Aplicação de plasma de argônio endoscópico para tratamento do reganho de peso após cirurgia bariátrica em uma clínica privada de Florianópolis / Using of endoscopic argon plasma for treatment of weight regain after bariatric surgery in a private clinic in Florianópolis

Introdução: Atualmente o bypass gástrico em Y de Roux (BGYR) é o método cirúrgico de escolha no tratamento da obesidade. Todavia, pode ocorrer reganho de peso após a cirurgia. A aplicação do plasma de argônio por via endoscópica constitui uma opção terapêutica que visa redução do calibre da anastomose gastrojejunal, com consequente perda de peso. Objetivo: Avaliar a relação da redução do calibre da anastomose gastrojejunal com a perda de peso e sensação de saciedade nos pacientes que readquiriram peso após BGYR. Métodos: Estudo observacional transversal, que incluiu 34 pacientes submetidos à aplicação do plasma de argônio entre 2014 e 2018, na Usuy Clínica Médica em Florianopólis. As diferenças entre as médias de peso, IMC e diâmetro da anastomose gastrojejunal frente a aplicação do plasma de argônio e saciedade referida foram estabelecidas pelo teste de Wilcoxon (p≤0,05). Resultados: Observou-se redução de 6,26% do peso, 6,21% do IMC e 43,04% do diâmetro anastomótico comparando as médias pré e pós seis meses do procedimento. 53,3% dos pacientes sentiram-se mais saciados. Conclusão: A aplicação do plasma de argônio mostrou-se eficaz na redução do diâmetro da anastomose gastrojejunal, perda de peso corporal e diminuição do IMC.

Introduction: Nowadays the Roux-en-Y Gastric Bypass (RYGB) is the surgical choice method in obesity treatment. However, weight regain may occur after the surgery. The endoscopy applied argon plasma constitutes one therapeutic option in order to reduce the gastrojejunal anastomosis caliber and consequently weight loss. Objective: To evaluate the relation between the gastrojejunal anastomosis caliber reduction, weight loss and sensation of satiety in patients who regained weight after RYGB. Methods: Observational cross-sectional study that includes 34 patients submitted to argon plasma application between 2014 and 2018 at the Usuy Medical Center in Florianopolis. Weight averages, Body Mass Index (BMI) and gastrojejunal anastomosis diameter differences regarding argon plasma application and referred satiety were established by the Wilcoxon Test (p ≤ 0,05). Results: A reduction of 6.26 % of the weight, 6.21 % of the BMI and 43.04 % of the anastomotic diameter was observed upon comparing the average rate six months before and after the procedure. 53.3 % of the patients felt more satiated. Conclusion: The argon plasma application was effective in reducing gastrojejunal anastomosis diameter, body weight and BMI.

Taxa de erradicação do helicobacter pylori e fatores associados em indivíduos de uma clínica do município de Florianópolis / Helicobacter pylori eradication rate and associated factors in individuals from the city of Florianópolis

A infecção pelo Helicobacter pylori (H.pylori) está relacionada à patogênese de diversas doenças como gastrite crônica, adenocarcinoma gástrico, úlcera péptica. Tendo em vista a diminuição da erradicação do H.pylori nos últimos anos, objetivou-se avaliar a taxa da erradicação da infecção pelo H.pylori e fatores associados em indivíduos de uma clínica do município de Florianópolis. Foram coletados dados de prontuários de 79 pacientes de 17 a 80 anos, com diagnóstico da infecção a partir do teste rápido da urease e que realizaram o tratamento entre os meses de novembro de 2016 a novembro de 2017. A erradicação foi determinada a partir do teste rápido da urease e teste histológico após, pelo menos, quatro semanas do término do tratamento. O estudo foi conduzido em uma clínica particular em Florianópolis, referência em Gastroenterologia. A taxa de erradicação geral do H.pylori foi de 75,9%. Em indivíduos com idade inferior a 50 anos, observou-se erradicação em 84,4% (RP: 1,30; IC: 0,99-1,72; p<0,05), destes, a maioria realizou o tratamento de primeira linha. Em indivíduos que utilizaram a primeira linha de tratamento a erradicação foi de 83,6% (RP:1,60; IC:1,05-2,44; p=0,005). Com relação ao número de vezes em que foi realizado o tratamento, observou-se uma taxa de erradicação de 84% (RP:1,60; IC:1,05-2,45; p<0,05) em pacientes que nunca realizaram o tratamento. A taxa de erradicação foi significativamente maior em indivíduos com idade inferior a 50 anos, quando administrado o tratamento de primeira linha com claritromicina e amoxicilina por sete dias e que realizaram o tratamento pela primeira vez.

