Avaliação da microbiota intestinal em adultos com esofagite erosiva / Assessment of the intestinal microbiota in adults with erosive esophagitis

ABSTRACT BACKGROUND: The intestinal microbiota influences the appropriate function of the gastrointestinal tract. Intestinal dysbiosis may be associated with a higher risk of esophageal lesions, mainly due to changes in gastroesophageal motility patterns, elevation of intra-abdominal pressure, and increased frequency of transient relaxation of the lower esophageal sphincter. OBJECTIVE: The aim of this study was to evaluate the intestinal microbiota in individuals with erosive esophagitis and in healthy individuals using metagenomics. METHODS: A total of 22 fecal samples from adults aged between 18 and 60 years were included. Eleven individuals had esophagitis (eight men and three women) and 11 were healthy controls (10 men and one woman). The individuals were instructed to collect and store fecal material into a tube containing guanidine solution. The DNA of the microbiota was extracted from each fecal samples and PCR amplification was performed using primers for the V4 region of the 16S rRNA gene. The amplicons were sequenced using the Ion Torrent PGM platform and the data were analyzed using the QIIME™ software version 1.8. Statistical analyses were performed using the Mann-Whitney non-parametric test and the ANOSIM non-parametric method based on distance matrix. RESULTS: The alpha-diversity and beta-diversity indices were similar between the two groups, without statistically significant differences. There was no statistically significant difference in the phylum level. However, a statistically significant difference was observed in the abundance of the family Clostridiaceae (0.3% vs 2.0%, P=0.032) and in the genus Faecaliumbacterium (10.5% vs 4.5%, P=0.045) between healthy controls and esophagitis patients. CONCLUSION: The findings suggest that reduced abundance of the genus Faecaliumbacterium and greater abundance of the family Clostridiaceae may be risk factors for the development of erosive esophagitis. Intervention in the composition of the intestinal microbiota should be considered as an adjunct to current therapeutic strategies for this clinical condition.

RESUMO CONTEXTO: A doença do refluxo gastroesofágico (DRGE) é uma das enfermidades mais comuns na prática clínica e possui fisiopatologia multifatorial. Disbiose da microbiota intestinal pode ter influência em mecanismos envolvidos nesta doença, como mudanças nos padrões motores gastrointestinais, elevação da pressão intra-abdominal e aumento da frequência de relaxamentos transitórios do esfíncter esofágico inferior. Contudo, a avaliação da microbiota intestinal, neste contexto, ainda é pouco documentada. OBJETIVO: Este estudo avaliou a microbiota bacteriana intestinal, em indivíduos com doença do refluxo gastroesofágico erosivo e em indivíduos saudáveis, utilizando técnicas de metagenômica. MÉTODOS: Estudo incluiu amostras fecais de 22 adultos, com idades entre 18 e 60 anos: 11 com esofagite erosiva (oito homens e três mulheres) e 11 controles saudáveis (dez homens e uma mulher). Os pacientes foram orientados a coletar e armazenar o material fecal em tubo contendo solução de guanidina. O DNA da microbiota foi extraído das amostras de fezes e amplificação por PCR foi realizada usando iniciadores para a região V4 do gene 16S rRNA. Os amplicons foram seqüenciados usando a plataforma Ion PGM Torrent e os dados foram analisados usando o software QIIME™ versão 1.8 (Quantitative Insights Into Microbial Ecology). Análise de estatística foi realizada utilizando-se o teste não paramétrico de Mann-Whitney e o teste ANOSIM, método não paramétrico baseado em matriz de distância. RESULTADOS: Os índices de alfa-diversidade e beta-diversidade foram semelhantes entre os dois grupos, sem diferença estatisticamente significante. Não houve diferença estatisticamente significante no nível de filo, classe e ordem. Entretanto, observou-se diferença estatisticamente significante na abundância da família Clostridiaceae (0,3% vs 2,0%, P=0,032) e no gênero Faecaliumbacterium (10,5% vs 4,5%, P=0,045) entre controles saudáveis e pacientes com DRGE erosiva, respectivamente. CONCLUSÃO: Os achados sugerem que menor abundância do gênero Faecaliumbacterium e maior abundância da família Clostridiaceae, nos pacientes com DRGE, podem influenciar na fisiopatologia desta doença.

