Analysis of the Influence of Interleukin-1ß Gene Polymorphism on Gastric Inflammatory Response and Precancerous Lesions Development in Patients with Functional Dyspepsia.

The present study aimed to evaluate the influence of the IL1B -31C/T polymorphism on gastric inflammatory response and precancerous lesions development - atrophic gastritis (AG) and intestinal metaplasia (IM) - in patients positive for Helicobacter pylori infection with functional dyspepsia (FD). The diagnosis of FD followed the Rome III criteria, and the H. pylori infection was evaluated by urease test and histological examination of gastric biopsies (corpus, antrum, and incisura). The severity of chronic inflammation and inflammatory activity, as well as the presence of precancerous lesions were evaluated accordingly to the updated Sydney System. Genotyping of the IL1B -31C/T polymorphism (rs1143627) was performed by polymerase chain reaction-restriction fragment length polymorphism. A total of 303 patients positive for H. pylori infection with FD were analyzed (81.8% women; mean age of 46.3 ± 12.3 years). No differences were observed in overall genotype frequencies among outcomes evaluated. However, in the dominant -31C allele model (CC+CT vs. TT), the frequency of the TT genotype was significantly higher among patients with moderate/severe chronic inflammation of the antrum than the frequency of the CC+CT genotypes (80.8% vs. 65.2%; OR = 2.25; 95% CI = 1.23-4.24; P = .005). The presence of AG and IM in the gastric mucosa of patients was of 19.5% and 19.1%, respectively. No significant association was observed concerning the frequencies of the genotypes of IL1B -31C/T polymorphism with development of precancerous lesions. In conclusion, our data suggest that genetic variants of the IL1B -31C/T polymorphism play a role in chronic inflammation of the gastric mucosa in H. pylori-infected FD patients.

Potential roles of Helicobacter pylori treatment, body mass index and waist circumference in the causation of erosive esophagitis: a randomized clinical trial (HEROES-GERD).

BACKGROUND: In recent decades, the prevalence of gastroesophageal reflux disease (GERD) and obesity has been increasing while Helicobacter pylori infection has been decreasing. OBJECTIVE: To evaluate if H. pylori treatment, excess body weight and other anthropometric measurements are associated with incident erosive esophagitis, as a secondary objective of a trial which tested the efficacy of treatment of H. pylori on the symptoms of functional dyspepsia. SUBJECTS/METHODS: Upper gastrointestinal endoscopy and anthropometric assessments were performed, at baseline and after 12 months, in H. pylori positive patients with functional dyspepsia who had no baseline reflux symptoms or esophagitis. Patients were randomly assigned to receive omeprazole, amoxicillin, and clarithromycin (antibiotic group; n = 201) or omeprazole plus placebo (control group; n = 203). The primary outcome was the incidence of esophagitis 12 months after randomization, according to treatment groups, and the association of BMI and other anthropometric measurements. RESULTS: Four hundred and four patients were included (mean age, 46.1 years; 78.7% women). The 12-month follow-up endoscopic esophagitis rates for the antibiotic and control groups were 10.9% (22/201) and 9.4% (19/203), respectively (p = 0.60). The number needed to harm was 67. Baseline anthropometric measurements were performed in 94% (380/404) of patients. The 12-month follow-up esophagitis rates for overweight and normal body weight patients were 13.6% (29/213) and 6.0% (10/167), respectively (p = 0.015); rates for patients with and without increased baseline waist circumference were 15.4% (24/156) and 6.7% (15/224), respectively (p = 0.006). Following logistic regression, only the combination of increased baseline body mass index and waist, but not H. pylori treatment, was independently associated with new-onset esophagitis (OR 2.88; 95% CI: 1.28-6.45). CONCLUSIONS: Excess body weight and concomitant increased waist circumference, but not H. pylori treatment, predicts new-onset esophagitis.

IVTH BRAZILIAN CONSENSUS CONFERENCE ON HELICOBACTER PYLORI INFECTION.

