Anti-TNF therapy for ulcerative colitis in Brazil: a comparative real-world national retrospective multicentric study from the Brazilian study group of IBD (GEDIIB).

BACKGROUND: Anti-TNF therapy represented a landmark in medical treatment of ulcerative colitis (UC). There is lack of data on the efficacy and safety of these agents in Brazilian patients. The present study aimed to analyze rates of clinical and endoscopic remission comparatively, between adalimumab (ADA) and infliximab (IFX), in Brazilian patients with UC, and evaluate factors associated with clinical and endoscopic remission after 1 year of treatment. METHODS: A national retrospective multicenter study (24 centers) was performed including patients with UC treated with anti-TNF therapy. Outcomes as clinical response and remission, endoscopic remission and secondary loss of response were measured in different time points of the follow-up. Baseline predictive factors of clinical and endoscopic remission at week 52 were evaluated using logistic regression model. Indirect comparisons among groups (ADA and IFX) were performed using Student's t, Pearson χ2 or Fisher's exact test when appropriated, and Kaplan Meier analysis. RESULTS: Overall, 393 patients were included (ADA, n = 111; IFX, n = 282). The mean age was 41.86 ± 13.60 years, 61.58% were female, most patients had extensive colitis (62.40%) and 19.39% had previous exposure to a biological agent. Overall, clinical remission rate was 66.78%, 71.62% and 82.82% at weeks 8, 26 and 52, respectively. Remission rates were higher in the IFX group at weeks 26 (75.12% vs. 62.65%, p < 0.0001) and 52 (65.24% vs. 51.35%, p < 0.0001) when compared to ADA. According to Kaplan-Meier survival curve loss of response was less frequent in the Infliximab compared to Adalimumab group (p = 0.001). Overall, endoscopic remission was observed in 50% of patients at week 26 and in 65.98% at week 52, with no difference between the groups (p = 0.114). Colectomy was performed in 23 patients (5.99%). Age, non-prior exposure to biological therapy, use of IFX and endoscopic remission at week 26 were associated with clinical remission after 52 weeks. Variables associated with endoscopic remission were non-prior exposure to biological therapy, and clinical and endoscopic remission at week 26. CONCLUSIONS: IFX was associated with higher rates of clinical remission after 1 year in comparison to ADA. Non-prior exposure to biological therapy and early response to anti-TNF treatment were associated with higher rates of clinical and endoscopic remission.

C-reactive protein levels and prevalence of leukopenia in patients with inflammatory bowel disease treated with azathioprine and/or mesalazine: a real-life study.

OBJECTIVE: To examine serum C-reactive protein levels and the prevalence of leukopenia in patients with Crohn's disease or ulcerative colitis undergoing treatment with azathioprine and/or mesalazine. METHODS: Retrospective observational study based on clinical and laboratory data collected from medical records of 76 adult patients with inflammatory bowel disease treated with azathioprine, mesalazine or both. Sex, age, diagnosis, number of blood samples and elevated serum C-reactive protein levels during the follow-up period were recorded. The following variables were analyzed in terms of C-reactive protein levels and leukopenia episodes: sex, age, diagnosis of inflammatory bowel disease and type of drug. Statistical analyses included multiple logistic regression and the Fisher's exact test for qualitative variables. RESULTS: Leukopenia was observed in 18.4% of patients and was associated with older age and higher doses of medication. In 44% of patients, C-reactive protein levels were high. However, symptoms were not associated with abnormal levels of this marker. CONCLUSION: Regardless of symptoms, serum C-reactive protein levels were not a reliable indicator of controlled inflammatory bowel disease. Leukopenia was independently associated with older age and higher doses of medication and is a common side effect, which should be routinely monitored.

C-reactive protein levels and prevalence of leukopenia in patients with inflammatory bowel disease treated with azathioprine and/or mesalazine: a real-life study

ABSTRACT Objective To examine serum C-reactive protein levels and the prevalence of leukopenia in patients with Crohn's disease or ulcerative colitis undergoing treatment with azathioprine and/or mesalazine. Methods Retrospective observational study based on clinical and laboratory data collected from medical records of 76 adult patients with inflammatory bowel disease treated with azathioprine, mesalazine or both. Sex, age, diagnosis, number of blood samples and elevated serum C-reactive protein levels during the follow-up period were recorded. The following variables were analyzed in terms of C-reactive protein levels and leukopenia episodes: sex, age, diagnosis of inflammatory bowel disease and type of drug. Statistical analyses included multiple logistic regression and the Fisher's exact test for qualitative variables. Results Leukopenia was observed in 18.4% of patients and was associated with older age and higher doses of medication. In 44% of patients, C-reactive protein levels were high. However, symptoms were not associated with abnormal levels of this marker. Conclusion Regardless of symptoms, serum C-reactive protein levels were not a reliable indicator of controlled inflammatory bowel disease. Leukopenia was independently associated with older age and higher doses of medication and is a common side effect, which should be routinely monitored.