The Helicobacter pylori infection (H. pylori) is related to the pathogenesis of several diseases such as chronic gastritis, gastric adenocarcinoma, ulcer peptic. Considering that the eradication has been decreased in recent years, the aim was to evaluate the eradication rate of Helicobacter pylori infection and associated factors in individuals at a clinic in the city of Florianópolis. Data was collected from 79 patients ages 17 to 80 who had been diagnosed with H. pylori infection by a rapid urease test and underwent treatment between November 2016 and November 2017. Eradication was determined with a rapid urease test and histological test at least four weeks after treatment was terminated. The study was carried out at a private clinic in Florianópolis that specializes in gastroenterology. The overall eradication rate of H. pylori was 75.9%. Among individuals younger than 50, the eradication rate was observed in 84.4% (PR: 1.30, CI: 0.99-1.72, p <0.05), of these, most underwent first-line treatment. Among individuals who underwent first-line treatment, the eradication rate was 83.6% (PR: 1.60, CI: 1.05-2.44, p = 0.005). Concerning the number of times treatment was performed, the eradication rate was 84% (PR: 1.60; CI: 1.05-2.45; p <0.05) for first-time patients. The eradication rate was significantly higher for first-time patients, that were younger than 50, when administered first-line treatment with clarithromycin and amoxicillin for seven days.

The performance of prognostic models as predictors of mortality in patients with acute decompensation of cirrhosis.

BACKGROUND: Although several prognostic models have been proposed for cirrhotic patients listed for transplantation, the performance of these scores as predictors of mortality in patients admitted for acute decompensation of cirrhosis has not been satisfactorily investigated. AIMS: To study MELD, MELD-Na, MESO, iMELD, Refit-MELD and Refit MELD-Na models as prognostic predictors in cirrhotic patients admitted for acute decompensation, and to compare their performance between admission and 48 hours of hospitalization to predict in-hospital mortality. MATERIAL AND METHODS: This cohort study included cirrhotic patients admitted to hospital due to complications of the disease. Individuals were evaluated on admission and after 48 h of hospitalization, and mortality was evaluated during the present admission. RESULTS: One hundred and twenty-three subjects with a mean age of 54.26 ± 10.79 years were included; 76.4% were male. Mean MELD score was 16.43 ± 7.08 and 52.0% of patients were Child-Pugh C. Twenty-seven patients (22.0%) died during hospitalization. Similar areas under the curve (AUROCs) for prognosis of mortality were observed when different models were compared on admission (P > 0.05) and after 48 h of hospitalization (P > 0.05). When models executed after 48 h of hospitalization were compared to their corresponding model calculated on admission, significantly higher AUROCs were obtained for all models (P < 0.05), except for MELD-Na (P = 0.075) and iMELD (P = 0.119). CONCLUSION: The studied models showed similar accuracy as predictors of in-hospital mortality in cirrhotic patients admitted for acute decompensation. However, the performance of these models was significantly better when applied 48 h after admission when compared to their calculation on admission.

Single-centre validation of the EASL-CLIF consortium definition of acute-on-chronic liver failure and CLIF-SOFA for prediction of mortality in cirrhosis.

