Doenças do Aparelho Digestivo

Módulo do Programa de Valorização do Profissional da Atenção Básica (PROVAB), aborda o tema "Doenças do Aparelho Digestivo". A integralidade da atenção à saúde exige do profissional de saúde, principalmente do médico, uma grande amplitude de conhecimentos, quer seja no manejo das condições clínicas, quer seja na correta utilização dos recursos existentes na rede pública de saúde. A formação dos profissionais médicos, geralmente centrada no atendimento de doenças, focada na utilização de tecnologias pesadas e na atenção terciária, dificulta a atuação do médico na atenção primária. Lidar com quadros iniciais das patologias, utilizando com responsabilidade os recursos finitos do SUS, exige destes profissionais o estabelecimento de competências para qualificar a atenção à saúde dos usuários. O módulo é composto por três unidades de ensino, com carga horária total de 45 h, tendo como clientela os profissionais médicos. A Unidade 1 traz as diretrizes do acolhimento da demanda espontânea com foco nas doenças do aparelho digestivo, a classificação dos quadros e a conduta frente às diferentes situações segundo o protocolo. Na sequencia faz um resgate sobre a importância de se realizar uma boa história clínica e exame clínico para subsidiar o raciocínio clínico; os principais exames subsidiários e indicações. Dentro do contexto da atenção integral à pessoa, consideramos fundamental o médico saber orientar a dieta alimentar a fim de garantir a saúde do indivíduo e entender as consequências da utilização do tabaco e álcool sobre o aparelho digestivo. O papel do médico frente às demandas diárias podem ocasionar desconforto à saúde mental deste profissional, pensando nisto consideramos oportuno fazer uma breve abordagem à respeito do tema Resiliência. A Unidade 2 aborda os quadros agudos de dor abdominal e hemorragia digestiva, trazendo conteúdo adequado para orientar o profissional médico para fazer a suspeição diagnóstica dos quadros agudos de maior frequência, o manejo destes pacientes até serem referenciado a serviços de maior complexidade. Fizemos uma discussão à respeito dos principais exames que devem ser solicitados frente a um quadro de abdome agudo, para que o profissional saiba orientar seu paciente ao referenciá-lo. Na unidade 3 abordaremos as patologias do aparelho digestivo de maior ocorrência na Atenção Primária. Nesta serão discutidos a apresentação clínica destas patologias, a indicação de exames subsidiários e o tratamento medicamentoso e não medicamentoso. Assim como os limites de atuação do médico generalista no manejo destes pacientes.

Treatment of Crohn's disease in pregnant women: drug and multidisciplinary approaches.

Inflammatory bowel disease affects a substantial number of women in their reproductive years. Pregnancy presents a number of challenges for clinicians and patients; the health of the baby needs to be balanced with the need to maintain remission in the mother. Historically, treatments for Crohn's disease (CD) were often discontinued during the pregnancy, or nursing period, due to concerns about teratogenicity. Fortunately, observational data has reported the relative safety of many agents used to treat CD, including 5-aminosalicylic acid, thiopurines, and tumor necrosis factor. Data on the long-term development outcomes of children exposed to these therapies in utero are still limited. It is most important that physicians educate the patient regarding the optimal time to conceive, discuss the possible risks, and together decide on the best management strategy.

Nephrolithiasis in patients with inflammatory bowel disease in the community.