Oral administration of exogenous lactase in tablets for patients diagnosed with lactose intolerance due to primary hypolactasia / Administração oral de lactase exógena em comprimidos em pacientes portadores de intolerância à lactose devido à hipolactasia primária

ABSTRACT Background Primary hypolactasia is a common condition where a reduced lactase activity in the intestinal mucosa is present. The presence of abdominal symptoms due to poor absorption of lactose, which are present in some cases, is a characteristic of lactose intolerance. , Objective Evaluate the efficacy of a product containing exogenous lactase in tablet form compared to a reference product with proven effectiveness in patients with lactose intolerance. Methods Multicentre, randomized, parallel group, single-blind, comparative non-inferiority study. One hundred twenty-nine (129) adult lactose intolerance patients with hydrogen breath test results consistent with a diagnosis of hypolactasia were randomly assigned to receive the experimental product (Perlatte(r) - Eurofarma Laboratórios S.A.) or the reference product (Lactaid(r) - McNeilNutritionals, USA) orally (one tablet, three times per day) for 42 consecutive days. Results Data from 128 patients who actually received the studied treatments were analysed (66 were treated with the experimental product and 62 with the reference product). The two groups presented with similar baseline clinical and demographic data. Mean exhaled hydrogen concentration tested at 90 minutes after the last treatment (Day 42) was significantly lower in the experimental product treated group (17±18 ppm versus 34±47 ppm) in the per protocol population. The difference between the means of the two groups was -17 ppm (95% confidence interval [95% CI]: -31.03; -3.17). The upper limit of the 95% CI did not exceed the a priori non-inferiority limit (7.5 ppm). Secondary efficacy analyses confirmed that the treatments were similar (per protocol and intention to treat population). The tolerability was excellent in both groups, and there were no reports of serious adverse events related to the study treatment. Conclusion The experimental product was non-inferior to the reference product, indicating that it was an effective replacement therapy for endogenous lactase in lactose intolerance patients.

RESUMO Contexto A hipolactasia primária é uma condição muito frequente na qual há redução da atividade da lactase na mucosa intestinal.A presença de sintomas abdominais devidos à má absorção da lactose presente em alguns casos caracteriza a intolerância à lactose. Objetivo Avaliar a eficácia de um produto contendo lactase exógena em comprimidos comparativamente a de um produto comparador com eficácia comprovada em pacientes portadores de intolerância à lactose. Métodos Estudo multicêntrico, randomizado, de grupos paralelos, com investigador cego, comparativo de não-inferioridade. Cento e vinte e nove (129) pacientes adultos portadores de intolerância à lactose e teste do hidrogênio no ar expirado compatível com o diagnóstico de hipolactasia foram randomizados para receber o produto experimental (Perlatte(r) - Eurofarma Laboratórios S.A.) ou o produto comparador (Lactaid(r) - McNeil Nutritionals, EUA), por via oral (um comprimido, três vezes ao dia), durante 42 dias consecutivos. Resultados Os dados dos 128 pacientes que efetivamente receberam o tratamento do estudo foram avaliados (66 tratados com o produto experimental e 62 com o produto comparador). Os dois grupos se mostraram homogêneos quanto aos dados demográficos e clínicos basais. A média da concentração do hidrogênio expirado aos 90 minutos no teste realizado ao final do tratamento (Dia 42) foi significativamente menor no grupo tratado com o produto experimental (17±18 ppm versus 34±47 ppm na população por protocolo). A diferença entre as médias dos dois grupos foi de -17 ppm (intervalo de confiança de 95% [IC95%]: -31,03; -3,17). O limite superior do IC95% não ultrapassou a margem de não-inferioridade estipulada a priori (7,5 ppm). As análises secundárias de eficácia confirmaram a semelhança entre os tratamentos (populações por protocolo e com intenção de tratamento). A tolerabilidade foi excelente em ambos os grupos e não houve relato de eventos adversos graves relacionados ao produto. Conclusão O produto experimental se mostrou não-inferior ao produto comparador, indicando sua eficácia no tratamento substitutivo da lactase endógena em pacientes portadores de intolerância à lactose.

ORAL ADMINISTRATION OF EXOGENOUS LACTASE IN TABLETS FOR PATIENTS DIAGNOSED WITH LACTOSE INTOLERANCE DUE TO PRIMARY HYPOLACTASIA.