Significant progress has been obtained since the III Brazilian Consensus Conference on H. pylori infection held in 2012, in Bento Gonçalves, Brazil, and justify a fourth meeting to establish updated guidelines on the current management of H. pylori infection. Therefore, the Núcleo Brasileiro para Estudo do Helicobacter pylori e Microbiota (NBEHPM), association linked to Brazilian Federation of Gastroenterology (FBG) held its fourth meeting again in Bento Gonçalves, RS, Brazil, on August 25-27, 2017. Twenty-six delegates, including gastroenterologists, endoscopists, and pathologists from the five regions of Brazil as well as one international guest from the United States, participated in the meeting. The participants were invited based on their knowledge and contribution to the study of H. pylori infection. The meeting sought to review different aspects of treatment for infection; establish a correlation between infection, dyspepsia, intestinal microbiota changes, and other disorders with a special emphasis on gastric cancer; and reassess the epidemiological and diagnostic aspects of H. pylori infection. Participants were allocated into four groups as follows: 1) Epidemiology and Diagnosis, 2) Dyspepsia, intestinal microbiota and other afections, 3) Gastric Cancer, and, 4) Treatment. Before the consensus meeting, participants received a topic to be discussed and prepared a document containing a recent literature review and statements that should be discussed and eventually modified during the face-to-face meeting. All statements were evaluated in two rounds of voting. Initially, each participant discussed the document and statements with his group for possible modifications and voting. Subsequently, during a second voting in a plenary session in the presence of all participants, the statements were voted upon and eventually modified. The participants could vote using five alternatives: 1) strongly agree; 2) partially agree; 3) undecided; 4) disagree; and 5) strongly disagree. The adopted consensus index was that 80% of the participants responded that they strongly or partially agreed with each statement. The recommendations reported are intended to provide the most current and relevant evidences to management of H. pylori infection in adult population in Brazil.

Detection of Helicobacter pylori resistance to clarithromycin and fluoroquinolones in Brazil: A national survey.

AIM: To evaluate bacterial resistance to clarithromycin and fluoroquinolones in Brazil using molecular methods. METHODS: The primary antibiotic resistance rates of Helicobacter pylori (H. pylori) were determined from November 2012 to March 2015 in the Southern, South-Eastern, Northern, North-Eastern, and Central-Western regions of Brazil. Four hundred ninety H. pylori patients [66% female, mean age 43 years (range: 18-79)] who had never been previously treated for this infection were enrolled. All patients underwent gastroscopy with antrum and corpus biopsies and molecular testing using GenoType HelicoDR (Hain Life Science, Germany). This test was performed to detect the presence of H. pylori and to identify point mutations in the genes responsible for clarithromycin and fluoroquinolone resistance. The molecular procedure was divided into three steps: DNA extraction from the biopsies, multiplex amplification, and reverse hybridization. RESULTS: Clarithromycin resistance was found in 83 (16.9%) patients, and fluoroquinolone resistance was found in 66 (13.5%) patients. There was no statistical difference in resistance to either clarithromycin or fluoroquinolones (P = 0.55 and P = 0.06, respectively) among the different regions of Brazil. Dual resistance to clarithromycin and fluoroquinolones was found in 4.3% (21/490) of patients. The A2147G mutation was present in 90.4% (75/83), A2146G in 16.9% (14/83) and A2146C in 3.6% (3/83) of clarithromycin-resistant patients. In 10.8% (9/83) of clarithromycin-resistant samples, more than 01 mutation in the 23S rRNA gene was noticed. In fluoroquinolone-resistant samples, 37.9% (25/66) showed mutations not specified by the GenoType HelicoDR test. D91N mutation was observed in 34.8% (23/66), D91G in 18.1% (12/66), N87K in 16.6% (11/66) and D91Y in 13.6% (9/66) of cases. Among fluoroquinolone-resistant samples, 37.9% (25/66) showed mutations not specified by the GenoType HelicoDR test. CONCLUSION: The H. pylori clarithromycin resistance rate in Brazil is at the borderline (15%-20%) for applying the standard triple therapy. The fluoroquinolone resistance rate (13.5%) is equally concerning.