BACKGROUND & AIMS: The idea of acute-on-chronic liver failure (ACLF) has emerged to identify those subjects with organ failure and high mortality rates. However, the absence of a precise definition has limited the clinical application and research related to the ACLF concept. We sought to validate the ACLF definition and the CLIF-SOFA Score recently proposed by the EASL-CLIF Consortium in a cohort of patients admitted for acute decompensation (AD) of cirrhosis. METHODS: In this prospective cohort study, patients were followed during their hospital stay and thirty and 90-day mortality was evaluated by phone call, in case of hospital discharge. All subjects underwent laboratory evaluation at admission. RESULTS: Between December 2010 and November 2013, 192 cirrhotic patients were included. At enrollment, 46 patients (24%) met the criteria for ACLF (Grades 1, 2 and 3 in 18%, 4% and 2% respectively). The 30-day mortality was 65% in ACLF group and 12% in the remaining subjects (P < 0.001). Logistic regression analysis showed that 30-day mortality was independently associated with ascites and ACLF at admission. The Kaplan-Meier survival probability at 90-day was 92% in patients without ascites or ACLF and only 22% for patients with both ascites and ACLF. The AUROC of CLIF-SOFA in predicting 30-day mortality was 0.847 ± 0.034, with sensitivity of 64%, specificity of 90% and positive likelihood ratio of 6.61 for values ≥9. CONCLUSION: In our single-centre experience the CLIF-SOFA and the EASL-CLIF Consortium definition of ACLF proved to be strong predictors of short-term mortality in cirrhotic patients admitted for AD.

Clinical and laboratorial features of spontaneous bacterial peritonitis in southern Brazil.

CONTEXT AND OBJECTIVE: Spontaneous bacterial peritonitis (SBP) is a severe complication that occurs in 8-27% of hospitalized patients with liver cirrhosis and ascites, with high mortality rates. This study aimed to identify the clinical characteristics associated with SBP. DESIGN AND SETTING: Cross-sectional study, conducted in a public university. METHODS: The study consecutively included individuals with liver cirrhosis and ascites between September 2009 and March 2012. Forty-five patients were included: mean age 53.2 ± 12.3 years, 82.2% male, 73.8% Caucasian, mean Model of End-stage Liver Disease (MELD) score of 19.5 ± 7.2, and 33.3% with SBP. The subjects were divided into two groups: SBP and controls. RESULTS: Comparison between individuals with SBP and controls showed that those with SBP had lower mean prothrombin activity time (36.1 ± 16.0% versus 47.1 ± 17.2%; P = 0.044) and lower median serum-ascites albumin gradient (SAAG) (1.2 versus 1.7, P = 0.045). There was a tendency towards higher mean MELD in the SBP group, not significant (22.2 ± 7.6 versus 17.9 ± 6.7; P = 0.067). There was a strong positive correlation between the neutrophil count in ascitic fluid and serum leukocyte count (r = 0.501; P = 0.001) and a negative correlation between the neutrophil count in ascitic fluid with prothrombin activity time (r = -0.385; P = 0.011). CONCLUSION: A few characteristics are associated with the presence of SBP, especially liver dysfunction, SAAG and peripheral leukocytosis.

Clinical and laboratorial features of spontaneous bacterial peritonitis in southern Brazil / Características clínicas e laboratoriais da peritonite bacteriana espontânea no sul do Brasil

CONTEXT AND OBJECTIVE: Spontaneous bacterial peritonitis (SBP) is a severe complication that occurs in 8-27% of hospitalized patients with liver cirrhosis and ascites, with high mortality rates. This study aimed to identify the clinical characteristics associated with SBP. DESIGN AND SETTING: Cross-sectional study, conducted in a public university. METHODS: The study consecutively included individuals with liver cirrhosis and ascites between September 2009 and March 2012. Forty-five patients were included: mean age 53.2 ± 12.3 years, 82.2% male, 73.8% Caucasian, mean Model of End-stage Liver Disease (MELD) score of 19.5 ± 7.2, and 33.3% with SBP. The subjects were divided into two groups: SBP and controls. RESULTS: Comparison between individuals with SBP and controls showed that those with SBP had lower mean prothrombin activity time (36.1 ± 16.0% versus 47.1 ± 17.2%; P = 0.044) and lower median serum-ascites albumin gradient (SAAG) (1.2 versus 1.7, P = 0.045). There was a tendency towards higher mean MELD in the SBP group, not significant (22.2 ± 7.6 versus 17.9 ± 6.7; P = 0.067). There was a strong positive correlation between the neutrophil count in ascitic fluid and serum leukocyte count (r = 0.501; P = 0.001) and a negative correlation between the neutrophil count in ascitic fluid with prothrombin activity time (r = -0.385; P = 0.011). CONCLUSION: A few characteristics are associated with the presence of SBP, especially liver dysfunction, SAAG and peripheral leukocytosis. .

