Evaluación gastrointestinal en los pacientes con fiebre mediterránea familiar con dolor abdominal crónico y tratados con colchicina: serie de casos / Gastrointestinal evaluation in colchicine-treated familial Mediterranean fever patients with chronic abdominal pain: Cases series

El objetivo de este estudio fue evaluar a los pacientes con fiebre mediterránea familiar (familial Mediterranean fever, FMF) y dolor abdominal crónico resistentes al tratamiento con colchicina. Se incluyó a 48 pacientes diagnosticados en nuestro consultorio de reumatología pediátrica que tenían dolor abdominal a pesar del tratamiento con colchicina. A todos los pacientes se los derivó a un gastroenterólogo pediátrico. Se registraron las características del dolor, tales como aparición, duración y frecuencia; se planificó una endoscopía digestiva para obtener un diagnóstico diferencial. Se determinó la presencia de una mutación del gen MEFV en 46 pacientes. La mediana de la duración del tratamiento fue de 2,8 años. Aproximadamente el 60% de los pacientes tenían dolor abdominal todos los días o de dos a tres veces a la semana; en el 73% de los casos, duró menos de tres horas. A 41 pacientes se les realizó una endoscopía digestiva alta. La gastroduodenitis es un hallazgo frecuente en los pacientes con FMF y dolor abdominal persistente a pesar del tratamiento. Los pacientes con los puntajes más altos de severidad de la enfermedad tenían inflamación digestiva grave.

The aim of the study to evaluate familial mediterranean fever (FMF) patients with chronic abdominal pain unresponsive to colchicine treatment. Forty-eight patients who diagnosed in our Pediatric Rheumatology clinics and suffering from abdominal pain despite colchicine treatment were include. All patients were referred to a pediatric gastroenterologist. The pain characteristics such as onset, duration and frequency were recorded; gastrointestinal (GI) endoscopy was planned for differential diagnosis. MEFV mutation was determined in 46 patients. The median duration of treatment was 2.8 years. Approximately 60% of the patients suffered from abdominal pain every day or 2-3 times a week, in 73% of the cases it lasted less than three hours. Forty-one patients underwent upper GI endoscopy. Gastroduodenitis is a common finding in persisting abdominal pain despite therapy of FMF patients. The patients with the highest disease severity scores had severe inflammation within the entire GI system.

A eficácia dos diferentes tratamentos endoscópicos versus métodos sham, farmacológicos ou cirúrgicos para o refluxo gastroesofágico crônico: uma revisão sistemática e meta-análise / The efficacy of the different endoscopic treatments versus sham, pharmacologic or surgical methods for chronic gastroesophageal reflux disease: a systematic review and meta-analysis

ABSTRACT BACKGROUND: Endoscopic antireflux treatments for gastroesophageal reflux disease (GERD) are still evolving, and most of the published studies address symptom relief in the short-term. Objective - We aimed to perform a systematic review and meta-analysis focused on evaluating the efficacy of the different endoscopic procedures. METHODS: Search was restricted to randomized controlled trials (RCTs) on MedLine, Cochrane, SciELO, and EMBASE for patients with chronic GERD (>6 months), over 18 years old and available follow up of at least 3 months. The main outcome was to evaluate the efficacy of the different endoscopic treatments compared to sham, pharmacological or surgical treatment. Efficacy was measured by different subjective and objective outcomes. RESULTS: We analyzed data from 16 RCT, totaling 1085 patients. The efficacy of endoscopic treatments compared to sham and proton pump inhibitors (PPIs) treatment showed a significant difference up to 6 months in favor of endoscopy with no heterogeneity (P<0.00001) (I2: 0%). The subgroup analysis showed a statistically significant difference up to 6 months in favor of endoscopy: endoscopy vs PPI (P<0.00001) (I2: 39%). Endoscopy vs sham (P<0.00001) (I2: 0%). Most subjective and objective outcomes were statistically significant in favor of endoscopy up to 6 and 12 months follow up. CONCLUSION: This systematic review and meta-analysis shows a good short-term efficacy in favor of endoscopic procedures when comparing them to a sham and pharmacological or surgical treatment. Data on long-term follow up is lacking and this should be explored in future studies.