Background: Primary hypolactasia is a common condition where a reduced lactase activity in the intestinal mucosa is present. The presence of abdominal symptoms due to poor absorption of lactose, which are present in some cases, is a characteristic of lactose intolerance. Objective: Evaluate the efficacy of a product containing exogenous lactase in tablet form compared to a reference product with proven effectiveness in patients with lactose intolerance. Methods: Multicentre, randomized, parallel group, single-blind, comparative non-inferiority study. One hundred twenty-nine (129) adult lactose intolerance patients with hydrogen breath test results consistent with a diagnosis of hypolactasia were randomly assigned to receive the experimental product (Perlatte(r) - Eurofarma Laboratórios S.A.) or the reference product (Lactaid(r) - McNeilNutritionals, USA) orally (one tablet, three times per day) for 42 consecutive days. Results: Data from 128 patients who actually received the studied treatments were analysed (66 were treated with the experimental product and 62 with the reference product). The two groups presented with similar baseline clinical and demographic data. Mean exhaled hydrogen concentration tested at 90 minutes after the last treatment (Day 42) was significantly lower in the experimental product treated group (17±18 ppm versus 34±47 ppm) in the per protocol population. The difference between the means of the two groups was -17 ppm (95% confidence interval [95% CI]: -31.03; -3.17). The upper limit of the 95% CI did not exceed the a priori non-inferiority limit (7.5 ppm). Secondary efficacy analyses confirmed that the treatments were similar (per protocol and intention to treat population). The tolerability was excellent in both groups, and there were no reports of serious adverse events related to the study treatment. Conclusion: The experimental product was non-inferior to the reference product, indicating that it was an effective replacement therapy for endogenous lactase in lactose intolerance patients.

Predictive factors of hospitalization in children with acute asthma at a university emergency care unit.

OBJECTIVE: This study analyzed the factors that predicted the hospitalization of children with asthma following standardized treatment in emergency care unit (ECU). METHODS: This retrospective study examined data collected from the clinical records of children, 14 years or younger, who were diagnosed with asthma (often with bronchopneumonia, pneumonia, or other illnesses) and treated at the ECU of Santo André from January 2005 to December 2009. The following data were analyzed: month and year of care, child's age and sex, period of observation, and need for hospitalization. A pediatrician confirmed the clinical diagnoses of all participants. The children were first given clinical treatments and were then admitted to ECU for follow-up assessment. RESULTS: The number of hospital admissions was analyzed, and correlations were found with regard to this variable and child age (χ(2) = 166.9; P = 0.00001), the presence of associated illnesses (χ(2) = 63.8; P < 0.00001), and the observation period length (χ(2) = 11.4; P = 0.009). The number of hospital admissions was not correlated with child sex (χ(2) = 0.013; P = 0.9) or time of year (χ(2) = 15.8; P = 0.1). The 3-day observation period was not significant (P = 0.4) with regard to the remainder of the variables in the multiple logistic regression analysis. CONCLUSIONS: Age, mainly children younger than 1 year, the presence of associated illnesses, and the observation period length predicted the hospitalization of children with asthma following treatment in ECU. Sex and seasonality did not affect the need for hospitalization.

Antieméticos na redução dos vômitos por gastroenterite aguda em criançase adolescentes / Antiemetics for reducing vomiting in acute gastroenteritis in children and adolescents

Introdução: O vômito é uma manifestação comum da gastroenterite aguda em crianças e adolescentes. Quando não tratado, pode ser um obstáculo para a terapia de reidratação oral, que é a pedra angular no controle da gastroenterite aguda. Ainda são necessárias evidências relativas à segurança e à eficácia do uso de antieméticos para vômitos em gastroenterite aguda em crianças.Objetivos: Avaliar a eficácia e a segurança de antieméticos para o vômito induzido por gastroenterite em crianças e adolescentes.Métodos: Busca por estudos: Os autores buscaram no CochraneUpper Gastrointestinal and Pancreatic Diseases Group Trials Register, que contém referências identificadas a partir de amplas pesquisas de banco de dados eletrônicos, e realizaram também busca manual em revistas relevantes e livros de resumos de conferências. A busca foi refeita e está atualizada até 20 de julho de 2010. Critérios de seleção dos estudos: Foram incluídos apenas ensaios clínicos randomizados (ECR) e quasi-randomizados comparando o uso de máscaras cirúrgicas descartáveis com a não utilização de máscara.Coleta e análise dos dados: Dois revisores extraíram os dadosindependentemente.Principais resultados: Foram incluídos 7 estudos envolvendo 1.020 participantes. O tempo médio para a cessação do vômito foi de 0,34 dias a menos com supositório de dimenidrinato em comparação com placebo (P = 0,036) (n = 1 estudo). Dados de 3 estudos comparando ondansetrona oral com placebo mostraram: (a) redução imediata da taxa de internação hospitalar (risco relativo [RR] = 0,40; número necessário para tratar [NNT] = 17; intervalo de confiança [IC] 95% = 10 a 100), mas nenhuma diferença entre as taxas de hospitalização em 72 horas após a alta do Departamento de Emergência (DE); (b) redução das taxas de reidratação intravenosa, tanto durante a estadia no DE (RR = 0,41; NNT = 5; IC95% = 4 a 8) quanto no seguimento de 72 horas após a alta da estadia no DE (do pior ao melhor cenário para o ondansetrona: RR = 0,57; NNT = 6; IC 95% = 4 a 13) e (c) um aumento na proporção de pacientes com a cessação do vômito (RR = 1,34; NNT = 5; IC 95% = 3 a 7). Não houve diferença significativa nas taxas de retorno ao médico ou de eventos adversos, embora diarreia tenha sido relatada como um efeito colateral em quatro dos cinco estudos com ondansetrona. Em um estudo da proporção de pacientes com a cessaçãodo vômito em 24 horas foi de 58% com ondansetrona intravenosa, 17% com placebo e 33% com metoclopramida (valor de P = 0,039).Conclusão: A ondansetrona oral aumentou a proporção de pacientes que pararam de vomitar e reduziu o número dos que necessitaram de hidratação intravenosa e internação imediata. A ondansetrona e a metoclopramida intravenosas reduziram o número de episódios de vômitos e de internação hospitalar, e o supositório de dimenidrinato reduziu aduração de vômitos.