CONTEXTO E OBJETIVO: Peritonite bacteriana espontânea (PBE) é uma complicação grave que ocorre em 8-27% dos pacientes hospitalizados com cirrose hepática e ascite, e apresenta altas taxas de mortalidade. O objetivo deste estudo é identificar as características clínicas associadas à PBE. TIPO DE ESTUDO E LOCAL: Estudo transversal, conduzido em uma universidade pública. MÉTODOS: O estudo incluiu, consecutivamente, indivíduos com cirrose hepática e ascite entre setembro 2009 e março 2012. Foram incluídos 45 indivíduos com média de idade de 53,2 ± 12,3 anos, sendo 82,2% homens, 73,8% brancos, com MELD (Modelo para Doença Hepática Terminal) de 19,5 ± 7,2, e 33,3% com PBE. Os indivíduos foram divididos em dois grupos: PBE e controles. RESULTADOS: Quando se compararam os indivíduos com PBE aos controles, observou-se menor média de tempo de atividade da protrombina (TAP; 36,1 ± 16,0% versus 47,1 ± 17,2%; P = 0,044) e menor mediana de gradiente albumina soro-ascite (GASA; 1,2 versus 1,7; P = 0,045). Houve tendência do grupo com PBE de apresentar maior média de MELD, sem significância estatística (22,2 ± 7,6 versus 17,9 ± 6,7; P = 0,067). Foi observada forte correlação positiva entre neutrófilos do líquido ascítico e contagem sérica de leucócitos (r = 0,501; P = 0,001) e correlação negativa de neutrófilos do líquido ascítico com TAP (r = -0,385; P = 0,011). CONCLUSÃO: Poucas características estão associadas à presença de PBE, em especial a disfunção hepática, o GASA e a leucocitose periférica. .

Prevalence and clinical features of celiac disease in patients with hepatitis B virus infection in Southern Brazil.

INTRODUCTION: Celiac disease is an autoimmune disorder that involves gluten intolerance and can be triggered by environmental factors including hepatitis B virus (HBV) infection. This study aimed to describe the prevalence of celiac disease in individuals with HBV infection and to describe the clinical and laboratory characteristics of celiac disease associated with HBV. METHODS: This cross-sectional study included 50 hepatitis B patients tested for IgA anti-endomysial antibodies (EMAs) and tissue anti-transglutaminase (TTG) between August 2011 and September 2012. RESULTS: Fifty patients were included with a mean age of 46.0 ± 12.6 (46.0) years; 46% were female and 13% were HBeAg+. Six patients had positive serology for celiac disease, four were EMA+, and five were TTG+. When individuals with positive serology for celiac disease were compared to those with negative serology, they demonstrated a higher prevalence of abdominal pain (100% vs. 33.3%, p = 0.008), lower median creatinine (0.7 mg/dL vs. 0.9 mg/dL, p = 0.007) and lower mean albumin (3.6 ± 0.4 g/L vs. 3.9 ± 0.3g/L, p = 0.022). All individuals with positive serology for celiac disease underwent upper digestive endoscopy, and three of the patients exhibited a macroscopic pattern suggestive of celiac disease. Histologically, five patients demonstrated an intra-epithelial lymphocytic infiltrate level > 30%, and four patients showed villous atrophy associated with crypt hyperplasia on duodenal biopsy. CONCLUSIONS: An increased prevalence of celiac disease was observed among hepatitis B patients. These patients were symptomatic and had significant laboratory abnormalities. These results indicate that active screening for celiac disease among HBV-infected adults is warranted.

Acute phase proteins for the diagnosis of bacterial infection and prediction of mortality in acute complications of cirrhosis.