RESUMO CONTEXTO: Os tratamentos endoscópicos para a doença do refluxo gastroesofágico (DRGE) ainda estão em evolução e a maioria dos estudos publicados abordam o alívio dos sintomas em curto prazo. OBJETIVO: Pretendemos realizar uma revisão sistemática e meta-análise focada na avaliação da eficácia dos diferentes procedimentos endoscópicos. MÉTODOS: A pesquisa foi restrita a ensaios clínicos randomizados em MedLine, Cochrane, SciELO e EMBASE para pacientes com DRGE crônica (>6 meses), com mais de 18 anos e acompanhamento disponível por pelo menos 3 meses. O principal desfecho foi avaliar a eficácia dos diferentes tratamentos endoscópicos em comparação com o tratamento sham, farmacológico ou cirúrgico. A eficácia foi medida por diferentes resultados subjetivos e objetivos. RESULTADOS: Analisamos dados de 16 ensaios clínicos randomizados, totalizando 1085 pacientes. A eficácia dos tratamentos endoscópicos em comparação com o tratamento com sham e inibidores da bomba de prótons mostrou uma diferença significativa até 6 meses a favor da endoscopia sem heterogeneidade (P<0,00001) (I2: 0%). A análise do subgrupo mostrou diferença estatisticamente significativa até 6 meses a favor da endoscopia: endoscopia vs inibidores da bomba de prótons (P<0,00001) (I2: 39%). Endoscopia vs sham (P<0,00001) (I2: 0%). A maioria dos resultados subjetivos e objetivos foram estatisticamente significativos em favor da endoscopia até 6 e 12 meses de acompanhamento. CONCLUSÃO: Esta revisão sistemática e meta-análise mostrou uma boa eficácia a curto prazo em favor dos procedimentos endoscópicos ao compará-los a tratamento sham, farmacológico ou cirúrgico. Não existem dados sobre o acompanhamento a longo prazo e isso deve ser explorado em estudos futuros.

Índice de Rockall y necesidad de hemotransfusión en pacientes con hemorragia digestiva alta no varicosa / Rockall Index and Need of Blood Transfusion in Patients with Non-Variceal Upper Gastrointestinal Bleeding

Introducción: la reducción de la mortalidad en pacientes con hemorragia digestiva alta está dada no solo por la terapéutica endoscópica, sino por el adecuado manejo clínico que incluye reposición de volumen y transfusión sanguínea si es requerida; por lo que es necesaria la evaluación de la utilidad de parámetros pronósticos en la estratificación del riesgo de necesidad de hemotransfusión. Objetivo: evaluar la utilidad del Índice de Rockall en la estratificación del riesgo de necesidad de hemotransfusión en pacientes con hemorragia digestiva alta no varicosa. Métodos: estudio longitudinal, descriptivo y prospectivo desde diciembre de 2011 hasta junio de 2012. Fueron incluidos los pacientes admitidos en el Cuerpo de Guardia del Hospital Militar Central Carlos J. Finlay, con evidencia clínica de hemorragia digestiva alta, a quienes se les realizó una endoscopia dentro de las 24 horas siguientes al ingreso. Se evaluaron parámetros clínicos (edad, comorbilidad y estado hemodinámico), endoscópicos (hallazgos, estigmas de sangrado) y la necesidad de hemotransfusión. Se relacionaron pacientes transfundidos con las diferentes variables incluidas en la Escala de Rockall para determinar factores de riesgo de necesidad de hemotransfusión. Resultados: se estudiaron 89 pacientes, con predominio del sexo masculino (n= 64; 71,91 por ciento), la edad promedio fue de 63,58 años. Se identificaron como factores de riesgo de necesidad transfusional, la comorbilidad, el estado hemodinámico y la presencia de estigmas de sangrado activo o reciente. Del total de pacientes 26 por ciento de los casos (n= 23) tenía un Índice de Rockall alto. Dicho Índice tuvo pobre capacidad predictiva para la necesidad transfusional (área bajo la curva de COR de 0,682; p= 0,00). Conclusión: el índice de Rockall fue útil en la estratificación de riesgo de necesidad de hemotransfusión, lo que puede tenerse en cuenta para una adecuada selección del paciente con hemorragia digestiva alta no varicosa que requiera una terapia transfusional(AU)