Enteropatia associada à Olmesartana / Olmesartan associated enteropathy

A enteropatia induzida por olmesartana é uma entidade reconhecida recentemente como diagnóstico diferencial de atrofia vilosa. A apresentação clínica é semelhante à doença celíaca, porém a não resposta à retirada do glúten e sorologia antitransglutaminase negativa são chaves para o diagnóstico diferencial. A fisiopatologia é incerta, havendo especulações quanto à predisposição genética e mecanismo de ação da própria droga. A melhora clínica e histológica após a suspensão da medicação é a principal característica. Aqui reportamos um caso de enteropatia induzida por olmesartana de apresentação clínica aguda.(AU)

The olmesartan induced enteropathy is a recently recognized entity in the differential diagnosis of villous atrophy. The clinical presentation is similar to celiac disease, but transglutaminase negative sorology and noimprovement after gluten removal are key to the differential diagnosis. The pathophysiology is uncertain, withspeculations about genetic predisposition and the medication's mechanism of action itself. The clinical and histological improvement after drug discontinuation is the main feature. Here we report a case of Olmesartaninduced enteropathy with acute clinical presentation.(AU)

Changing pattern of indications of endoscopic retrograde cholangiopancreatography in children and adolescents: a twelve-year experience.

BACKGROUND: There are few data regarding endoscopic retrograde cholangiopancreatography (ERCP) usefulness in children and adolescents. We reviewed the long-term experience with diagnostic and therapeutic ERCP in a tertiary single center in Southern Brazil. METHODS: A retrospective chart review of patients aged 0-18 years who had undergone ERCPs from January 2000 to June 2012 was done. Data on demographics, indications, diagnosis, treatments, and complications were collected. RESULTS: Seventy-five ERCPs were performed in 60 patients. The median age of the patients at the procedure was 13.9 years (range: 1.2-17.9). Of the 60 patients, 47 (78.3%) were girls. Of all ERCPs, 48 (64.0%) were performed in patients above 10 years and 35 (72.9%) of them were in girls. ERCP was indicated for patients with bile duct obstruction (49.3%), sclerosing cholangitis (18.7%), post-surgery complication (12%), biliary stent (10.7%), choledochal cyst (5.3%), and pancreatitis (4%). The complication rate of ERCP was 9.7% involving mild bleeding, pancreatitis and cholangitis. Patients who had therapeutic procedures were older (13.7±3.9 vs. 9.9±4.9 years; P=0.001) and had more extrahepatic biliary abnormalities (82% vs. 50%; P=0.015) than those who had diagnostic ERCPs. A marked change in the indications of ERCPs was found, i.e., from 2001 to 2004, indications were more diagnostic and from 2005 therapeutic procedures were predominant. CONCLUSIONS: Diagnostic ERCPs are being replaced by magnetic resonance cholangiopancreatography and also by endoscopic ultrasound. All these procedures are complementary and ERCP still has a role for therapeutic purposes.

Diagnosis and management of Barrett's metaplasia: What's new.

Barrett's esophagus (BE) is a complication of gastroesophageal reflux disease, and a premalignant lesion for esophageal adenocarcinoma (EAC). Observational studies suggest that endoscopic surveillance is associated with the detection of dysplasia and EAC at an early stage along with improved survival, but controversies still remain. The management of patients with BE involves endoscopic surveillance, preventive and clinical measures for cancer, and endoscopic and surgical approaches to treatment. Deciding upon the most appropriate treatment is a challenge. This study presents the results and the effectiveness of these practices.

Doença celíaca: "Procura e encontrarás" / Celiac Disease: "Search and you will find"

A doença celíaca, que é causada pela ingestão do glúten, é hoje reconhecida como a doença auto-imune mais prevalente mundialmente e que se manifesta com um amplo espectro de manifestações clínicas com gravidade variável. A forma de apresentação clássica ocorre em crianças onde tipicamente há diarréia crônica, retardo de crescimento, baixo peso, anemia e distensão abdominal. No adulto predominam as manifestações extra-intestinais, que podem acometer vários órgãos e sistemas. O diagnóstico de DC requer achados histopatológicos característicos em biópsia duodenal feita por endoscopia (aumento dos linfócitos intra-epiteliais, hiperplasia de criptas e atrofia das vilosidades) seguida por uma melhora clínica e histológica após dieta isenta de glúten. O grande desafio para os médicos clínicos e das diversas especialidades é identificar a grande população de pacientes não diagnosticados que existem na comunidade e oferecer tratamento com dieta isenta de glúten, o que melhora a qualidade de vida e previne o surgimento de complica- ções (AU)