A morphometric study of the intestinal mucosa of rats submitted to omentoenteropexy.

CONTEXT: The omentoenteropexy technique was developed as an alternative method for intestinal neovascularization, due to the angiogenic properties of factors from the omentum. OBJECTIVES: This study investigated changes in intestinal villi heights and crypts depths due to surgical techniques: seromiotomy with and without omentoenteropexy. METHOD: Thirty rats were operated on, after being divided into three groups, namely GI, GII and GIII with 10 rats each. In the GI rats were submitted to omentoenteropexy; rats in GII were submitted only to a seromiotomy, and in the GIII only laparotomy. Sixty days after the first surgery, the animals were sacrificed and a segment of intestine was removed for histology using Masson's trichrome technique and morphometric study of intestinal mucosa. RESULTS: The histological findings showed that seromiotomy with or without omentoenteropexy increased the length of intestinal villi when compared with GIII (only laparotomy) (analysis of variance: P = 0.0068; GI 38.88 ± 4.17; GII 39.41± 6.33; GIII 31.85 ± 5.56; GI = GII P>0.05; GII>GIII P<0.05; GI>GIII P<0.001). CONCLUSION: No differences were demonstrated in relation to crypt depths between the groups (P = 0.60). Ongoing studies are being set forth by our group to add more data on the role of omentopexy as a tool to promote neovascularization and intestinal mucosal growth.

A morphometric study of the intestinal mucosa of rats submitted to omentoenteropexy / Estudo morfométrico da mucosa intestinal de ratos submetidos a omentoenteropexia

CONTEXT: The omentoenteropexy technique was developed as an alternative method for intestinal neovascularization, due to the angiogenic properties of factors from the omentum. OBJECTIVES: This study investigated changes in intestinal villi heights and crypts depths due to surgical techniques: seromiotomy with and without omentoenteropexy. METHOD: Thirty rats were operated on, after being divided into three groups, namely GI, GII and GIII with 10 rats each. In the GI rats were submitted to omentoenteropexy; rats in GII were submitted only to a seromiotomy, and in the GIII only laparotomy. Sixty days after the first surgery, the animals were sacrificed and a segment of intestine was removed for histology using Masson's trichrome technique and morphometric study of intestinal mucosa. RESULTS: The histological findings showed that seromiotomy with or without omentoenteropexy increased the length of intestinal villi when compared with GIII (only laparotomy) (analysis of variance: P = 0.0068; GI 38.88 ± 4.17; GII 39.41± 6.33; GIII 31.85 ± 5.56; GI = GII P>0.05; GII>GIII P<0.05; GI>GIII P<0.001). CONCLUSION: No differences were demonstrated in relation to crypt depths between the groups (P = 0.60). Ongoing studies are being set forth by our group to add more data on the role of omentopexy as a tool to promote neovascularization and intestinal mucosal growth.

CONTEXTO: a omentoenteropexia foi desenvolvida como técnica alternativa para a neovascularização intestinal, devido às propriedades angiogênicas de fatores provenientes do omento. OBJETIVO: Investigar as alterações nas alturas vilositárias e profundidades de cripta na mucosa intestinal de ratos submetidos a seromiotomia com e sem omentopexia. MÉTODOS: Trinta ratos foram operados após serem divididos em três grupos com 10 animais cada um. No grupo I (GI) os ratos foram submetidos seromiotomia seguida por omentoenteropexia; no grupo II (GII) foi realizada apenas a seromiotomia, e no grupo III (GIII) apenas a laparotomia. após 60 dias, os animais foram sacrificados e seus intestinos examinados histologicamente, corados pelo tricrômio de Masson, sendo realizado também estudo morfométrico da mucosa intestinal. RESULTADOS: O estudo mostrou que a altura vilositária é maior nos grupos submetidos a seromiotomia, com ou sem omentopexia, do que no grupo em que se realizou laparotomia apenas, porém entre os dois primeiros grupos não houve diferença significante (análise de variância: P = 0,0068; GI 38,88 ± 4,17; GII 39,41 ± 6,33; GIII 31,85 ± 5,56; GI = GII P>0,05; GII>GIII P<0,05; GI>GIII P<0,001). CONCLUSÕES: Não foram demonstradas diferenças quanto às profundidades de criptas entre os grupos (P = 0,60). Novos estudos estão sendo realizados por este grupo para acrescentar mais dados sobre o papel da omentopexia como forma de promover neovascularização e crescimento da mucosa intestinal.