Introduction: Reducing mortality in patients with upper gastrointestinal bleeding is due not only to endoscopic therapy but also to clinical care, including volume replacement and blood transfusion if required. So it is necessary to evaluate the utility of prognostic parameters on the stratification of the risk of need for blood transfusion. Objective: Evaluate the utility of Rockall index on the stratification of the risk of need for blood transfusion in patients with upper gastrointestinal bleeding episode of non varicosa origin. Methods: A longitudinal, descriptive and prospective study was carried out from December 2011 to June 2012. Patients admitted to the hospital emergency room, with clinical evidence of upper gastrointestinal bleeding, who underwent an endoscopy within 24 hours after admission. Clinical parameters (age, comorbidity, and hemodynamic status), endoscopic (findings, stigmata of bleeding) and need for blood transfusion were assessed. Transfused patients and different variables included in the Rockall index were listed to determine risk factors when transfusion need. Results: 89 patients were studied with a predominance of males (n= 64, 71.91 percent), mean age 63, 58 years. Comorbidity, hemodynamic state and the presence of stigmata of active or recent bleeding (RR= 8.31 IC: 0.73-1.27; RR= 2.43 IC: 0.22-1.78 y RR= 5.05 IC: 0.62-1.38 respectively. p=0.00) were identified as risk factors for transfusion need. 26 percent of cases (n= 23) had a high index Rockall. This index had predictive poor capacity of transfusion need (area under the ROC curve of 0.682; p= 0.020). Conclusion: Rockall index was useful to identify patients at increased risk of transfusion need, it can be used for the adequate selection of patients with non- varicosa gastrointestinal bleeding that need transfusional therapy(AU)

Cobertura de la estrategia preventiva de cáncer gástrico en Chile: resultados de la Encuesta Nacional de Salud 2009-2010 / Coverage of diagnostic upper gastrointestinal endoscopy for the prevention of gastric cancer in Chile: results from the 2009-2010 National Health Survey

Background: In Chile, gastric cancer (GC) is a major cause of cancer related deaths. The current screening strategy consists of an upper gastrointestinal endoscopy (UGE) for people aged 40 years or more with epigastric pain. Aim: To evaluate the diagnostic coverage of the use of UGE for early detection of GC in Chile. Material and Methods: As part of the digestive module of the 2009-10 National Health Survey, 5293 adults over 15 years were asked about the presence of epigastric pain, possible upper gastrointestinal bleeding (PUGB), use of proton pump inhibitors (PPIs) or histamine H2-receptor antagonists (H2RAs), family history of GC and having performed an UGE. Results: Persistent epigastric pain was observed in 3.4% of the population. PUGB signs were observed in 3.3% of the population. The prevalence of PPIs and H2RAs use was 4.3% and 2.2% respectively, reaching 21.6% in people aged 70 years and older. Life span prevalence of UGE was 18.3%, with differences by region, health insurance and educational level. UGE coverage in people aged 40 years or older with and without persistent epigastric pain was 14.4% and 3.2% respectively (Odds ratio 4.8, p < 0.01). The prevalence of UGE was similar among people with or without PUGB or family history of CG. Conclusions: The estimated coverage of the current GC prevention strategy in Chile is 14.4%, evaluated at a population level. Further studies are required to determine the impact of this strategy on early GC diagnosis and mortality.

Comparing the pain of propofol via different combinations of fentanyl, sufentanil or remifentanil in gastrointestinal endoscopy