Celiac Disease (CD) is an autoimmune disease with a worldwide high prevalence. It is caused by ingestion of gluten and has a wide spectrum of clinical findings with different degrees of severity. The classical presentation is an infant with chronic diarrhea, delayed growth, low weight, anemia and abdominal distention. In adults is more common to find extra intestinal symptoms. The diagnosis of CD is achieved by histopathological findings in duodenal biopsy obtained by upper GI endoscopy (increase of intraepithelial lymphocytes, crypt hyperplasia and villi atrophy) with clinical and histological improvement after a gluten-free diet. The big challenge is to identify the undiagnosed cases in the population and treat them with a gluten-free diet, which will avoid further complications and improve their quality of life (AU)

Clinical efficacy of dexmedetomidine alone is less than propofol for conscious sedation during ERCP.

BACKGROUND: Propofol is an accepted method of sedation for an ERCP and generally achieves deep sedation rather than conscious sedation, and dexmedetomidine has sedative properties of equivalent efficacy. OBJECTIVE: To examine the hypothesis that dexmedetomidine is as effective as propofol combined with fentanyl for providing conscious sedation during an ERCP. DESIGN AND SETTING: Randomized, blind, double-dummy clinical trial. PATIENTS: Twenty-six adults, American Society of Anesthesiologists status I to III, underwent an ERCP. INTERVENTIONS: Patients were randomized to receive either propofol (n = 14) (target plasma concentration range 2-4 microg/mL) combined with fentanyl 1 microg/kg, or dexmedetomidine (n = 12) 1 microg/kg for 10 minutes, followed by 0.2 to 0.5 microg/kg/min. Additional sedatives were used if adequate sedation was not achieved at the maximum dose allowed. MAIN OUTCOMES MEASUREMENTS: The sedation level was assessed by the Richmond alertness-sedation scale and the demand for additional sedatives. Furthermore, heart rate, blood pressure, oxygen saturation, and respiratory rate were continuously assessed. RESULTS: The relative risk (RR) was 2.71 (95% CI, 1.31-5.61) and the number of patients that needed to be treated (NNT) was 1.85 (95% CI, 1.19-4.21) to observe one additional patient with drowsiness 15 minutes after sedation in the dexmedetomidine group. Also, the RR was 9.42 (95% CI, 1.41-62.80), and the NNT was 1.42 (95% CI, 1.0-2.29) to require additional analgesic. However, there was also a greater reduction in blood pressure, a lower heart rate, and greater sedation after the procedure. CONCLUSIONS: Dexmedetomidine alone was not as effective as propofol combined with fentanyl for providing conscious sedation during an ERCP. Furthermore, dexmedetomidine was associated with greater hemodynamic instability and a prolonged recovery.

Randomized clinical trial comparing sodium picosulfate with mannitol on the preparation FOR colonoscopy in hospitalized patients.

BACKGROUND: The cleansing of the colon for a colonoscopy exam must be complete so as to allow the visualization and inspection of the intestinal lumen. The ideal cleansing agent should be easily administered, have a low cost, and minimum collateral effects. Sodium picosulfate together with the magnesium citrate is a cathartic stimulant and mannitol is an osmotic laxative, both usually used for this purpose. AIMS: Assess the colon cleanliness comparing the use of mannitol and sodium picosulfate as well as evaluate the level of patient satisfaction, the presence of foam, pain, and abdominal distension in hospitalized patients undergoing colonoscopy. METHODS: A prospective, randomized, single-blind study with 80 patients that compared two groups: mannitol (40) and sodium picosulfate (40). Both groups received the same dietary orientation. The study was approved by the hospital's Ethics and Research Committee. The endoscopist was blind to the type of preparation. Outcomes evaluated: level of the colons cleanliness, patients satisfaction, the presence of foam, abdominal pain and distension, and the duration of the exam. The data was analyzed by means of the chi-squared test for proportions and Mann-Whitney for independent samples. RESULTS: There were no statistically significant differences between the groups in relation to the level of the colon's cleanliness, patients satisfaction, the presence of foam, abdominal pain, and the duration of the exam. Fifteen percent of the exams of the mannitol group were interrupted while from the sodium picosulfate group it was 5%. The presence of foam was similar for both groups. The average duration for carrying out the exam was 28.44 minutes for the mannitol group and 35.59 minutes for the sodium picosulfate group. Abdominal distension was more frequent in the mannitol group. If they would have to do the same exam, the answer was that 80% said yes from the mannitol group and 92.5% from the sodium picosulfate group. CONCLUSION: The quality of the colon preparation, foam formation, exam duration, and the collateral effects (nauseas, vomiting, and abdominal pain) were similar in both kinds of preparations. Abdominal distension was greater in the mannitol group. Both methods of preparation were well accepted by the hospitalized patients.