A study on the diagnosis of minimal endoscopic lesions in nonerosive reflux esophagitis using computed virtual chromoendoscopy (FICE).

CONTEXT: Gastroesophageal reflux disease is very prevalent in the world. Endoscopically it can be classified as nonerosive when there is no mucosal erosive lesion on endoscopy. The presence of endoscopic minimal lesions is included in the Los Angeles classification for reflux disease. Virtual chromoendoscopy Fuji Intelligent Color Enhancement (FICE) is an endoscopic technique that enhances detection of small lesions of the digestive tract. OBJECTIVE: To evaluate whether the use of FICE improves the diagnosis of minimal lesions on endoscopy, and to assess the association of symptoms with minimal lesions in patients with nonerosive reflux disease. METHODS: One hundred fifty-five patients were enrolled, 62 with typical reflux symptoms and 93 without esophageal symptoms. The patients had normal esophageal endoscopy or minimal lesions. Each patient was examined initially by conventional video endoscopy and then using FICE. RESULTS: Among 155 patients, 113 had a normal conventional endoscopy and 42 had minimal lesions. Sixty-two patients had typical reflux symptoms, and 93 other symptoms unrelated to reflux. In 104 patients, the esophageal mucosa was normal for both conventional endoscopy and FICE, in 42 patients both techniques showed minimal lesions, in 9 patients conventional endoscopy was normal and minimal lesions were shown by FICE. The height and circumference of minimal lesions were greater using FICE than that measured by conventional endoscopy. There was a significant association of the presence of minimal lesions with male gender, but not with alcoholism, smoking, anti-inflammatory drugs and age. The diagnosis of minimal lesions was observer-dependent, both in conventional endoscopy as using FICE. CONCLUSIONS: The use of FICE improves the diagnosis of minimal lesions as compared to conventional videoendoscopy, although this diagnosis remains observer-dependent. There was no association between the presences of minimal lesions with reflux symptoms.

A study on the diagnosis of minimal endoscopic lesions in nonerosive reflux esophagitis using computed virtual chromoendoscopy (FICE) / Estudo sobre o diagnóstico de lesões endoscópicas mínimas na esofagite de refluxo não-erosiva usando cromoendoscopia virtual (FICE)

CONTEXT: Gastroesophageal reflux disease is very prevalent in the world. Endoscopically it can be classified as nonerosive when there is no mucosal erosive lesion on endoscopy. The presence of endoscopic minimal lesions is included in the Los Angeles classification for reflux disease. Virtual chromoendoscopy Fuji Intelligent Color Enhancement (FICE) is an endoscopic technique that enhances detection of small lesions of the digestive tract. OBJECTIVE: To evaluate whether the use of FICE improves the diagnosis of minimal lesions on endoscopy, and to assess the association of symptoms with minimal lesions in patients with nonerosive reflux disease. METHODS: One hundred fifty-five patients were enrolled, 62 with typical reflux symptoms and 93 without esophageal symptoms. The patients had normal esophageal endoscopy or minimal lesions. Each patient was examined initially by conventional video endoscopy and then using FICE. RESULTS: Among 155 patients, 113 had a normal conventional endoscopy and 42 had minimal lesions. Sixty-two patients had typical reflux symptoms, and 93 other symptoms unrelated to reflux. In 104 patients, the esophageal mucosa was normal for both conventional endoscopy and FICE, in 42 patients both techniques showed minimal lesions, in 9 patients conventional endoscopy was normal and minimal lesions were shown by FICE. The height and circumference of minimal lesions were greater using FICE than that measured by conventional endoscopy. There was a significant association of the presence of minimal lesions with male gender, but not with alcoholism, smoking, anti-inflammatory drugs and age. The diagnosis of minimal lesions was observer-dependent, both in conventional endoscopy as using FICE. CONCLUSIONS: The use of FICE improves the diagnosis of minimal lesions as compared to conventional videoendoscopy, although this diagnosis remains observer-dependent. There was no association between the presences of minimal lesions with reflux symptoms.

CONTEXTO: A doença do refluxo gastroesofágico é muito prevalente no mundo. Endoscopicamente pode ser classificada como não-erosiva quando não há lesões erosivas da mucosa à endoscopia. A presença de lesões mínimas à endoscopia está incluída na classificação de Los Angeles para a doença do refluxo. A cromoendoscopia virtual "Fuji Intelligent Color Enhancement" (FICE) é uma técnica endoscópica que melhora a detecção de lesões pequenas do trato digestório. OBJETIVO: Avaliar se o uso de FICE melhora o diagnóstico de lesões mínimas à endoscopia, e avaliar a associação de lesões mínimas com a sintomatologia em pacientes com doença do refluxo não-erosiva. MÉTODOS: Cento e cinquenta e cinco pacientes foram incluídos no estudo, sendo 62 com sintomas típicos de refluxo e 93 sem sintomas esofágicos. Os pacientes apresentavam esôfago normal ou lesões mínimas à endoscopia. Cada paciente era examinado inicialmente pela videoendoscopia convencional e em seguida usando FICE. RESULTADOS: Entre os 155 pacientes, 113 tiveram endoscopia convencional normal e 42 tinham lesões mínimas. Sessenta e dois pacientes tinham sintomas típicos de refluxo e 93 outros sintomas não relacionados a este. Em 104 pacientes a mucosa esofágica era normal tanto pela endoscopia convencional como pelo FICE, em 42 pacientes ambas as técnicas demonstraram lesões mínimas, em 9 pacientes a endoscopia convencional foi normal e o FICE diagnosticou lesões mínimas. A altura e a circunferência das lesões mínimas foram maiores quando observadas com FICE do que pela endoscopia convencional. Houve associação significante da presença de lesões mínimas com o gênero masculino, mas não com etilismo, tabagismo, o uso de antiinflamatórios e idade. O diagnóstico de lesões mínimas foi observador-dependente, tanto na endoscopia convencional quanto usando FICE. CONCLUSÕES: O uso de FICE melhora o diagnóstico de lesões mínimas. Entretanto, este diagnóstico é observador-dependente. Não houve associação da presença de lesões mínimas com sintomas de refluxo.

