Echoendoscopy with elastography in mediastinal lymph nodes.

Elastography is a widely used procedure in conventional ultrasonography that has recently been incorporated in echoendoscopy. This is an innovative and promising technology that aims to increase the negative predictive value of endoscopic ultrasonography and fine-needle aspiration punctures. It is useful for directing punctures in suspect areas and, consequently, improves diagnostic performance. This is a non-invasive technique, easy to perform, without additional costs or complications. The main indications are the analysis of solid pancreatic masses, lymph nodes, subepithelial lesions, lesions in the left hepatic lobe and in the left adrenal. Negative or inconclusive cases of fine-needle aspiration can be submitted to elastography when there is a strong suspicion of malignancy. Elastography has a high precision for the differential diagnosis of solid masses and in difficult-to-access anatomic sites, as well as in mediastinal lymph nodes and pancreatic tumors. The procedure is based on the degree of tissue elasticity measurement, with a good correlation between the elasticity index and histopathological features. We report the case of four patients evaluated by echoendoscopy and qualitative elastography who had differential diagnoses in mediastinal lymph nodes: sarcoidosis, lymphoma, histoplasmosis and esophageal neoplasia.

Improvement of Body Composition and Quality of Life Following Intragastric Balloon.

BACKGROUND: The aim is to evaluate the effects of IGB in overweight or class I obese patients, by analyzing body composition and quality of life (QOL). METHODS: Prospective study including patients with BMI 27-34.9 kg/m2.body composition analysis (BCA) was performed before IGB implantation and its removal, after 6 months of treatment. QOL was assessed by the Short Form 36 (SF-36) Health Survey at baseline and after treatment. RESULTS: Forty patients were included in this study, but four were excluded. The total weight decreased by 12.29 kg after 6 months of use of IGB, which corresponds to loss of 13.69% of the total weight. There was a significant reduction in body fat mass and fat area. QOL improved in all eight sections analyzed (p < 0.001 to 0.041): functional capacity, physical aspects, pain, general health status, vitality, social aspects, emotional aspects, and mental health. CONCLUSIONS: IGB induces not only weight loss but changes in body composition through the reduction of body fat mass and fat area. Furthermore, it improves QOL.

Fecal microbiota transplant by push enteroscopy to treat diarrhea caused by Clostridium difficile.

Clostridium difficile is the major etiological agent of pseudomembranous colitis and is found in up to 20% of adult inpatients. The recommended treatment is antibiotic therapy with metronidazole and/or vancomycin. However, the recurrence rate may reach up to 25% and it increases in each episode. The newest alternative to treat diarrhea due to recurrent Clostridium difficile is fecal microbiota transplantation. The procedure was performed in 12 patients, with a 6-month follow-up on 10 of them. Of the ten cases, bacterial recurrence was diagnosed in only one patient, after a course of antibiotic to treat urinary tract infection, without presenting with diarrhea. The particularity of our study, besides being an unprecedented event in South America, is the way to perform the infusion of fecal microbiota by enteroscopy.

Systematic review and meta-analysis of endoscopic ablative treatment of Barrett's esophagus.

BACKGROUND: Barrett's esophagus (BE) is the main risk factor for esophageal adenocarcinoma. Its therapeutic approach is controversial and surgical treatment in the presence of high-grade intraepithelial neoplasia may be indicated. Endoscopic approach is an alternative with lower mortality and morbidity rates and favorable results. OBJECTIVE: To define the best option, according to literature, to treat Barrett's Esophagus. DESIGN: Systematic review of PUBMED, EMBASE, LILACS, and Cochrane Library databases was conducted and articles of randomized, controlled studies on BE endoscopic ablative treatment were selected. The systematic review through PUBMED retrieved results with higher evidence level and available recommendation grade regarding BE ablative therapy. Nine articles on randomized, controlled studies classified as A or B according to the Oxford table were selected. Cryotherapy, laser, photodynamic therapy (PDT), multipolar electrocoagulation (MPEC), and ablation through argon plasma coagulation (APC) and radiofrequency were considered ablation therapies. PATIENTS: 649 patients from 10 different studies were analysed. RESULTS: PDT was found to present an increase in treatment failure compared with APC, NNH = -7. BE ablation through MPEC or APC was found to have similar risk for treatment failure in meta-analysis. PDT associated with proton pump inhibitor (PPI) is beneficial for BE ablation regarding PPI use alone, NNT = 2.Radiofrequency with PPI is an efficient method to reduce risk of treatment failure, NNT = 1. CONCLUSIONS: There are no studies demonstrating the benefit of indicating cryotherapy or laser therapy for BE endoscopic approach. APC ablation was found to have superior efficacy compared with PDT and ablation through APC and MPEC was found to present effective, similar results. Radiofrequency is the most recent approach requiring comparative studies for indication.