Impact of Gastric Bypass on Erosive Esophagitis and Barret's Esophagus.

BACKGROUND: The association between gastroesophageal reflux disease (GERD) and obesity is clearly defined. The incidence of erosive esophagitis (EE) and Barrett's esophagus (BE) are as high as 26 and 6%, respectively. Gastric bypass (GBP) is considered the gold standard for obese patients with GERD. Evidence about the impact of GBP on EE and BE is not yet clear but more inspiring every day. METHODS: Obese patients operated by GBP with EE or BE were included for this study. Demographics, BMI, %EWL, and the evolution of EE and BE with pre and postoperative upper endoscopy were analyzed. RESULTS: In this study, 64 patients were included, 55 with EE and 9 with BE. The preoperative BMI was 44.29 km/m2 ± 3.5 and the %EWL was 78.5 ± 5.8 in the first year postoperative. Preoperatively, EE was distributed as follows: A: 54.5% (30), B: 34.5% (19), C: 9% (5), D: 2% (1). BE findings were the following: short segment (SSBE): 45% (4) and long segment (LSBE): 55% (5). Postoperatively, 80% of the patients with EE resolved their condition, 11% improved, 7% had no changes, and 2% worsened. From the patients with SSBE, 75% resolved their condition and 40% with LSBE resolved their condition after 24 months and no patient progressed to dysplasia. CONCLUSION: Patients with EE had a statistically significant resolution after GBP. BE was improved or even resolved in many patients without acquiring significance but also without progression. Long-term surveillance data is necessary to define the certain evolution of EE and BE after GBP.

Effect of Roux-en-Y gastric bypass in the control of erosive esophagitis

Introduction: Gastroesophageal reflux disease (GERD) is a multifactorial disease associated with environmental and genetic factors. Obesity is among the risk factors for its development, which also correlates with an increase in severity of clinical presentation and a higher incidence of complications associated with reflux. Methods: This historical cohort study included a sample of 249 patients who had undergone bariatric surgery using the Roux-en-Y gastric bypass technique at the Hospital São Vicente de Paulo, Passo Fundo, southern Brazil, from January 2014 to December 2015. Results: Of 249 patients, 77.9% (190 patients) were female and the mean age was 38 years. The occurrence of reflux esophagitis was 81.1% (196 patients) in the preoperative period and 31.3% (75 patients) in the postoperative period. With regard to bariatric treatment response to control moderate and severe esophagitis (grades B, C and D), there was a reduction in prevalence from 62 (25%) to 12 (5%) patients (p<0.05). Conclusions: Bariatric surgery using the Roux-en-Y gastric bypass technique is effective in the control of reflux esophagitis. Regression is observed mainly in cases of moderate and severe esophagitis. (AU)

Estudio de la motilidad esofágica en pacientes con esofagitis erosiva / Esophageal motility study in patients with erosive esophagitis

Introducción: el fallo de la barrera antirreflujo permite el desarrollo de la enfermedad por reflujo gastroesofágico. La manometría esofágica permite estudiar los factores de motilidad que conforman la barrera antirreflujo. Objetivo: caracterizar los factores de motilidad en pacientes con esofagitis erosiva, a partir de la tecnología y los programas desarrollados. Método: se realizó un estudio descriptivo y transversal de 210 pacientes con esofagitis erosiva, en los cuales se estudiaron los factores de motilidad a través de la manometría esofágica. Resultados: el patrón de motilidad obtenido demostró hipotonía en el esfínter esofágico inferior, inestabilidad de este, con una frecuencia importante de hernia hiatal y trastornos motores esofágicos de tipo severo. Conclusiones: el principal daño en la barrera antirreflujo se desarrolla desde los grados más leves de la enfermedad, sin una correspondencia real entre este y el grado de esofagitis erosiva. La importante afectación de la peristalsis puede constituir uno de los elementos que interviene en el inicio de la enfermedad(AU)