Contribuição da tomografia helicoidal no estadiamento pré-operatório do carcinoma gástrico / Contribution of abdominal helical tomography in the preoperative staging of gastric carcinoma

Objetivo: Analisar a sensibilidade da tomografia helicoidal abdominal na detecção do comprometimento linfonodal e de metástases hepáticas e peritoneais no estadiamento pré-operatório do carcinoma gástrico. Método: Foram estudados retrospectivamente 52 doentes operados por carcinoma gástrico e estadiados por tomografia helicoidal abdominal com contraste oral e intravenoso. Os resultados baseados nos laudos correspondentes foram correlacionados com os achados intraoperatórios e exame anatomopatológico dos espécimes cirúrgicos. Resultados: A neoplasia gástrica localizou-se na região do antropilórica em 38 (73,1%) doentes, na cárdia em 8 (15,4%) e no corpo e fundo em 6 (11,5%). A tomografia helicoidal abdominal detectou lesão gástrica em 25 (48,1%) doentes, metástases hepáticas em 6 (11,5%), acometimento de linfonodos em 5 (9,6%), ascite em 4 (7,7%) e comprometimento no fígado, baço e pâncreas em 1 (1,9%). Na laparotomia, constataram-se metástases hepáticas em 6 (11,5%) doentes e ascite em 12 (23,1%). Nos doentes submetidos à ressecção com intenção curativa da neoplasia, foram identificados pela tomografia helicoidal abdominal pré-operatória 27 (67,5%) linfonodos sugestivos de comprometimento. O exame anatomopatológico mostrou 16 (40,0%) doentes com linfonodos infiltrados pelo carcinoma gástrico. A sensibilidade do exame de tomografia helicoidal abdominal na identificação pré-operatória da lesão gástrica foi 48,1%, para linfonodos acometidos foi de 18,5% e para metástases hepáticas a sensibilidade foi 100,0%. Treze (25%) doentes apresentaram metástases peritoneais não reveladas pela tomografia helicoidal. Conclusões: O exame de tomografia computadorizada helicoidal abdominal no pré-operatório do carcinoma gástrico apresentou sensibilidade elevada na detecção de metástases hepáticas, sensibilidade baixa na detecção do comprometimento linfonodal pela neoplasia e não foi capaz de identificar metástases peritoneais.

Objective: To analyze the sensitivity of preoperative abdominal helical tomography of gastric carcinoma in detecting lymph node compromise and hepatic and peritoneal metastases. Method: We examined retrospectively 52 patients with gastric carcinoma who had undergone surgery. Patients were staged in according to the findings using abdominal helical tomography with oral and intravenous contrast. Results of pre-operative abdominal tomography correlated with intra-operative findings and anatomopathological results. Results: Gastric neoplasia was located in the antropyloric region in 38 patients (73.1%), in the cardia region in 8 (15.4%), and in the body and fundus in 6 (11.5%). Abdominal tomography detected gastric lesions in 25 patients (48.1%), revealed hepatic metastases in 6 (11.5%), lymph node invasion in 5 (9.6%), ascitis in 4 (7.7%), and neoplastic infiltration in the liver, spleen, and pancreas in 1 (1.9%). Laparotomy detected hepatic metastases in 6 (11.5%) patients and ascitis in 12 (23.1%). Among the patients submitted to curative resection, 27 (67.5%) were identified as having lymph nodes compromised on preoperative abdominal tomography. Anatomopathological examination of the operative specimen showed that 16 patients (40.0%) had lymph nodes invaded by carcinoma. The sensitivity of pre-operative abdominal tomography exams in identifying gastric lesion was 48.1, 18.5% for invaded lymph nodes, and 100.0% for hepatic metastases. Although 13 (25%) patients presented peritoneal metastases intra-operatively, the abdominal tomography exams did not reveal such lesions. Conclusions: Exams of the gastric carcinoma presented high sensitivity in detecting hepatic metastases, low sensitivity in detecting lymph node invasion by neoplasia, and inability to identify peritoneal metastases.