PURPOSE: To evaluate the pain on injection of propofol via different combinations of fentanyl, sufentanil or remifentanil in gastrointestinal endoscopy. METHODS: Total 439 patients were randomly allocated into 6 groups. Propofol & fentanil (PF) group received 1 μg/kg fentanyl, propofol & sufentanil (PS) group received 0.1 μg/kg sufentanil and propofol & remifentanyl (PR) group received 1 μg/kg remifentanyl prior to administration of 1-2 mg/kg of propofol. The propofol & half-fentanil (Pf) group, propofol & half-sufentanil (Ps) group and propofol & half-remifentanyl (Pr) group were given 0.5 μg/kg fentanyl, 0.05 μg/kg sufentanil and 0.5 μg/kg remifentanyl, respectively and later administrated 1-2 mg/kg propofol. All patients were monitored for the blood pressure (MAP), heart rate (HR), and oxygen saturation (SpO2). Additionally, the pain intensity was assessed using a 4-point verbal rating scale (VRS) by professional doctors. RESULTS: The incidence of pain due to propofol injection in Ps group (33.8%) was significantly lower than other 5 groups. The heart rate (HR) and mean arterial pressure (MAP) were maintained within the normal limits in all six groups and there was no hypotension or bradycardia encountered during the study period. CONCLUSION: Propofol and sufentanil group was the most suitable program for painless gastroscopy. .

Use of the complete Rockall score and the Forrest classification to assess outcome in patients with non-variceal upper gastrointestinal bleeding subject to after-hours endoscopy: a retrospective cohort study / El uso de la puntuación de Rockall completa y la clasificación de Forrest para evaluar resultados en pacientes con hemorragia gastrointestinal alta no varicosa sometidos a endoscopía de urgencia: un estudio de cohorte retrospectivo

OBJECTIVES: To evaluate the usefulness of the Forrest classification and the complete Rockall score with customary cut-off values for assessing the risk of adverse events in patients with upper gastrointestinal bleeding (UGI-B) subject to after-hours emergency oesophago-gastro-duodenoscopy (E-EGD) within six hours after admission. METHODS: The medical records of patients with non-variceal UGI-B proven by after-hours endoscopy were analysed. For 'high risk' situations (Forrest stage Ia-IIb/complete Rockall score > 2), univariate analysis was conducted to evaluate odds ratio for reaching the study endpoints (30-day and one-year mortality, re-bleeding, hospital stay > 3 days). RESULTS: During the study period (75 months), 86 cases (85 patients) met the inclusion criteria. Patients' age was 66.36 ± 14.38 years; 60.5% were male. Mean duration of hospital stay was 15.21 ± 19.24 days. Mortality rate was 16.7% (30 days) and 32.9% (one year); 14% of patients re-bled. Univariate analysis of post-endoscopic Rockall score > 2 showed an odds ratio of 6.09 for death within 30 days (p = 0.04). No other significant correlations were found. CONCLUSION: In patients with UGI-B subject to after-hours endoscopy, a 'high-risk'Rockall score permits an estimation of the risk of death within 30 days but not of re-bleeding. A 'high-risk'Forrest score is not significantly associated with the study endpoints.

OBJETIVOS: Evaluar la utilidad de la clasificación de Forrest y la puntuación de Rockall completa con los valores límites habituales a fin de evaluar el riesgo de eventos adversos en los pacientes con hemorragia gastrointestinal alta (HGIA) sometidos a una esofagogastroduodenoscopia (EGD) de urgencia dentro de seis horas después del ingreso. MÉTODOS: Se analizaron las historias clínicas de pacientes con HGIA de origen no varicoso comprobada por endoscopia de urgencia. Para las situaciones de 'alto riesgo' (etapa Forrest Ia- IIb/puntuación de Rockall completa >2), se realizó un análisis univariado para evaluar las probabilidades de riesgo (oddsratio) y llegar a los criterios de valoración del estudio (mortalidad de 30 días y un año, resangrado, estancia hospitalaria > 3 días). RESULTADOS: Durante el periodo de estudio (75 meses), 86 casos (85 pacientes) cumplieron los criterios de inclusión. La edad de los pacientes fue de 66.36 ± 14.38 años; 60.5% eran varones. La duración promedio de estancia hospitalaria fue de 15.21 ± 19.24 días. La tasa de mortalidad fue de 16.7% (30 días) y 32.9% (1 año); el 14% de los pacientes volvió a tener sangramiento. El análisis univariado de la puntuación Rockall postendoscópica > 2 mostró un odds-ratio de 6.09 por muerte en 30 días (p = 0.04). No se encontraron otras correlaciones significativas. CONCLUSIÓN: En pacientes con HGIA sometidos a endoscopía de urgencia, una puntuación Rockall de 'alto riesgo'permite una estimación del riesgo de muerte dentro de 30 días, pero no de resangrado. Una puntuación Forrest de 'alto riesgo' no es significativa con respecto a los criterios de valoración del estudio.