Introduction: failed anti-reflux barrier allows the development of gastroesophageal reflux disease. The motility factors making up the anti-reflux barrier may be studied through the esophageal manometry. Objective: to characterize motility factors in patients with erosive esophagitis by means of developed software and technologies. Methods: a descriptive cross-sectional study was carried out in patients with erosive esophagitis by analyzing the motility factors through esophageal manometry. Results: the resulting pattern showed unstable and hypotonic lower esophageal sphincter, significant frequency of hiatal hernia and severe esophageal motor disorders. Conclusions: the main damage observed in the anti-reflux barrier occurs from the mildest degrees of the disease, without real association between this one and the degree of erosive esophagitis. The significant effect on peristalsis may be one of the elements leading to the onset of the disease(AU)

Reflujo gastroesofágico y esofagitis erosiva / GASTROESOPHAGEAL REFLUX AND EROSIVE ESOPHAGITIS

Objetivo: Determinar la frecuencia de esofagitis erosiva asociada a la sintomatología de reflujo gastroesofágico. Métodos: Se realizó un estudio prospectivo, descriptivo, transversal. Con una población de 153 pacientes con síntomas de enfermedad por reflujo gastroesofágico. La muestra se conformó con los pacientes en los que se evidenció esofagitis erosiva durante la endoscopia digestiva superior, en el periodo comprendido entre noviembre y diciembre 2012 en el Hospital Dr. Miguel Pérez Carreño, Caracas Venezuela. Resultados: 45 pacientes (29,4%) presentaron esofagitis erosiva, siendo en su mayoría de sexo femenino y edad entre 35 a 65 años. No hubo relación de frecuencia y severidad de pirosis con esofagitis erosiva, tampoco en cuanto al IMC o tiempo de evolución de los síntomas. La relación entre la presencia de síntomas nocturnos y hernia hiatal si fue estadísticamente significativa (p=0,034). Conclusiones: los resultados obtenidos son similares a las estadísticas conocidas a nivel mundial del porcentaje de esofagitis erosiva en pacientes con síntomas de ERGE. La mayoría de los pacientes se corresponden al sexo femenino, con un IMC normal y dentro del grupo adulto contemporáneo.

Objective: To determine the frequency of erosive esophagitis associated with gastroesophageal reflux symptoms. Methods: We performed a prospective, descriptive, transversal study. Our population were 153 patients with symptoms of gastroesophageal reflux disease, the sample comprises those patients whose erosive esophagitis was evident during upper endoscopy gastrointestinal in the period between November and December 2012 in the Hospital Dr. Miguel Perez Carreño, Caracas Venezuela. Results: 45 patients (29,4%) had erosive esophagitis, of these the majority were female and between 35-65 years old. No relationship was found between the frequency and severity of heartburn with erosive esophagitis. Niether with respect to BMI or duration of symptoms. The relationship between the presence of hiatal hernia and nocturnal symptoms was statistically significant (p=0,034). Conclusions: There is a relation between the results obtained and the known worldwide statistics on the percentage of patients with erosive GERD. The presence of hiatal hernia and nocturnal symptoms was significant. Most patients were female, with a normal BMI group and within the adult contemporary ages.