INTRODUCTION: Bacterial infection is a frequent complication in patients with decompensated liver cirrhosis and is related to high mortality rates during follow-up of these individuals. We sought to evaluate the diagnostic value of C-reactive protein (CRP) and procalcitonin (PCT) in diagnosing infection and to investigate the relationship between these biomarkers and mortality after hospital admission. MATERIAL AND METHODS: Prospective study that included cirrhotic patients admitted to the hospital due to complications of the disease. The diagnostic accuracy of CRP and PCT for the diagnosis of infection was evaluated by estimating the sensitivity and specificity and by measuring the area under the receiver operating characteristics curve (AUROC). RESULTS: A total of 64 patients and 81 hospitalizations were analyzed during the study. The mean age was 54.31 ± 11.87 years with male predominance (68.8%). Significantly higher median CRP and PCT levels were observed among infected patients (P < 0.001). The AUROC of CRP and PCT for the diagnosis of infection were 0.835 ± 0.052 and 0.860 ± 0.047, respectively (P = 0.273). CRP levels > 29.5 exhibited sensitivity of 82% and specificity of 81% for the diagnosis of bacterial infection. Similarly, PCT levels > 1.10 showed sensitivity of 67% and specificity of 90%. Significantly higher levels of CRP (P = 0.026) and PCT (P = 0.001) were observed among those who died within three months after admission. CONCLUSION: CRP and PCT were reliable markers of bacterial infection in subjects admitted due to complications of liver cirrhosis and higher levels of these tests are related to short-term mortality in those patients.

Prevalence and clinical features of celiac disease in patients with hepatitis B virus infection in Southern Brazil

Introduction Celiac disease is an autoimmune disorder that involves gluten intolerance and can be triggered by environmental factors including hepatitis B virus (HBV) infection. This study aimed to describe the prevalence of celiac disease in individuals with HBV infection and to describe the clinical and laboratory characteristics of celiac disease associated with HBV. Methods This cross-sectional study included 50 hepatitis B patients tested for IgA anti-endomysial antibodies (EMAs) and tissue anti-transglutaminase (TTG) between August 2011 and September 2012. Results Fifty patients were included with a mean age of 46.0 ± 12.6 (46.0) years; 46% were female and 13% were HBeAg+. Six patients had positive serology for celiac disease, four were EMA+, and five were TTG+. When individuals with positive serology for celiac disease were compared to those with negative serology, they demonstrated a higher prevalence of abdominal pain (100% vs. 33.3%, p = 0.008), lower median creatinine (0.7mg/dL vs. 0.9mg/dL, p = 0.007) and lower mean albumin (3.6 ± 0.4g/L vs. 3.9 ± 0.3g/L, p = 0.022). All individuals with positive serology for celiac disease underwent upper digestive endoscopy, and three of the patients exhibited a macroscopic pattern suggestive of celiac disease. Histologically, five patients demonstrated an intra-epithelial lymphocytic infiltrate level > 30%, and four patients showed villous atrophy associated with crypt hyperplasia on duodenal biopsy. Conclusions An increased prevalence of celiac disease was observed among hepatitis B patients. These patients were symptomatic and had significant laboratory abnormalities. These results indicate that active screening for celiac disease among HBV-infected adults is warranted. .

IGF-I and IGFBP-3 serum levels in patients hospitalized for complications of liver cirrhosis.

BACKGROUND: IGF-I and IGFBP-3 are part of IGF system and, due to their predominantly hepatic synthesis, they seem to correlate with hepatic dysfunction intensity. AIMS: To investigate the significance of IGF-I and IGFBP-3 in patients with decompensated liver disease. MATERIAL AND METHODS: Cross-sectional study that included cirrhotic patients admitted to hospital due to complications of the disease, in whom IGF-I and IGFBP-3 serum levels were measured by chemiluminescence. RESULTS: Seventy-four subjects with a mean age of 53.1 ± 11.6 years were included in the study, 73% were males. IGF-I levels were positively correlated with IGFBP-3 and albumin, and negatively correlated with Child-Pugh, MELD, creatinine, INR and aPTT ratio. IGFBP-3 levels were positively correlated with IGF-I and albumin, and negatively correlated with Child-Pugh, MELD, creatinine, INR, total bilirubin and aPTT ratio. Significantly lower scores of IGF-I and IGFBP-3 were observed in patients with higher MELD values and higher Child-Pugh classes (P < 0.05). CONCLUSIONS: In cirrhotic patients admitted to hospital due to complications of the disease, IGF-I and IGFBP-3 serum levels were associated with variables related to liver dysfunction and to more advanced liver disease. The levels of these markers seem to undergo little influence from other clinical and laboratory variables, therefore mainly reflecting hepatic functional status.

