gordura). RESULTADOS: Foram avaliados os parâmetros de frequência dominante (FD), distribuição da % de FD, coeficiente de instabilidade e "power ratio" (PR). Foram incluídos 20 indivíduos (11 mulheres e 9 homens) com idade média de 39,5 +/- 7,4 anos. A FD média (95%CI) variou de 2,4 a 3,1 cpm no período de basal (pré-prandial) e de 2,6 a 3,2 cpm no período pós-prandial. A % da FD na faixa de normogastria foi >70% em todos os indivíduos saudáveis. Identificamos que apenas um indivíduo não apresentou resposta positiva a refeição de prova, e os outros 19 indivíduos apresentaram PR>1. O coeficiente de instabilidade não mudou significativamente com a ingesta da refeição de prova. CONCLUSÃO: A EGG multicanal transcutânea pode ser aplicada em estudos futuros para a avaliar distúrbios da motilidade gástrica na população brasileira.

Microbiota intestinal, prebióticos, probióticos e simbióticos em doenças gastrointestinais e hepáticas: procedimentos de reunião conjunta da Sociedade Brasileira de Hepatologia (SBH), Núcleo Brasileiro de Estudos do Helicobacter pylori e Microbiota (NBEHPM) e Federação Brasileira de Gastroenterologia (FBG) / Gut microbiota, prebiotics, probiotics, and synbiotics in gastrointestinal and liver diseases: proceedings of a joint meeting of the brazilian society of hepatology (sbh), brazilian nucleus for the study of helicobacter pylori and microbiota (nbehpm), and brazilian federation of gastroenterology (fbg)

ABSTRACT Over the last years, there is growing evidence that microorganisms are involved in the maintenance of our health and are related to various diseases, both intestinal and extraintestinal. Changes in the gut microbiota appears to be a key element in the pathogenesis of hepatic and gastrointestinal disorders, including non-alcoholic fatty liver disease, alcoholic liver disease, liver cirrhosis, inflammatory bowel disease, irritable bowel syndrome, and Clostridium difficile - associated diarrhea. In 2019, the Brazilian Society of Hepatology (SBH) in cooperation with the Brazilian Nucleus for the Study of Helicobacter Pylori and Microbiota (NBEHPM), and Brazilian Federation of Gastroenterology (FBG) sponsored a joint meeting on gut microbiota and the use of prebiotics, probiotics, and synbiotics in gastrointestinal and liver diseases. This paper summarizes the proceedings of the aforementioned meeting. It is intended to provide practical information about this topic, addressing the latest discoveries and indicating areas for future studies.

RESUMO Nos últimos anos, um volume crescente de evidências indica que os microrganismos estão envolvidos na manutenção da saúde humana e também estão relacionados a várias doenças, tanto intestinais quanto extraintestinais. Alterações na microbiota intestinal parecem ser um elemento chave na patogênese de doenças hepáticas e gastrointestinais, incluindo doença hepática gordurosa não-alcoólica, doença hepática alcoólica, cirrose hepática, doenças inflamatórias intestinais, síndrome do intestino irritável e diarreia associada ao Clostridium difficile. Em 2019, a Sociedade Brasileira de Hepatologia (SBH) em colaboração com o Núcleo Brasileiro para Estudo do Helicobacter pylori e Microbiota (NBEHPM) e a Federação Brasileira de Gastroenterologia (FBG) realizaram um encontro exclusivamente voltado para a discussão sobre microbiota e uso de prebióticos, probióticos e simbióticos em doenças hepáticas e gastrointestinais. Este texto resume os principais pontos discutidos durante o evento, e tem a intenção de fornecer informações práticas sobre o assunto, abordando as descobertas mais recentes e indicando áreas para estudos futuros.

Standard Triple Therapy versus Sequential Therapy in Helicobacter pylori Eradication: A Double-Blind, Randomized, and Controlled Trial.