Randomized clinical trial comparing sodium picosulfate with mannitol on the preparation FOR colonoscopy in hospitalized patients

BACKGROUND: The cleansing of the colon for a colonoscopy exam must be complete so as to allow the visualization and inspection of the intestinal lumen. The ideal cleansing agent should be easily administered, have a low cost, and minimum collateral effects. Sodium picosulfate together with the magnesium citrate is a cathartic stimulant and mannitol is an osmotic laxative, both usually used for this purpose. AIMS: Assess the colon cleanliness comparing the use of mannitol and sodium picosulfate as well as evaluate the level of patient satisfaction, the presence of foam, pain, and abdominal distension in hospitalized patients undergoing colonoscopy. METHODS: A prospective, randomized, single-blind study with 80 patients that compared two groups: mannitol (40) and sodium picosulfate (40). Both groups received the same dietary orientation. The study was approved by the hospital’s Ethics and Research Committee. The endoscopist was blind to the type of preparation. Outcomes evaluated: level of the colon’s cleanliness, patient’s satisfaction, the presence of foam, abdominal pain and distension, and the duration of the exam. The data was analyzed by means of the chi-squared test for proportions and Mann-Whitney for independent samples. RESULTS: There were no statistically significant differences between the groups in relation to the level of the colon’s cleanliness, patient’s satisfaction, the presence of foam, abdominal pain, and the duration of the exam. Fifteen percent of the exams of the mannitol group were interrupted while from the sodium picosulfate group it was 5 percent. The presence of foam was similar for both groups. The average duration for carrying out the exam was 28.44 minutes for the mannitol group and 35.59 minutes for the sodium picosulfate group. Abdominal distension was more frequent in the mannitol group. If they would have to do the same exam, the answer was that 80 percent said yes from the mannitol group and 92.5 percent...

RACIONAL: A limpeza do cólon para o exame de colonoscopia deve ser completa de modo a permitir a visualização e inspeção do lúmen intestinal. O agente de limpeza ideal deveria ser de fácil administração, com baixo custo e com o mínimo de efeitos colaterais. O picosulfato de sódio juntamente com o citrato de magnésio é um estimulante catártico e o manitol é um laxativo osmótico, ambos geralmente utilizados para este propósito. OBJETIVOS: Verificar a limpeza do cólon comparando o uso de manitol e picosulfato de sódio assim como avaliar o nível de satisfação do paciente, presença de espuma, dor e distensão abdominal em pacientes hospitalizados submetidos a colonoscopia. MÉTODOS: Estudo prospectivo, randomizado, simples-cego com 80 pacientes que comparou dois grupos: manitol (40) e picosulfato de sódio (40). Ambos os grupos receberam a mesma orientação dietética. O estudo foi aprovado pelo Comitê de Ética do hospital e pelo Comitê de Pesquisa. O endoscopista foi cego para o tipo de preparo. Desfechos avaliados: nível de limpeza do cólon, satisfação do paciente, presença de espuma, dor e distensão abdominal e tempo de duração do exame. Os dados foram analisados pelas médias de testes qui-quadrado para proporções e Mann-Whitney para amostras independentes. RESULTADOS: Não houve diferença significativa entre os grupos em relação ao nível de limpeza do cólon, satisfação do paciente, presença de espuma, dor abdominal e tempo de exame. Quinze porcento dos exames do grupo manitol foram interrompidos enquanto que grupo picosulfato de sódio foi de 5 por cento. A presença de espuma foi similar em ambos os grupos. A média de duração do exame foi de 28h 44min para o grupo manitol e 35h 59min para o grupo picosulfato de sódio. A distensão abdominal foi mais freqüente no grupo manitol. Se eles tivessem que repetir o exame, a resposta foi de 80 por cento disse sim do grupo manitol e 92,5 por cento do grupo picosulfato de sódio. CONCLUSÕES: A qualidade do...