Uso del dispositivo SILS™ en cirugía transanal mínimamente invasiva para el manejo de lesiones benignas de recto / Using the device SILS ™ Transanal minimally invasive surgery for the management of benign rectal

Minimally invasive transanal microsurgery was described in 2009. It allows the excision polyps or small malignant lesions. We report a 73 years old female consulting for hematochezia. A sessile polyp located 9 cm above the anal margin was discovered during a colonoscopy that corresponded to a villous adenoma. The polyp was excised transanally, using a SILS* port for transanal endoscopic microsurgery.

La cirugía transanal mínimamente invasiva fue descrita inicialmente en el año 2009 como un abordaje híbrido para lograr la resección endoluminal de lesiones rectales, surgiendo como una alternativa más económica al uso del TEM (Transanal endoscopic microsurgery). La resección transanal de pólipos, así como de pequeñas lesiones malignas rectales con instrumentos laparoscópicos y de puerto único, utiliza la tecnología desarrollada inicialmente para procedimientos desde un orificio natural como es el recto. Nuestra intención es presentar la técnica quirúrgica, así como su aplicación en la resección de lesiones benignas como malignas del recto no realizables a través de una resección transanal convencional.

Comparación de la efectividad de la ligadura vs esclerosis endoscópica en pacientes con sangrado de várices esofágicas en el Hospital Hernán Henríquez de Temuco: estudio de cohortes comparativas / Comparison of band ligation with sclerotherapy for the treatment of bleeding esophageal varices

Background: Endoscopic band ligation is the treatment of choice for bleeding esophageal varices. However it is not clear if this procedure is associated with less early and late mortality than sclerotherapy. Aim: To assess rates of re-bleeding and mortality in cohorts of patients with bleeding esophageal varices treated with endos-copic injection or band ligation. Patients and Methods: Analysis of medical records and endoscopy reports of two cohorts of patients with bleeding esophageal varices, treated between 1990 and 2010. Of these, 54 patients were treated with sclerotherapy and 90 patients with band ligation. A third cohort of 116patients that did not require endoscopic treatment, was included. The mean analyzed follow up period was 2.5 years (range 1-16). Collection of data was retrospective for patients treated with sclerotherapy and prospective for patients treated with band ligation. Rates of re-bleeding and medium term mortality were assessed. Results: During the month ensuing the first endoscopic treatment, re-bleeding was recorded in 39 and 72% of patients treated with band ligation and sclerotherapy, respectively (p < 0.01). The relative risk of bleeding after band ligation was 0.53 (95% confidence limits 0.390.73). Death rates until the end of follow up were 20 and 48% among patients with treated with band ligation and sclerotherapy, respectively (p < 0.01), with a relative risk of dying for patients subjected to band ligation of 0.41 (95% confidence limits 0.25-0.68). Conclusions: Band ligation was associated with lower rates of re-bleeding and mortality in these cohorts of patients.

Endoscopic mucosal resection in colorectal lesion: a safe and effective procedure even in lesions larger than 2 cm and in carcinomas / Mucosectomia em lesões do cólon e reto: procedimento seguro e eficaz mesmo em pacientes com lesões maiores que 2 cm e em carcinomas