Aim. To compare 10-day standard triple therapy versus sequential therapy as first-line treatment in patients infected with H. pylori. Methods. One hundred H. pylori positive patients (diagnosed by rapid urease test and histology), with average age of 47.2, M/F = 28/72, were randomized to receive either standard triple treatment (TT) as follows: lansoprazole 30 mg, clarithromycin 500 mg, and amoxicillin 1 g, b.i.d. for ten days, or sequential treatment (ST) as follows: lansoprazole 30 mg, amoxicillin and placebo 1.0 g b.i.d for the first five days, followed by lansoprazole 30 mg, clarithromycin 500 mg, and tinidazole 500 mg b.i.d, for the remaining five days. Eradication rates were determined 60 days after treatment by urease, histology, or (13)C-urea breath test. Results. In intention to treat (ITT) analysis, the rate of H. pylori eradication in the TT and ST groups was the same for both regimens as follows: 86% (43/50), 95% CI 93,3 to 73.4%. In Per protocol (PP) analysis, the rate of H. pylori eradication in the TT and ST groups was 87.8% (43/49), 95% CI 94,5 to 75.3% and 89.6% (43/48), 95% CI 95,8 to 77.3%, respectively. Conclusions. In Brazil, standard triple therapy is as equally effective as sequential therapy in eradicating Helicobacter pylori patients. This study was registered under Clinical Trials with number ISRCTN62400496.

Efficacy of levofloxacin, amoxicillin and a proton pump inhibitor in the eradication of Helicobacter pylori in Brazilian patients with peptic ulcers.

OBJECTIVES: The eradication of Helicobacter (H.) pylori allows peptic ulcers in patients infected with the bacteria to be cured. Treatment with the classic triple regimen (proton pump inhibitor, amoxicillin and clarithromycin) has shown decreased efficacy due to increased bacterial resistance to clarithromycin. In our country, the eradication rate by intention to treat with this regimen is 83%. In Brazil, a commercially available regimen for bacterial eradication that uses levofloxacin and amoxicillin with lansoprazole is available; however, its efficacy is not known. Considering that such a treatment may be an alternative to the classic regimen, we aimed to verify its efficacy in H. pylori eradication. METHODS: Patients with peptic ulcer disease infected with H. pylori who had not received prior treatment were treated with the following regimen: 30 mg lansoprazole bid, 1,000 mg amoxicillin bid and 500 mg levofloxacin, once a day for 7 days. RESULTS: A total of 66 patients were evaluated. The patients' mean age was 52 years, and women comprised 55% of the sample. Duodenal ulcers were present in 50% of cases, and gastric ulcers were present in 30%. The eradication rate was 74% per protocol and 73% by intention to treat. Adverse effects were reported by 49 patients (74%) and were mild to moderate, with a prevalence of diarrhea complaints. CONCLUSIONS: Triple therapy comprising lansoprazole, amoxicillin and levofloxacin for 7 days for the eradication of H. pylori in Brazilian peptic ulcer patients showed a lower efficacy than that of the classic triple regimen.

Efficacy of levofloxacin, amoxicillin and a proton pump inhibitor in the eradication of Helicobacter pylori in Brazilian patients with peptic ulcers

OBJECTIVES: The eradication of Helicobacter (H.) pylori allows peptic ulcers in patients infected with the bacteria to be cured. Treatment with the classic triple regimen (proton pump inhibitor, amoxicillin and clarithromycin) has shown decreased efficacy due to increased bacterial resistance to clarithromycin. In our country, the eradication rate by intention to treat with this regimen is 83%. In Brazil, a commercially available regimen for bacterial eradication that uses levofloxacin and amoxicillin with lansoprazole is available; however, its efficacy is not known. Considering that such a treatment may be an alternative to the classic regimen, we aimed to verify its efficacy in H. pylori eradication. METHODS: Patients with peptic ulcer disease infected with H. pylori who had not received prior treatment were treated with the following regimen: 30 mg lansoprazole bid, 1,000 mg amoxicillin bid and 500 mg levofloxacin, once a day for 7 days. RESULTS: A total of 66 patients were evaluated. The patients’ mean age was 52 years, and women comprised 55% of the sample. Duodenal ulcers were present in 50% of cases, and gastric ulcers were present in 30%. The eradication rate was 74% per protocol and 73% by intention to treat. Adverse effects were reported by 49 patients (74%) and were mild to moderate, with a prevalence of diarrhea complaints. CONCLUSIONS: Triple therapy comprising lansoprazole, amoxicillin and levofloxacin for 7 days for the eradication of H. pylori in Brazilian peptic ulcer patients showed a lower efficacy than that of the classic triple regimen. .