Hallazgos endoscópicos en pacientes con síntomas cardinales de enfermedad de reflujo gastroesofágico

La enfermedad de reflujo gastroesofágico (ERGE) es una enfermedad recurrente relacionada con el flujo retrógrado del contenido gástrico al esófago, con o sin daño tisular a dicho nivel. La Hernia Hiatal (HH) se asocia con ERGE, y se ha relacionado con grados severos de la enfermedad (Esofagitis Erosiva Severa y Esófago de Barrett). Objetivo: Describir la presencia y las alteraciones a nivel de la mucosa esofágica reportadas endoscópicamente en los pacientes que consultan con síntomas de ERGE al servicio de Gastroenterología del Hospital Vargas. Pacientes y métodos: estudio descriptivo de corte transversal, en el cual se evaluaron hallazgos endoscópicos de pacientes que acudieron con síntomas de ERGE a las consultas del servicio de gastroenteologia del Hospital Vargas entre enero-mayo de 2007. Resultados: de 674 pacientes encuestados, 204 pacientes (59 hombres y 145 mujeres)presentaron síntomas de ERGE, a 60 de ellos se les realizó videogastroscopia de manera aleatoria, reportando 23,33% (14 pacientes) con ERGE erosiva, 1,66% (1paciente) con tu submucoso de esófago, 6,66% con esófago Barret y 75% (45 pacientes) sin alteraciones esofágicas. 23 (38,33%) con hernia hiatal, 8 de ellos con esofagitis erosiva. Conclusiones: Nuestro trabajo confirma el valor de la endoscopia digestiva superior en la evaluación de pacientes con síntomas cardinales de ERGE.

Gastro-esophageal reflux disease (GERD) is a recurrent disease related with retrograde progression of gastric contents to the esophagus with or without mucosal damage at this level. Hiatal hernia is associated with GERD and it has been related with severe grades of the disease (severe erosive esophagitis and BarrettÊs esophagus). Aims: to describe the presence of endoscopic features in GERD patientss with cardinals symptoms attended at the Gastroenterology Division of the Vargas Hospital in Caracas. Patients and Methods: this was a descriptive, transversal cohort study in which endoscopic findings in patients with GERD symptoms were evaluated, at the Gastroenterology Service, between January and May 2007. Results: of 674 patients interviewed, 204 patients (59 men and 145 women) presented GERD symptoms; to 60 of them an upper endoscopy randomly was performed. 23,33% (14 patients) had erosive GERD, 1,66% (1 patient) a submucous esophageal tumor, 6,66 % with BarrettÊs esophagus and 75% (45 patients) without esophageal changes, 23 (38,33%) with hiatal hernia, 8 of them with erosive esophagitis. Conclusion: our study supports the importance of performing an upper endoscopy in patients with cardinals symptoms of GERD.

Esofagitis por reflujo no erosiva: Correlación clínico-morfológica. Reporte preliminar

Llevamos a cabo un estudio descriptivo de 20 pacientes con síntomas típicos de enfermedad por reflujo gastroesofágico (pirosis y regurgitación) sin alteraciones en la endoscopia digestiva superior. Los cambios histológicos en la esofagitis son: hiperplasia basal, papilomatosis, acantosis, dilatación de los espacios intercelulares. Encontramos que el 45 % de los casos presentó alteraciones histológicas compatibles con ERGE. Lo cual puede evidenciar la utilidad de las biopsias particularmente en los pacientes con ERNE, cuando estas son tomadas a un centímetro por encima de la línea Z. En un futuro estudio compararemos estos hallazgos con pacientes que presenten síntomas típicos y esofagitis erosiva y un grupo control caracterizado por estar asintomático.

We carried out a descriptive study with 20 patients with typical GERD symptoms (heartburn and regurgitation) with a normal upper endoscopy. Histological alterations in esophagitis are: basal cell hyperplasia, papillomatosis, acanthosis and dilation of intercellular spaces. We found in 45 % of the cases histological alterations compatible with GERD. This technique, can evidence the usefulness of biopsies, in patients with GERD, when biopsy samples are taken one centimeter above the Z-line. In a future study we will compare these findings with patients who have typical symptoms of GERD with erosive esophagitis and a control group.