BACKGROUND: Inflammatory bowel disease (IBD) has been associated with renal stone formation. The objective of this study was to determine prospectively the prevalence of nephrolithiasis in a community-based population of patients with IBD and to analyze factors associated with renal calculus formation. METHODS: Screening renal ultrasound was performed in a well characterized cohort of patients seen between 2009 and 2012 at an IBD clinic. We enrolled 168 patients, including 93 with Crohn's disease and 75 with ulcerative colitis. Clinical and phenotypic variables associated with asymptomatic nephrolithiasis were determined. RESULTS: Nephrolithiasis was detected in 36 patients with Crohn's disease and in 28 patients with ulcerative colitis (38% for both). Although none of the patients had been previously hospitalized for symptomatic nephrolithiasis, nine with Crohn's disease and five with ulcerative colitis had recurrent urinary tract infections or hydronephrosis. In patients with Crohn's disease, ileocolonic (L3) disease was associated with a greater risk of nephrolithiasis than was ileal (L1) or colonic (L2) disease (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.8-7). Active ulcerative colitis (regardless of severity) represented a significant risk factor for formation of renal calculi (OR 4.2, 95% CI 1.1-15, P = 0.02). CONCLUSION: In surgery-naïve patients with IBD in the community, asymptomatic nephrolithiasis is common and should be considered when renal dysfunction or infection is detected.

Serum calprotectin levels correlate with biochemical and histological markers of disease activity in TNBS colitis.

BACKGROUND AND AIM: Serum calprotectin is elevated in patients with inflammatory bowel disease (IBD). Whether it correlates other markers of disease activity is unknown. The aim of this study was to correlate serum calprotectin with biochemical and histological measures of intestinal inflammation. MATERIALS AND METHODS: TNBS colitis was induced in wistar rats, and serial blood samples were collected at 0, 3, and 12 days. Animals were subsequently sacrificed for pathological evaluation at day 12. Serum calprotectin and cytokines were measured by ELISA. Pathologic changes were classified at the macroscopic and microscopic levels. RESULTS: TNBS colitis induced elevated serum calprotectin, TNF and IL-6 within 24 h. Levels of serum calprotectin remained elevated in parallel to persistence of loose stool and weight loss to day 12. Serum calprotectin levels correlated with serum levels of TNF-α and IL6 (p < 0.001), but not CRP. Animals with liquid stool had significantly higher levels of serum calprotectin than control animals. There was a correlation between macroscopic colitis scores, and levels of serum calprotectin. CONCLUSION: Serum calprotectin levels correlate with biochemical and histological markers of inflammation in TNBS colitis. This biomarker may have potential for diagnostic use in patients with IBD.

Ocular manifestations in a community-based cohort of patients with inflammatory bowel disease.

BACKGROUND: Ophthalmologic diseases in patients with inflammatory bowel disease (IBD) have been reported with varying frequency, mostly from tertiary referral centers. The aim was to describe the spectrum of ophthalmologic conditions in patients with IBD in a community setting and to compare it with a control non-IBD cohort. METHODS: A prospective cohort of patients with Crohn's disease (CD), ulcerative colitis (UC), and non-IBD controls underwent evaluation by an ophthalmologist, including visual acuity, slit-lamp exam, and assessment of lacrimal output. RESULTS: The ophthalmologic exam was completed in 112 subjects; 48 with CD, 40 with UC, and 24 controls. Active intestinal disease was present in 52/88 (59%) of the IBD patients, and 79/88 (89%) were taking 5-aminosalicylates (5-ASAs). The IBD and control populations had similar age and gender profiles. Patients with IBD were more likely to report ocular symptoms (odds ratio [OR] 5.6, 95% confidence interval [CI] 1.5-20), particularly dry eyes (OR 5.3, 95% CI 1.4-19), than the control population. On objective exam, 42% of IBD patients had evidence of dry eyes. In a univariate analysis, 5-ASA use was associated with an increased risk of ocular symptoms (OR 7.4, 95% CI 0.9-64), and 5-ASA use >3 g per day was associated with an increased odds ratio of dry eyes (OR 15, 95% CI 1.9-122). Active disease was not associated with eye symptoms or dry eyes. Other eye conditions such as episcleritis, uveitis, or cataracts were infrequent in this cohort. CONCLUSIONS: Patients with IBD in the community frequently have dry eyes. This is associated with 5-ASA use, particularly doses >3 g per day. Whether this is a surrogate marker of disease severity is unclear.