Rare cause of abdominal incidentaloma: Hepatoduodenal ligament teratoma.

The occurrence of a hepatoduodenal ligament teratoma is extremely rare, with only a few cases reported in the literature. This case report describes the discovery of a hepatoduodenal ligament lesion revealed during abdominal ultrasonography for cholelithiasis-related abdominal pain in a 27-year-old female. Cross-sectional imaging identified a 5 cm × 4 cm heterogeneous mass of fat tissue with irregular calcification located in the posterior-superior aspect of the head of the pancreas. An encapsulated lesion showing no invasion to the common bile duct or adjacent organs and vessels was exposed during laparotomy and resected. Intraoperative cholangiography during the cholecystectomy showed no abnormalities. The postoperative course was uneventful. Pathological analysis of the resected mass indicated hepatoduodenal ligament teratoma. This case report demonstrates that cross-sectional imaging, such as computed tomography, can reveal suspected incidences of this rare type of teratoma, which can then be confirmed after pathologic analysis of the specimen. The prognosis after complete surgical resection of lesions presenting with benign pathological features is excellent.

Endoscopic findings in uninvestigated dyspepsia.

BACKGROUND: It is important to know the causes of dyspepsia to establish the therapeutic approach. Dyspepsia is a frequent syndrome in our country, where there are restrictions to endoscopy and high prevalence of Helicobacter pylori (H. pylori) infection. This study aimed to assess the endoscopic findings of the syndrome, in an outpatient screening clinic of a tertiary hospital in São Paulo. METHODS: Outpatients with uninvestigated dyspepsia, according to Rome III criteria, answered a dyspepsia questionnaire and underwent esophagogastroduodenoscopy. The Rapid Urease Test was applied to fragments of the antral mucosa and epidemiological data were collected from the studied population. Organic dyspepsia findings were analyzed with different variables to verify statistically significant associations. RESULTS: Three hundred and six patients were included and 282 were analyzed in the study. The mean age was 44 years and women comprised 65% of the sample. Forty-five percent of the patients reported alarm symptoms. Functional dyspepsia was found in 66% of the patients (20% with normal endoscopy results and 46% with gastritis), 18% had GERD and 13% had ulcers (duodenal in 9% and gastric in 4%). Four cases of gastric adenocarcinoma were identified (1.4%), one without alarm characteristics, 1 case of adenocarcinoma of the distal esophagus and 1 case of gastric lymphoma. The prevalence of H. pylori was 54% and infection, age and smoking status were associated with organic dyspepsia. The age of 48 years was indicative of alarm signs. CONCLUSIONS: The endoscopic diagnosis of uninvestigated dyspepsia in our setting showed a predominance of functional disease, whereas cancer was an uncommon finding, despite the high prevalence of H. pylori. Organic dyspepsia was associated with infection, age and smoking status.

Association of a probiotic to a Helicobacter pylori eradication regimen does not increase efficacy or decreases the adverse effects of the treatment: a prospective, randomized, double-blind, placebo-controlled study.