Predictive factors of oxygen desaturation of patients submitted to endoscopic retrograde cholangiopancreatography under conscious sedation

RACIONAL: A hipoxemia pode ocorrer durante a colangiopancreatografia endoscópica retrógrada, provavelmente induzida pela analgesia e sedação realizadas, além da posição do paciente em pronação, que dificulta a ventilação adequada. A hipoxemia e a hipoventilação podem não ser observadas pela equipe de enfermagem. OBJETIVOS: Estudo transversal para investigar possíveis fatores preditivos de dessaturação de oxigênio em pacientes sedados com midazolam associado à meperidina durante a colangiopancreatografia endoscópica retrógrada. PACIENTES E MÉTODOS: O total de 186 pacientes foi monitorado com oxímetro de pulso continuamente. Foi utilizada a regressão de poisson para medir o efeito independente de cada fator ajustado para os efeitos de cada um dos outros fatores. As variáveis estudadas foram: idade, gênero, níveis de hematócrito e hemoglobina, uso de escopolamina, exame diagnóstico ou terapêutico escores da Sociedade Americana de Anestesiologia (ASA), duração do exame, sedativo midazolam usado na média de 0,07 mg/kg e a droga analgésica meperidina na média de 0,7 mg/kg, tituladas de acordo com as reações do paciente. RESULTADOS: Não dessaturaram 113 (60,8%) pacientes, dessaturação moderada (SpO2 <92%) 22 (11,8%) pacientes e dessaturação grave (SpO2 <90%) 51 (27,4%) pacientes. A dessaturação foi reconhecida somente através do oxímetro de pulso. Não houve necessidade de utilizar qualquer droga antagonista do sedativo e do analgésico nos pacientes que apresentaram dessaturação grave, que foram estimulados à respiração profunda e foi instalado oxigênio a 2 L/min em cateter nasal. As variáveis detectadas como preditivas de dessaturação foram idade >60 anos e escore ASA III. O tempo do exame foi levemente significativo para a dessaturação. CONCLUSÕES: As variáveis idade de 60 anos ou mais e escore ASA III foram identificadas como risco aumentado para dessaturação para pacientes submetidos a colangiopancreatografia endoscópica retrógrada sob sedação consciente. Longo tempo de exame sugere dessaturação de oxigênio do paciente. Tais pacientes requerem uma monitorização mais acurada da equipe de enfermagem para a dessaturação e hipoventilação, alertando para a depressão respiratória. O uso do oxímetro de pulso e a solicitação de respiração profunda durante o exame auxilia a diminuir tais riscos.

Predictive factors of oxygen desaturation of patients submitted to endoscopic retrograde cholangiopancreatography under conscious sedation.

BACKGROUND AND AIMS: Hypoxemia can occur during endoscopic retrograde cholangiopancreatography probably induced by the analgesia and sedation done. Moreover the patients prone position difficults the adequate ventilation. The hypoxemia and hypoventilation may not be noticed by nursing staff. A transversal study was used to investigate possible predictive factors of oxygen desaturation in sedated patients with midazolam associated to meperidine undergoing endoscopic retrograde cholangiopancreatography. PATIENTS AND METHODS: A total of 186 patients were monitored with continuous pulse oximetry. Poisson regression was used to measure the independent effect of each factor adjusted for effects of each of the other factors. The variables studied were: age, gender, hematocrit and hemoglobin levels, scopolamine use, diagnostic or therapeutic exam, American Society of Anesthesiologists Scores (ASA), duration time of exam, sedative used midazolam in the average of 0.07 mg/kg and analgesic drug meperidine in the average of 0.7 mg/kg that was titrated according patients reaction. RESULTS: No desaturation was found in 113 (60.8%) patients, mild desaturation (SpO2 <92%) in 22 (11.8%) and severe desaturation (SpO2 <90%) in 51 (27.4%). This desaturation was recognized only by the pulse oximeter. There was no need to use any antagonist drug of the sedatives in patients who had severe desaturation, they were just stimulated to deep breaths and oxygen was offered at 2 liters per minute via catheter. The variables found to predict desaturation were age >60 years old and ASA score III. The duration of exam was barely significant for desaturation. CONCLUSIONS: The variables of age of 60 years old or more, and ASA III score are identified as increased risk for desaturation for patients who undergo endoscopic retrograde cholangiopancreatography under conscious sedation. Long time of exam suggests the patient oxygen desaturate. Such patients require very close monitoring to desaturation and hypoventilation by the assistants and nursing staff alerting to respiratory depression. The use of pulse oximeter and asking for deep breaths during the exam helps to diminish such risks.