CONTEXT: Endoscopic mucosal resection is a minimally invasive technique used in the treatment of colorectal neoplasms, including early carcinomas of different size and morphology. OBJECTIVES: To evaluate procedure safety, efficacy, outcomes, and recurrence rate in endoscopic mucosal resection of colorectal lesions. METHODS: A total of 172 lesions in 156 patients were analyzed between May 2003 and May 2009. All lesions showed pit pattern suggestive of neoplasia (Kudo types III-V) at high-magnification chromocolonoscopy with indigo carmine. The lesions were evaluated for macroscopic classification, size, location, and histopathology. Lesions 20 mm or smaller were resected en bloc and lesions larger than 20 mm were removed using the piecemeal technique. Complications and recurrence were analyzed. Patients were followed up for 18 months. RESULTS: There were 83 (48.2 percent) superficial lesions, 57 (33.1 percent) depressed lesions, 44 (25.6 percent) laterally spreading tumors, and 45 (26.2 percent) protruding lesions. Mean lesion size was 11.5 mm ± 9.6 mm (2 mm-60 mm). Patients' mean age was 61.6 ± 12.5 years (34-93 years). Regarding lesion site, 24 (14.0 percent) lesions were located in the rectum, 68 (39.5 percent) in the left colon, and 80 (46.5 percent) in the right colon (transverse, ascending, and cecum). There were 167 (97.1 percent) neoplasms: 142 (82.5 percent) adenomatous lesions, 24 (14.0 percent) intramucosal carcinomas, and 1 (0.6 percent) invasive carcinoma. En bloc resection was performed in 158 (91.9 percent) cases and piecemeal resection in 14 (8.1 percent). Bleeding occurred in 5 (2.9 percent) cases. Recurrence was observed in 4.1 percent (5/122) of cases and was associated with lesions larger than 20 mm (P<0.01), piecemeal resection (P<0.01), advanced neoplasm (P = 0.01), and carcinoma compared to adenoma (P = 0.04). CONCLUSIONS: Endoscopic mucosal resection of colorectal lesions is a safe and effective procedure, with low complication and local recurrence rates. Recurrence is associated with lesions larger than 20 mm and carcinomas.

CONTEXTO: A mucosectomia endoscópica é uma técnica minimamente invasiva para o tratamento de neoplasias de cólon e reto, inclusive carcinomas precoces, de diferentes tamanhos e aspectos morfológicos. OBJETIVO: Avaliar a segurança, a eficácia, os resultados e a recurrência das lesões após mucosectomia. MÉTODOS: Entre maio de 2003 e maio de 2009 um total de 172 lesões em 156 pacientes foi incluído no estudo. Todas as lesões tinham padrão de criptas sugestivo de neoplasias (III-V), segundo a classificação de Kudo, com o diagnóstico feito por colonoscópios com magnificação de imagens e índigo-carmin. As lesões foram avaliadas quanto à macroscopia, tamanho, localização e histopatologia. Lesões com até 20 mm foram removidas em bloco e as maiores que 20 mm pela técnica de piecemeal. Complicações e recurrência foram analisadas. O seguimento foi de 18 meses. RESULTADOS: Este estudo identificou 83 (48,2 por cento) lesões superficiais, sendo 57 (33,1 por cento) deprimidas, além de 44 (25,6 por cento) lesões de espraiamento lateral e 45 (26,2 por cento) protrusas. O tamanho médio foi de 11,5 ± 9,6 mm (2-60 mm) e a idade média de 61,6 ± 12,5 anos (34-93 anos). No reto estavam 24 (14 por cento) lesões, 68 (39,5 por cento) no cólon esquerdo e 80 (46,5 por cento) no cólon direito (transverso, ascendente e ceco). Foram 167 (97,1 por cento) neoplasias, sendo 142 (82,5 por cento) lesões adenomatosas, 24 (14,0 por cento) carcinomas intramucosos e 1 (0,6 por cento) carcinoma invasivo. Foram tratadas em bloco 158 (91,9 por cento) lesões e 14 (8,1 por cento), por piecemeal. Houve cinco casos (2,9 por cento) de sangramento. A recurrência foi de 4,1 por cento (5/122) e associada a lesões maiores que 20 mm (P<0,01), à técnica piecemeal (P<0,01), à neoplasia avançada (P = 0,01) e ao carcinoma quando comparado ao adenoma (P = 0,04). CONCLUSÕES: A mucosectomia endoscópica de lesões colorretais é procedimento seguro, eficaz, com baixo índice de complicações e recidiva local. A recidiva de lesão é associada a lesões maiores que 20 mm e aos carcinomas.