BACKGROUND: The treatment for the eradication of Helicobacter pylori (H. pylori) is complex; full effectiveness is rarely achieved and it has many adverse effects. In developing countries, increased resistance to antibiotics and its cost make eradication more difficult. Probiotics can reduce adverse effects and improve the infection treatment efficacy.If the first-line therapy fails a second-line treatment using tetracycline, furazolidone and proton-pump inhibitors has been effective and low cost in Brazil; however it implies in a lot of adverse effects. The aim of this study was to minimize the adverse effects and increase the eradication rate applying the association of a probiotic compound to second-line therapy regimen. METHODS: Patients with peptic ulcer or functional dyspepsia infected by H. pylori were randomized to treatment with the furazolidone, tetracycline and lansoprazole regimen, twice a day for 7 days. In a double-blind study, patients received placebo or a probiotic compound (Lactobacillus acidophilus, Lactobacillus rhamnosus, Bifidobacterium bifidum and Streptococcus faecium) in capsules, twice a day for 30 days. A symptom questionnaire was administered in day zero, after completion of antibiotic therapy, after the probiotic use and eight weeks after the end of the treatment. Upper digestive endoscopy, histological assessment, rapid urease test and breath test were performed before and eight weeks after eradication treatment. RESULTS: One hundred and seven patients were enrolled: 21 men with active probiotic and 19 with placebo plus 34 women with active probiotic and 33 with placebo comprising a total of 55 patients with active probiotic and 52 with placebo. Fifty-one patients had peptic ulcer and 56 were diagnosed as functional dyspepsia. The per-protocol eradication rate with active probiotic was 89.8% and with placebo, 85.1% (p=0.49); per intention to treat, 81.8% and 79.6%, respectively (p=0.53). The rate of adverse effects at 7 days with the active probiotic was 59.3% and 71.2% with placebo (p=0.20). At 30 days, it was 44.9% and 60.4%, respectively (p=0.08). CONCLUSIONS: The use of this probiotic compound compared to placebo in the proposed regimen in Brazilian patients with peptic ulcer or functional dyspepsia showed no significant difference in efficacy or adverse effects. TRIAL REGISTRATION: Current Controlled Trials ISRCTN04714018.

Helicobacter pylori antibiotic resistance in Brazil: clarithromycin is still a good option.

CONTEXT: The antibiotic susceptibility is the cornerstone for the eradication therapies of Helicobacter pylori. OBJECTIVES: To evaluate the prevalence of primary resistance of H. pylori was evaluated in an urban Brazilian population. METHODS: H. pylori isolates were obtained from patients submitted to an upper gastrointestinal endoscopy for the evaluation of dyspeptic symptoms. Biopsies from antrum, corpus and fundus were taken to determine the antibiotic susceptibility of H. pylori isolates. The minimal inhibitory concentration of furazolidone and bismuth were routinely determined by agar dilution method and the minimal inhibitory for amoxicillin, clarithromycin, tetracycline, levofloxacin, and metronidazole were routinely determined with the E-test. RESULTS: Fifty-four patients were included. In vitro antimicrobial susceptibility of H. pylori strains were obtained from 39 patients. Resistance to metronidazole was detected in 20 patients (51%), to clarithromycin in 3 patients (8%), to levofloxacin in 9 patients (23%) and to bismuth in 2 patients (5%). There was no observed resistance to amoxicillin, tetracycline or furazolidone. CONCLUSION: Due to the low amoxicillin and clarithromycin resistance observed in this study, therapies using these antimicrobials remain appropriated first-line H. pylori therapy.

Helicobacter pylori antibiotic resistance in Brazil: clarithromycin is still a good option / Resistência do Helicobacter pylori aos antibióticos no Brasil: a claritromicina ainda é uma boa opção

CONTEXT: The antibiotic susceptibility is the cornerstone for the eradication therapies of Helicobacter pylori. OBJECTIVES: To evaluate the prevalence of primary resistance of H. pylori was evaluated in an urban Brazilian population. METHODS:H. pylori isolates were obtained from patients submitted to an upper gastrointestinal endoscopy for the evaluation of dyspeptic symptoms. Biopsies from antrum, corpus and fundus were taken to determine the antibiotic susceptibility of H. pylori isolates. The minimal inhibitory concentration of furazolidone and bismuth were routinely determined by agar dilution method and the minimal inhibitory for amoxicillin, clarithromycin, tetracycline, levofloxacin, and metronidazole were routinely determined with the E-test. RESULTS: Fifty-four patients were included. In vitro antimicrobial susceptibility of H. pylori strains were obtained from 39 patients. Resistance to metronidazole was detected in 20 patients (51 percent), to clarithromycin in 3 patients (8 percent), to levofloxacin in 9 patients (23 percent) and to bismuth in 2 patients (5 percent). There was no observed resistance to amoxicillin, tetracycline or furazolidone. CONCLUSION: Due to the low amoxicillin and clarithromycin resistance observed in this study, therapies using these antimicrobials remain appropriated first-line H. pylori therapy.