Does methylene blue detect intestinal metaplasia in Barrett's esophagus?

BACKGROUND: Methylene blue has been used to selectively stain areas of specialized intestinal metaplasia in Barrett's esophagus. The sensitivity, specificity, and negative and positive predictive values for the detection of specialized intestinal metaplasia by methylene blue chromoendoscopy were determined in patients with Barrett's esophagus. METHODS: Thirty patients with Barrett's esophagus underwent endoscopy with biopsy specimens obtained from areas that stained positive and negative with methylene blue. Histopathologic findings were compared with methylene blue chromoendoscopy findings. RESULTS: Two hundred ninety-two biopsy specimens (mean 9.7/patient) were obtained: 203 from stained and 89 from unstained areas. Sensitivity, specificity, and negative and positive predictive values for detection of specialized intestinal metaplasia were, respectively, 72%, 46%, 22%, and 89%. Comparing 187 biopsy specimens from patients with long-segment Barrett's esophagus with 105 specimens from patients with short-segment Barrett's esophagus, the sensitivity, specificity, and negative and positive predictive values were, respectively, 77% versus 63% (p = 0.044), 79% versus 21% (p < 0.002), 28% versus 14% (p = 0.219), and 97% versus 73% (p < 0.002). The odds ratio for detection of specialized intestinal metaplasia in stained areas was 12.40 in long-segment and 0.45 in short-segment Barrett's esophagus. CONCLUSIONS: Data from this study confirm the value of methylene blue chromoendoscopy for detection of specialized intestinal metaplasia in long-segment Barrett's esophagus, but not in short-segment Barrett's esophagus.

Cromoendoscopia no esôfago de Barrett: revisão de literatura e análise crítica / Chromoendoscopy in Barret's esophagus: literature review and critical analysis

O corante ideal no EB seria aquele que selecionasse a metaplasia intestinal, assim como segmentos displásicos e neoplásicos, a fim de melhorar a acurácia diagnóstica do exame endoscópico e aumentar a efetividade da vigilância endoscópica, diminuindo os seus falsos-negativos. Até o momento, o corante que se aproxima dessas características é o azul de metileno, que cora a metaplasia intestinal e não cora áreas de displasia de alto grau ou cancer. No entanto, a sensibilidade, especificidade, valores preditivos negativos e positivos dessa tecnica são muito divergentes na literatura, provavelmente pela ampla variação da população estudada, tamanhos da amostra, técnicas de aplicação do azul de metileno e interpretação dos padrões de coloração. Esta, ao nosso ver, é a maior limitação do método, pois a variação na intensidade de coloração é muito sutil e examinador-dependente. O real benefício do azul de metileno para direcionar biópsias no EB ainda não está estabelecido e há necessidade de novos estudos de diferentes centros.

Acalasia na doença de Chagas é diferente de acalasia idiopática? Experiência do Hospital de Clínicas de Porto Alegre / Is achalasia in Chagas'disease different from idiopathic achalasia? Experience of the Hospital de Clínicas de Porto Alegre