Comparación de la endoscopia de alta resolución con magnificación y fice y la endoscopia de alta resolución en el diagnóstico de enfermedad de reflujo erosiva / Comparison of high resolution endoscopy and magnification endoscopy fice and high resolution in the diagnosis of erosive reflux disease

La enfermedad por reflujo gastroesofágico es una enfermedad crónica del esófago, su diagnóstico clínico está basado en sus síntomas, pero la endoscopia determina dos entidades clínicas. El 50 por ciento de los pacientes con enfermedad por reflujo gastroesofágico tienen enfermedad por reflujo gastroesofágico y esofagitis. El objetivo de este trabajo es demostrar que la endoscopia de alta resolución con magnificación y Fuji intelligent color enhancement, tienen un mayor porcentaje diagnóstico de enfermedad por reflujo gastroesofágico, tienen enfermedad por reflujo gastroesofágico y esofagitis cuando se compara con la endoscopia de alta resolución. Materiales y métodos: Se realizó endoscopia de alta resolución y endoscopia de alta resolución con magnificación y Fuji intelligent color enhancement a 50 pacientes con el diagnóstico clínico de enfermedad por reflujo gastroesofágico. Se comparó con un grupo control de 50 pacientes. Resultados: La endoscopia de alta resolución dio un 70 por ciento de diagnóstico de enfermedad por reflujo gastroesofágico tienen enfermedad por reflujo gastroesofágico y esofagitis y la endoscopia de alta resolución con magnificación y fuji intelligent color enhancement dio un 98 por ciento de diagnóstico de enfermedad por reflujo gastroesofágico tienen enfermedad por reflujo gastroesofágico y esofagitis (P=0,0002), estadísticamente significativa. Conclusión: La endoscopia de alta resolución con magnificación y fuji intelligent color enhancement, es el método endoscópico de elección, para diagnosticar la existencia de enfermedad por reflujo gastroesofágico tienen enfermedad por reflujo gastroesofágico y esofagitis, en los pacientes con diagnóstico clínico de enfermedad por reflujo gastroesofágico

The gastroesophageal reflux disease (GERD) is a chronic illness of the esophagus, where the clinical diagnosis is based on their symptoms, but the Endoscopy determines two clinical entities. 50 percent of the patients with gastroesophageal reflux disease has esophagitis. The Objective of this trial was demonstrate that the High Resolution Endoscopy with Magnification and Fuji Intelligent Color Enhancement (FICE) had a major percentage diagnosis of ERGEE, when it was compared with the High Resolution Endoscopy. Materials and Methods: It was performed High Resolution Endoscopy and High Resolution Endoscopy with Magnification and Fuji intelligent color enhancement to 50 patients with the clinical diagnosis of gastroesophageal reflux disease, and it was compared with a control group of 50 patients. Results: The high resolution endoscopy demonstrated 70 percent of diagnosis of gastroesophageal reflux disease has esophagitis and the high resolution endoscopy with magnification and Fuji intelligent color enhancement reported 98 percent of diagnosis of gastroesophageal reflux disease has esophagitis (P=0.0002), statistically significant. There was not significant statistical difference in the control group. Conclusion: The high resolution endoscopy with magnification and Fuji intelligent color enhancement was the method of choice to evaluate the existence of gastroesophageal reflux disease has esophagitis, in patients with clinical diagnosis of gastroesophageal reflux disease

Hallazgos endoscópicos en pacientes ambulatorios referidos a endoscopia por síntomas digestivos altos / Endoscopic findings in ambulatory patients referred to endoscopy for upper digestive symptoms

Antecedentes: La realización de endoscopia como primer estudio de un paciente con dispepsia es muy controvertida. Objetivos: Conocer la frecuencia de patología orgánica en pacientes con dispepsia a quienes se les solicita endoscopia digestiva alta, tanto desde la atención primaria como desde los consultorios de especialidades. Métodos: Se analizó la base de datos de endoscopias de nuestro centro en el período 1999-2002. Los diagnósticos de cáncer se confirmaron histológicamente. Resultados: En 10.275 endoscopias practicadas en ese período, 1.488 fueron por dispepsia, 2.536 por síndrome ulceroso y 1.055 por reflujo gastroesofágico. En el grupo con dispepsia se encontró patología orgánica en un 33 por ciento, predominando la gastritis significativa y la esofagitis erosiva. La frecuencia de cáncer gástrico fue baja (0,1 por ciento) y sólo apareció en pacientes sobre 40 años y especialmente en mayores de 60. Lo mismo ocurrió en pacientes referidos por síndrome ulceroso y por reflujo gastroesofágico. Conclusiones: Solicitar endoscopia a pacientes con dispepsia está justificado porque un tercio de ellos tienen patologías de fácil y efectivo tratamiento. El acceso irrestricto a la endoscopia como screening de cáncer gástrico no parece en cambio ser útil en pacientes de menores de 60 años.