CONTEXTO: A susceptibilidade aos antibióticos é a pedra fundamental dos tratamentos de erradicação do Helicobacter pylori. OBJETIVO: Avaliar a prevalência da resistência primária do H. pylori aos antibióticos em uma população urbana do Brasil. MÉTODOS: As cepas do H. pylori foram obtidas de pacientes submetidos a endoscopia digestiva para avaliação de sintomas dispépticos. Biopsias do antro, corpo e fundo gástrico foram realizadas para determinar a susceptibilidade das cepas do H. pylori aos antibióticos. A concentração inibitória mínima da furazolidona e do bismuto foram determinadas rotineiramente pelo método da diluição em Agar e a concentração inibitória mínima da amoxicilina, claritromicina, tetraciclina, levofloxacina e do metronidazol foram determinadas pelo E-test. RESULTADOS: Cinquenta e quarto pacientes foram incluídos no estudo. Destes, a susceptibilidade das cepas do H. pylori in vitro foi determinada em 39 pacientes. Resistência ao metronidazol foi detectada em 20 pacientes (51 por cento), à claritromicina em 3 pacientes (8 por cento), à levofloxacina in 9 pacientes (23 por cento) e ao bismuto em 2 pacientes (5 por cento). não foi observada resistência à amoxicilina, tetraciclina e à furazolidona. CONCLUSÃO: Devido à baixa resistência, observada neste estudo para a amoxicilina e a claritromicina, os tratamentos que usam estes antibióticos permanecem apropriados como esquemas de primeira linha para a erradicação do H. pylori.

Eosinophilic esophagitis in patients with typical gastroesophageal reflux disease symptoms refractory to proton pump inhibitor.

BACKGROUND: TREATMEN The contribution of eosinophilic esophagitis (EoE) to refractory gastroesophageal reflux disease (GERD) remains unknown. When EoE and GERD overlap, the clinical, endoscopic and histological findings are nonspecific and cannot be used to distinguish between the two disorders. Limited data are available on this topic, and the interaction between EoE and GERD is a matter of debate. AIM: We have conducted a prospective study of adult patients with refractory GERD to evaluate the overlap of reflux and EoE. METHODS: Between July 2006 and June 2008, we consecutively and prospectively enrolled 130 male and female patients aged 18 to 70 years old who experienced persistent heartburn and/or regurgitation more than twice a week over the last 30 days while undergoing at least six consecutive weeks of omeprazole treatment (at least 40 mg once a day). The patients underwent an upper digestive endoscopy with esophageal biopsy, and intraepithelial eosinophils were counted after hematoxylin/eosin staining. The diagnosis of EoE was based on the presence of 20 or more eosinophils per high-power field (eo/HPF) in esophageal biopsies. RESULTS: Among the 103 studied patients, 79 (76.7%) were females. The patients had a mean age of 45.5 years and a median age of 47 years. Endoscopy was normal in 83.5% of patients, and erosive esophagitis was found in 12.6%. Only one patient presented lesions suggestive of EoE. Histological examination revealed >20 eo/HPF in this patient. CONCLUSION: Our results demonstrated a low prevalence of EoE among patients with refractory GERD undergoing omeprazole treatment.

Eosinophilic esophagitis in patients with typical gastroesophageal reflux disease symptoms refractory to proton pump inhibitor

BACKGROUND: TREATMEN The contribution of eosinophilic esophagitis (EoE) to refractory gastroesophageal reflux disease (GERD) remains unknown. When EoE and GERD overlap, the clinical, endoscopic and histological findings are nonspecific and cannot be used to distinguish between the two disorders. Limited data are available on this topic, and the interaction between EoE and GERD is a matter of debate. AIM: We have conducted a prospective study of adult patients with refractory GERD to evaluate the overlap of reflux and EoE. METHODS: Between July 2006 and June 2008, we consecutively and prospectively enrolled 130 male and female patients aged 18 to 70 years old who experienced persistent heartburn and/or regurgitation more than twice a week over the last 30 days while undergoing at least six consecutive weeks of omeprazole treatment (at least 40 mg once a day). The patients underwent an upper digestive endoscopy with esophageal biopsy, and intraepithelial eosinophils were counted after hematoxylin/eosin staining. The diagnosis of EoE was based on the presence of 20 or more eosinophils per high-power field (eo/HPF) in esophageal biopsies. RESULTS: Among the 103 studied patients, 79 (76.7 percent) were females. The patients had a mean age of 45.5 years and a median age of 47 years. Endoscopy was normal in 83.5 percent of patients, and erosive esophagitis was found in 12.6 percent. Only one patient presented lesions suggestive of EoE. Histological examination revealed >20 eo/HPF in this patient. CONCLUSION: Our results demonstrated a low prevalence of EoE among patients with refractory GERD undergoing omeprazole treatment.