O presente trabalho tem como objetivo avaliar as diferenças entre a acalasia chagásica e a idiopática em pacientes do Hospital de Clínicas de Porto Alegre, através da análise de achados epidemiológicos, clínicos, radiológicos e manométricos. Foram estudados pacientes encaminhados ao Hospital de Clínicas de Porto Alegre, entre novembro de 1996 e dezembro de 2001, com suspeita de acalasia, posteriormente, confirmada por manometria esofágica. Além das características manométricas e radiológicas, os pacientes foram avaliados quanto a idade, sexo, sintomas e tempo de evolução. Entre 51 pacientes, nove (18 por cento) tiveram sorologia positiva para doença de Chagas e 42 (82 por cento) sorologia negativa. Indivíduos com sorologia negativa foram considerados portadores de acalasia idiopática. Pacientes com acalasia chagásica tinham média de idade de 62 mais ou menos 15 anos e os com idiopática 43 mais ou menos 18 anos (P<0,02). O período de evolução dos sintomas em pacientes com acalasia chagásica foi de 74 mais ou menos 47 meses e nos idiopáticos 49 mais ou menos 35 meses (P<0,05). Disfagia, regurgitação, dor torácica e emagrecimento, valores do esfíncter esofágico inferior (pressão basal, pressão e duração de relaxamento pós-deglutição e comprimento total) e do corpo esofágico (amplitude e duração das ondas pós-deglutição) foram similares em ambos os grupos). As únicas diferenças estatisticamente significativas encontradas entre os dois grupos foram a média de idade e o período de evolução dos sintomas, maiores nos pacientes chagásicos. Esses dados permitem especular sobre uma maior tolerância aos sintomas nos pacientes com idade mais avançada.

Gastrostomia endoscópica percutânea (PEG): avaliação e perspectivas / Percutaneous endoscopic gastrostomy (PEG): assessment and prospects

Desde sua criação em 1980, a gastrostomia endoscópica percutânea (PEG) tem sido incorporada às rotinas de tratamento de pacientes criticamente enfermos com dificuldades na deglutição. A expectativa de tempo mínimo de uso deve ser de duas a quatro semanas, com média de tempo de permanência de cerca de 216 dias. As contra-indicações absolutas são peritonite difusa, expectativa de vida muito curta, anorexia nervosa. O procedimento de inserção é rápido (14 min em média), realizado com anestesia local, necessitando auxílio endoscópico para visualização e posicionamento do aparato; É recomendável o uso de antibiotico-profilaxia. Os índices de complicações variam de acordo com as co-morbidades dos pacientes submetidos à gastrostomia e com a experiência da equipe multidisciplinar que insere e mantém os cuidados pós-procedimento. Complicações leves são da ordem de 6 a 30 por cento e as graves de 3 a 8por cento. Quando comparadas com a técnica cirúrgica com anestesia geral, houve menor mortalidade e menor índice de complicações graves. Trata-se de uma opção com provável melhor resultado nutricional e estético, com o benefício de menor morbimortalidade em relação aos métodos cirúrgico

Prevalência de adenocarcinoma do esôfago e da junçäo esofagogástrica durante 10 anos nun centro de referência para câncer no Sul do Brasil / Prevalence of adenocarcinoma of the esophagus and esophagogastric junction during a 10 year period in a cancer referral center in Southern Brazil

A incidência do adenocarcinoma do esôfago e junção esofagogástrica tem aumentado dramaticamente nos EUA e na Europa, mas dados epidemiológicos no Brasil são escassos. Objetivo e métodos - Foram revisados os casos de câncer envolvendo o esôfago e confirmados, histologicamente, num período de 10 anos (1987-1996) obtidos por biopsia durante endoscopia digestiva alta, para determinar a prevalência desse tumor em um centro médico de referência para câncer, no Sul do Brasil. Os casos de câncer foram classificados em três categorias: adenocarcinoma, carcinoma epidermóide e outros. Resultados - Entre 349 casos de câncer; encontrou-se adenocarcinoma em 53 (15,2 por cento), carcinoma epidermóide em 283 (81,1 por cento) e outras neoplasias em 13 (3,7 por cento). Conclusões - A prevalência encontrada de adenocarcinoma na população estudada foi de 15 por cento.

Síndrome de Caroli e carcinomatose peritoneal / Caroli's syndrome and peritoneal carcinomatosis

A Síndrome de Caroli é uma entidade incomum caracterizada pela presença de dilatações císticas da árvore biliar intra-hepática e fibrose hepática congênita. Pode comportar-se como condição pré-maligna, evoluindo em alguns casos para colangiocarcinoma. Relatamos um caso diagnosticado em paciente do sexo masculino, 37 anos, complicado por carcinomatose peritoneal de sítio desconhecido, fazendo também revisão da literatura