Validation and comparison of simple noninvasive models for the prediction of liver fibrosis in chronic hepatitis C.

INTRODUCTION: Although it is standard procedure in the evaluation of liver diseases, biopsy is an invasive method subject to sampling error and intra or inter-observer variability. Thus, surrogate markers of liver fibrosis have been proposed, with variable availability and accuracy. AIM: Validate and compare the performance of APRI and FIB-4 as predictors of liver fibrosis in HCV patients. MATERIAL AND METHODS: Cross-sectional study including patients with HCV-RNA (+) who underwent liver biopsy. Significant fibrosis was defined as METAVIR stage ≥ 2. The diagnostic performance of the models in predicting significant fibrosis were evaluated and compared by ROC curves. RESULTS: The study included 119 patients, mean age 43.7 ± 10.6 years and 62% males. Significant fibrosis was identified in 41 patients. The AUROCs observed were: APRI = 0.793 ± 0.047, FIB-4 = 0.811 ± 0.045 and AST/ALT = 0.661 ± 0.055 (P = 0.054 for APRI vs. AST/ALT, and P = 0.014 for FIB-4 vs. AST/ALT). Considering classic cutoffs, the PPV and NPV for APRI and FIB-4 were, respectively, 77% and 92% and 83% and 81%. Thirteen (19%) patients were misdiagnosed by APRI and 16 (18%) by FIB-4. By restricting the indication of liver biopsy to patients with intermediate values, it could have been correctly avoided in 47% and 63% of the patients with APRI and FIB-4, respectively. CONCLUSION: The models APRI and FIB-4 were superior to AST/ALT ratio in the diagnosis of significant fibrosis in chronic HCV infection. Even though the overall performance of APRI and FIB-4 was similar, a higher proportion of patients may be correctly classified by FIB-4.

Síndrome de Pancoast - perdendo o melhor momento de diagnosticar / Pancoast Syndrome - losing the best time to diagnose

Os autores descrevem um caso de Síndrome de Pancoastcom desfecho desfavorável por atraso no diagnóstico.Enfatiza-se a necessidade de alto índice de suspeiçãopara esta síndrome, a fim de oportunizar a sua detecçãoprecoce e, consequentemente, a possibilidade de tratamentocurativo ou maior sobrevida.

The authors describe a case of Pancoast Syndrome withunfavorable outcome because of delay on diagnosing.It?s emphasized the need of high suspicion index to thesyndrome, in order to nurture it?s early detection and,consequently, the possibility of curative treatment or increasedsurvival.

Pulmão do crack: manifestações clínicas e radiológicas após inalação

O crack é considerado a forma mais potente eviciante da cocaína, sendo os pulmões os principais órgãosacometidos após a sua inalação. Relata-se o caso de umpaciente masculino que evoluiu com insuficiênciarespiratória aguda após o uso do crack. Após três diasde internação, o paciente evoluiu com melhora clínica eradiológica evidente, sugerindo tratar-se de pulmão docrack: síndrome respiratória aguda após inalação dadroga. Paciente foi mantido em oxigenioterapia e recebeualta hospitalar assintomático sete dias após a internação.

Crack is considered the most powerfull and addictiveform of cocaine, with the lungs being the main organaffected after the inhalation. We report the case of amale patient who developed acute respiratory failureafter crack use. After three days of hospitalization, thepatient improved clinically and radiologically, suggestingit was the crack lung: acute respiratory syndrome afterinhalation of the drug. The patient was treated withoxygen and was discharged asymptomatic seven daysafter admission.