Clarithromycin-based triple therapy for Helicobacter pylori treatment in peptic ulcer patients.

INTRODUCTION: The scheme proton pump inhibitor/amoxicillin/clarithromycin (PPI/AC) is still the first-line treatment for Helicobacter pylori (H. pylori) infections despite evidence suggesting its failure in up to 20% to 30% of patients. METHODOLOGY: This study involved 493 patients who were prescribed omeprazole (20 mg twice a day) or another proton pump inhibitor in equivalent dosage, amoxicillin (1 g twice a day), and clarithromycin (500 mg twice a day) for seven days. Efficacy was determined by negative urease test and absence of H. pylori on gastric biopsy samples twelve weeks after the end of treatment. Safety was defined according to the adverse effects reported. Mean age of the patients was (± SD) 48.96 ± 13, and demographic and clinical data were recorded for correlation with treatment outcomes. RESULTS: Out of 493 patients, 316 (64.1%) presented duodenal ulcer, 111 (22.5%) gastric ulcer, and 66 (14.4%) simultaneous gastric and duodenal ulcers. Additionally, 267 (54.2%) patients had at least one risk factor for peptic ulcer disease, smoking being the most common (99 [36.5%]). Successful eradication was achieved in 408 patients. The eradication rates per protocol, and according to the intention to treat, were 88.8% and 82.7%, respectively.  Of 164 (35.5%) patients who presented adverse effects, 100 (61%) reported them as mild and only six (3.7%) patients had to discontinue treatment. Previous use of tobacco and non-steroid anti-inflammatory drugs was the only risk factor for treatment failure (P = 0.00). CONCLUSION: PPI/AC is still a valuable and remarkably tolerable option for first-line H. pylori eradication in Brazil.

Neither genotype nor the gastric colonization site of Helicobacter pylori are predictive factors for the development of erosive esophagitis in patients with peptic ulcer disease, 1 year after eradication.

CONTEXT: Whether Helicobacter pylori infection is a protective or predisposing factor for the development of gastroesophageal reflux disease remains controversial. The most virulent strains, such as those expressing the cytotoxin-associated gene A (CagA), and the site of gastric colonization have been correlated with the prevention or development of esophagitis. AIM: To determine the incidence of erosive esophagitis following eradication of H. pylori in patients with peptic ulcer disease and to evaluate the association of erosive esophagitis with virulent strains of H. pylori and the site of gastric colonization. METHODS: Triple therapy with lansoprazole, amoxicillin and clarithromycin was administered to 159 patients with peptic ulcer disease. Endoscopy, histopathology, urease and carbon-14 urea breath tests were performed prior to treatment, at 3 months and 1 year following treatment. Genotyping of H. pylori strains using polymerase chain reaction was performed separately on samples from the corpus and antrum. RESULTS: One year after treatment, 148 successfully treated patients were reevaluated. Twenty-eight patients (19%) had erosive esophagitis, classified as Los Angeles grade A in 24 and B in 4. The samples taken from the corpus were CagA-positive in 18 patients (64%), while the samples taken from the antrum were CagA-positive in 21 patients (75%). CONCLUSIONS: The incidence of erosive esophagitis in peptic ulcer patients who had their H. pylori eradicated was 19%. No correlation was found between the gastric site colonized by H. pylori or strains expressing CagA and the prevention or development of erosive esophagitis in patients with peptic ulcer disease, 1 year after infection eradication.