Calculose intra-hepática: desafio diagnóstico como causa de colestase: relato de caso / Íntra-hepatic gallstones: a diagnostic challenge as etiology of cholestasis: a case report

A colestase pode resultar de diversas etiologias e pode se constituir em importante problema diagnóstico na prática médica. Os exames laboratoriais são inespecíficos e não determinam a causa da colestase. O quadro clínico pode ser amplamente variável, podendo não revelar qualquer sintoma em algumas ocasiões, e, em outras, apresentar quadro toxêmico compatível com a síndrome colangio-hepatite ou a colangite piogênica. Na avaliação diagnóstica realizada por exames radiológicos de imagem, vários métodos podem ser utilizados com essa finalidade: ultrassonografia (US) e tomografia computadorizada de abdômen (TC), ressonância nuclear magnética com colangiografia (CRMN), colangiopancreatografia por via endoscópica retrógrada (CPRE), colangiografia por via transparieto-hepática (CTPH) ou por dreno biliar e, ainda, métodos complementares, como a colangioscopia e ultrassonografia intraoperatórias. Relata-se caso de calculose intra-hepática (ClH), diagnosticada por CRMN de repetição, em paciente assintomática e anictérica, que, após realização de vários métodos de imagem não elucidativos da causa de colestase, evoluiu com presença persistente de elevação dos níveis de enzimas canaliculares, desde o pós-operatório imediato até dois anos após a realização de colecistectomia.

Doença inflamatória intestinal / Inflammatory bowel disease

Nos últimos anos um crescente interesse tem sido focado sobre as doenças inflamatórias intestinais (DII). Atualmente, estas moléstias são entendidas como consequência de uma complexa interação entre fatores ambientais, genéticos e imunológicos, que têm como resultado o processo inflamatório persistente dos intestinos. O autor chama a atenção para aspectos de diagnóstico, frequentemente retardado pelo desconhecimento de suas principais manifestações clínicas, e expõe o papel fundamental do exame endoscópico, citando também outros meios diagnósticos. A doença de Crohn (DC) deve ser diferenciada de outros processos inflamatórios intestinais, entre eles as colites infecciosas, a colite isquêmica, outras moléstias como a doença de Behçet, tuberculose intestinal. O tratamento da DII deve ser precedido pela obtenção de dados clínicos, de imagem, laboratoriais e endoscópicos, no sentido de determinar se a doença está em remissão ou em atividade leve, moderada ou grave. É importante também definir a extensão e localização do processo inflamatório. Estas determinações irão direcionar a dose e via de administração dos medicamentos utilizados.O autor faz breve exposição sobre os principais fármacos usados no tratamento da DII: aminossalicilatos, corticoides, imunossupressores e a terapia biológica anti-TNF. São abordados também aspectos relacionados à gestante portadora de DII e ao rastreamento para câncer de cólon.

Enzyme-linked immunosorbent assay (ELISA) immunoassaying versus microscopy: advantages and drawbacks for diagnosing giardiasis

CONTEXTO E OBJETIVO: A giardíase é comum no Brasil. Para o diagnóstico laboratorial, o método mais empregado é o exame microscópico de amostras fecais. O método imunoenzimático (ELISA) também é utilizado. O objetivo deste trabalho é verificar as vantagens e desvantagens do método microscópico quando comparado ao imunoenzimático para o diagnóstico de Giardia lamblia em uma única amostra fecal. TIPO DE ESTUDO E LOCAL: Estudo prospectivo, duplo cego, no Laboratório de Parasitologia, Faculdade de Medicina da Fundação ABC. MÉTODOS: As amostras foram preparadas para exame de acordo com os tradicionais métodos de sedimentação (Hoffman, Pons e Janer) e Faust. Um resultado positivo significa o encontro de Giardia lamblia por um dos métodos ou ambos. O kit Prospect ELISA foi utilizado para detecção do antígeno específico de Giardia lamblia, de acordo com as instruções do fabricante. Os resultados foram expressos em escala visual como negativos ou positivos (+, ++, +++ ou ++++). RESULTADOS: O teste ELISA é positivo mesmo quando uma significante proporção das correspondentes amostras examinadas por microscopia ainda é negativa, sendo esta tendência estatisticamente significante (p < 0,001). A concordância de resultados entre os dois métodos é apenas moderada (0,5 pelo teste kappa). CONCLUSÃO: O teste ELISA é recomendável quando se busca uma elevada sensibilidade para a detecção de antígenos específicos de Giardia lamblia, como em estudos de prevalência. Para a prática diária, recomendamos o método microscópico, que tem custo muito menor e pode detectar outros parasitas na mesma amostra. A baixa taxa de positividade do método no exame de uma única amostra pode ser contornada pelo exame de três amostras, como recomendado pela maioria dos autores.

Enzyme-linked immunosorbent assay (ELISA) immunoassaying versus microscopy: advantages and drawbacks for diagnosing giardiasis.