Double pylorus in the era of proton pump inhibitors.

Double pylorus and gastroduodenal fistula are rare conditions and can be either congenital or acquired. We report a case of a 58-year-old man with epigastric pain and dyspepsia in which the upper gastrointestinal endoscopy revealed an acquired double pylorus, probably caused by a gastric ulcer.

Systematic review and meta-analysis of endoscopic ablative treatment of Barrett’s esophagus / Revisión sistemática y meta-análisis del tratamiento ablativo endoscópico del esófago de Barrett

Background: Barrett’s esophagus (BE) is the main risk factor for esophageal adenocarcinoma. Its therapeutic approach is controversial and surgical treatment in the presence of high-grade intraepithelial neoplasia may be indicated. Endoscopic approach is an alternative with lower mortality and morbidity rates and favorable results. Objective: To define the best option, according to literature, to treat Barrett’s Esophagus. Materials and methods: Design: Systematic review of PUBMED, EMBASE, LILACS, and Cochrane Library databases was conducted and articles of randomized, controlled studies on BE endoscopic ablative treatment were selected. The systematic review through PUBMED retrieved results with higher evidence level and available recommendation grade regarding BE ablative therapy. Nine articles on randomized, controlled studies classified as A or B according to the Oxford table were selected. Cryotherapy, laser, photodynamic therapy (PDT), multipolar electrocoagulation (MPEC), and ablation through argon plasma coagulation (APC) and radiofrequency were considered ablation therapies. Patients: 649 patients from 10 different studies were analysed. Results: PDT was found to present an increase in treatment failure compared with APC, NNH = -7. BE ablation through MPEC or APC was found to have similar risk for treatment failure in meta-analysis. PDT associated with proton pump inhibitor (PPI) is beneficial for BE ablation regarding PPI use alone, NNT = 2. Radiofrequency with PPI is an efficient method to reduce risk of treatment failure, NNT = 1. Conclusions: There are no studies demonstrating the benefit of indicating cryotherapy or laser therapy for BE endoscopic approach. APC ablation was found to have superior efficacy compared with PDT and ablation through APC and MPEC was found to present effective, similar results. Radiofrequency is the most recent approach requiring comparative studies for indication.

Introducción: El esófago e Barrett (BE) es un factor de riesgo importante para adenocarcinoma de esófago.Su manejo terapéutico es controversial y el tratamiento quirúrgico en la presencia de neoplasia intraepitelial de alto grado puede estar indicado. El manejo endoscópico es una alternative con menores tasas de morbilidad y mortalidad y con resultados favorables. Objetivo: Definir la major opción de tratamiento del esófago de Barrett de acuerdo a la literatura. Materiales y métodos: Diseño: Se realize una revisión sistemática de PUBMED, EMBASE, LILACS yla librería Cochrane y los artículos randomizados, controlados en ablación endoscópica de BE fueron seleccionados. Esta revisión de PUBMED mostró resultados de una evidencia muy alta y recomendación alta para el uso de terapia ablativa. Nueve artículos de studios randomizados y controlados fueron catalogados grado A o B de aacuerdo a la table de Oxford y fueron seleccionados.Fueron consideradas como terapia ablativa, la crioterapia, laser,terapia fotodinámica (PDT),electrocoagulación multipolar (MPEC) ,ablación con coagulación por argón plasma (APC) y radiofrecuencia. Pacientes: 649 pacientes de 10 estudios diferentes fueron analizados. Resultados: El PDT se halló que tenía mas fallas que el APC , NNH=-7. La ablación del esófago de barrett por MPEC o APC tuvieron el mismo riesgo de fracaso terapéutico en los meta-análisis.La PDT asociado al uso de Inhibidores de bomba de protones (PPI) es beneficiosa versus el uso de, los PPI solos, NNT=2. La radiofrecuencia con PPI es un método eficiente para reducer el riesgo de fracas terapéutico, NNT=1. Conclusiones: No hay studios que demuestren el beneficio de la crioterapia o la terapia con laser para el esófago de Barrett, se encontró que tiene una eficacia superior comparada con el PDT y la ablación por APC y MPEC tenían resultados efectivos y similares.La radiofrecuencia es el manejo más reciente y requiere estudios comparativos para su indicación.