CONTEXT AND OBJECTIVE: Giardiasis is common in Brazil. For laboratory diagnosis, the method most utilized is microscopic examination of fecal samples, but the immunoenzymatic method is also available. The aim of this work was to verify the advantages and drawbacks of immunoassaying versus microscopy for diagnosing Giardia lamblia, when a single fecal sample is analyzed. DESIGN AND SETTING: Prospective, double-blind study at the parasitology laboratory of Faculdade de Medicina da Fundação ABC. METHODS: Samples were prepared according to the traditional sedimentation (Hoffman, Pons and Janer) and Faust methods. Results were deemed positive when Giardia lamblia was found by one or both methods. The Prospect ELISA kit was used for detecting Giardia lamblia-specific antigen, in accordance with the manufacturer's instructions. Results were expressed on a visual scale as negative or positive (+, ++, +++ or ++++). RESULTS: The ELISA test was positive even when a significant proportion of corresponding samples examined by microscopy were negative. This trend was statistically significant (p < 0.001). The overall concordance of results between the ELISA test and microscopic examination of single samples was only moderate (0.50 by kappa test). CONCLUSION: The ELISA test is useful when just searching for Giardia lamblia, because of its high sensitivity. For daily practice, we recommend microscopy, which is much cheaper and can also detect other parasites. The low positivity of single samples in this method can be overcome by using three samples, as recommended by most authors.

Detection of anti-Helicobacter pylori antibodies in serum and duodenal fluid in peptic gastroduodenal disease.

AIM: To study the diagnosis of Helicobacter pylori (H pylori) infection through the determination of serum levels of anti-H pylori IgG and IgA antibodies, and the levels of anti-H pylori IgA antibodies in duodenal fluid. METHODS: Data were collected from 93 patients submitted to upper digestive endoscopy due to dyspeptic symptoms. The patients were either negative (group A) or positive (group B) to H pylori by means of both histological detection and urease tests. Before endoscopy, peripheral blood was collected for the investigation of anti-H pylori IgG and IgA antibodies. To perform the urease test, biopsies were obtained from the gastric antrum. For the histological evaluation, biopsies were collected from the gastric antrum (greater and lesser curvatures) and the gastric body. Following this, duodenal fluid was collected from the first and second portions of the duodenum. For the serological assaying of anti-H pylori IgG and IgA, and anti-H pylori IgA in duodenal fluids, the ELISA method was utilized. RESULTS: The concentration of serum IgG showed sensitivity of 64.0%, specificity of 83.7%, positive predictive value of 82.0%, negative predictive value of 66.6% and accuracy of 73.1% for the diagnosis of H pylori infection. For the same purpose, serum IgA showed sensitivity of 72.0%, specificity of 65.9%, positive predictive value of 72.0%, negative predictive value of 67.4% and accuracy of 69.8%. If the serological tests were considered together, i.e. when both were positive or negative, the accuracy was 80.0%, sensitivity was 86.6%, specificity was 74.2%, positive predictive value was 74.2% and negative predictive value was 86.6%. When values obtained in the test for detecting IgA in the duodenal fluid were analyzed, no significant difference (P = 0.43) was observed between the values obtained from patients with or without H pylori infection. CONCLUSION: The results of serum IgG and IgA tests for H pylori detection when used simultaneously, are more efficient in accuracy, sensitivity and negative predictive value, than those when used alone. The concentration of IgA antibodies in duodenal fluid is not useful in identifying patients with or without H pylori.

Efficacy of a triple therapy for Helicobacter pylori eradication in a well-developed urban area in Brazil.

CONTEXT: Helicobacter pylori eradication has become the standard treatment for peptic ulcer disease. Triple therapy with omeprazole plus two antibiotics has been used. Due to the lack of ideal treatment and the high rates of primary resistance to nitroimidazoles, the use of clarithromycin has been adopted. OBJECTIVE: To determine the Helicobacter pylori eradication rates using lansoprazole, amoxicillin and clarithromycin for seven days, in patients with peptic ulcer disease in a well developed urban area in Brazil. METHODS: This was a retrospective, open-label study carried out at the School of Medicine of the Fundação ABC. It included 130 patients with peptic ulcer disease (upper endoscopy) who had been tested positive for Helicobacter pylori infection (urease test, histology or breath test), without previous treatment. Patients were treated with lansoprazole 30 mg, amoxicillin 1,000 mg and clarithromycin 500 mg b.i.d., for seven days. Eradication was verified after 90 days. RESULTS: Follow-up data were available for 94 patients. Their mean age was 52.23 years; 51.54% were woman, 84.31% white, 37.69% smokers, 20.77% using nonsteroidal anti-inflammatory drugs and 8.46% alcoholics. Upper endoscopy revealed that 78.46% had duodenal ulcers and 21.53% had gastric ulcers (a 4:1 DU:GU ratio). The eradication rates were 85.11% per protocol and 61.54% by intention to treat; 97% had no adverse effects. CONCLUSION: Triple therapy using lansoprazole, amoxicillin and clarithromycin is well tolerated with high eradication rates and forms a good alternative for developing countries.