Double pylorus in the era of proton pump inhibitors / Doble píloro en la era de los inhibidores de la bomba de protones

Double pylorus and gastroduodenal fistula are rare conditions and can be either congenital or acquired. We report a case of a 58-year-old man with epigastric pain and dyspepsia in which the upper gastrointestinal endoscopy revealed an acquired double pylorus, probably caused by a gastric ulcer.

El doble píloro y la fístula gastroduodenal son condiciones raras y pueden ser congénitas o adquiridas. Se reporta un caso de un varón de 58 años con dolor epigástrico y dispepsia en quien la endoscopía digestiva alta mostró un doble píloro adquirido, probablemente causado por una úlcera gástrica.

Endoscopic treatment of large pancreatic fluid collections (PFC) using self-expanding metallic stents (SEMS) - a two-center experience.

UNLABELLED: Background/study aim: During the last several years, endoscopic ultrasound (EUS)-guided pancreatic fluid collections' (PFC) drainage has evolved into the preferred drainage technique. Recently, self-expanding metallic stents (SEMS) have been used as an alternative to double pigtail stents, with the advantage of providing a larger diameter fistula, thereby decreasing the risk of early obstruction and also allowing for direct endoscopic exploration of the cavity. The aim of this study was to evaluate the technical and clinical success, safety, and outcome of patients undergoing EUS-guided drainage of complex PFC using SEMS. PATIENTS/MATERIALS AND METHODS: The study was conducted at two tertiary hospitals from January 2010 to January 2013. All patients with PFC referred for endoscopic drainage were enrolled in a prospective database. The inclusion criteria were: (1) patients with pseudocysts or walled-off necrosis based on the revised Atlanta classification; (2) symptomatic patients with thick PFC; (3) PFC that persisted more than 6 weeks; and (4) large PFC diameter (≥ 9 cm). The exclusion criteria consisted of coagulation disorders, PFC bleeding or infection, and failure-to-inform written consent. RESULTS: A total of 16 patients (9 females, 7 males; mean age 52.6, range 20 - 82) underwent EUS drainage with SEMS. There were 14 cases of pseudocysts and 2 cases of walled-off necrosis. The etiologies of the PFC were mainly gallstones (8 of 16 patients, 50 %) and alcohol (5 of 16 patients, 31 %). Technical success was achieved in 100 % of the cases. All patients had a complete resolution of the PFC. CONCLUSION: Transmural EUS-guided drainage of complex PFC using SEMS is feasible, appears safe, and is efficacious. However, the exchange of the UC (uncovered)-SEMS for plastic stents is mandatory within 1 week. Future prospective studies, preferably multicenter studies, comparing SEMS versus traditional plastic stents for the drainage of PFC are warranted.

Pediatric nephrology patients are overweight: 20 years' experience in a single Canadian tertiary pediatric nephrology clinic.

BACKGROUND: Obesity is an independent risk factor for chronic kidney disease (CKD). We compared the body composition of pediatric nephrology patients with that of the general child population over 2 decades. METHODS: About 4,959 patients above 2 years of age (mean: 9.6 +/- 4.5) were referred to a tertiary pediatric nephrology clinic from 1985 to 2006. In 3,422 patients (69.0% with the same mean age) there were sufficient data to analyze body composition, expressed as body mass index (BMI) Z-score and calculated on the basis of normal data taken from the National (USA) Center for Health Statistics (2000). RESULTS: Hematuria (21.68%), recurrent urinary tract infections (16.09%), proteinuria (13.95%) and hypertension (8.27%) were the most common referral diagnoses. Mean BMI Z-score of the pediatric nephrology patients increased significantly from 0.29 +/- 1.07 during the years 1985-1991 to 0.44 +/- 1.27 in 1992-1999 and 0.87 +/- 1.70 in 2000-2006 (P < 0.0001, ANOVA). Whereas the rate of the increase in BMI Z-score was not statistically different from that seen in the normal population, the young nephrology patients had over the entire time consistently significantly higher BMI Z-scores (average +0.72) than the comparable normal USA data. Several disease groups with potential for development of CKD had higher BMI Z-scores than found in the age- and sex-adjusted control data. CONCLUSIONS: The increased rate of obesity in our studied population suggests that pediatric nephrology patients are at even greater risk for developing CKD later in life than could be predicted from their renal disease only. We recommend therapeutic intervention to address this potentially modifiable risk factor.