Background: The performance of upper digestive endoscopy as a first line study in patients with dyspepsia is highly controversial. Objectives: To investigate the frequency of organic diseases in dyspeptic patients referred from Primary Care centers or from Gastroenterology clinics for upper digestive endoscopy. Methods: The Endoscopy database of our unit was reviewed for the period 1999-2002. The endoscopic diagnosis of gastric cancer was confirmed by positive biopsies. Results: Out of 10.275 endoscopies performed in the study period, the reference diagnosis was: dyspepsia 1.488; ulcer syndrome 2.536 and gastroesophageal reflux 1.055. In the dyspepsia group, 33 percent of cases had some organic pathology, mainly gastritis and erosive esophagitis. The frequency of gastric cancer was low (0.1 percent) and it was found only in patients older than 40 years and specially older than 60 years. Similar results were found in patients referred for ulcer syndrome or gastroesophageal reflux. Conclusions: An upper digestive endoscopy in the initial work up of patients with dyspepsia seems to be acceptable one third of them present organic diseases with easy and effective therapies. On the other hand the irrestrictive acces to endoscopy as screening of gastric cancer does not seem to be useful in patients under 60 years.

Análisis de decisión: diagnóstico de diarrea crónica asociada a la infección por HIV / Decision analysis: diagnostic approach in HIV infection associated chronic diarrhea

Chronic diarrhea is still a problem of difficult management in patients with AIDS, even in the HAART (Highly Active Antiretroviral Therapy) era. AIM: To establish the most appropriate diagnostic procedure for HIV infected patients, with CD4 count below 200 cells/ml and chronic diarrhea, starting on HAART. METHODS: Using a decision tree as the tool of a decision analysis, two alternatives were considered for the ethiologic diagnosis in AIDS associated chronic diarrhea. The compared alternatives were a minimal evaluation (stool culture and parasite stool examination), and complete evaluation (adding endoscopies with intestinal biopsies). The decision tree was constructed by TreeAge Data 32 software. Diagnostic and therapeutic data for both alternatives were obtained from medical publications. The outcome was the reported survival estimation for HIV infected patients with CD4 level bellow 200 cells/ml, starting HAART, with and without chronic diarrhea. RESULTS: In the basic analysis, as well as in the sensitivity analysis, a complete evaluation was the alternative that showed the highest expected value: 7.79 years of survival. The minimal evaluation showed a value of 7.05 years of survival. CONCLUSION: In HIV infected patients with chronic diarrhea and CD4 count below 200 cells/ml, starting on HAART, digestive endoscopies with biopsy samples are the best diagnostic approach.

La diarrea crónica constituye un problema de difícil manejo en pacientes con SIDA, aun en la era de las terapias antirretrovirales de alta eficacia (HAART). Objetivo: Establecer la conducta diagnóstica más adecuada frente a pacientes con infección por HIV, con niveles de linfocitos CD4+ menores a 200 células/mm 3 y diarrea crónica que comienza con HAART. Métodos: Utilizando el análisis de decisión, con un árbol de decisionescomo herramienta, se consideraron dos alternativas para el diagnóstico etiológico de la diarrea crónica asociada al SIDA. Las alternativas comparadas fueron la evaluación mínima (estudios microbiológicos de materia fecal) y la evaluación completa (adicionando estudios endoscópicos con biopsias). La construcción del árbol de decisiones se efectuó con el software TreeAge Data 32. Con datos obtenidos en la literatura, se estimaron las probabilidades diagnósticas y respuestas terapéuticaspara cada rama. En la estimación del resultado final se eligió la expectativa de vida publicada para pacientes con CD4 menores de 200 células/mm 3, que inician HAART, con y sin diarrea crónica. Resultados: Tanto en el escenario de base como en los análisisde sensibilidad llevados a cabo, la evaluación completa resultó la estrategia con mayor valor esperado. La expectativa de vida esperada fue de 7.79 años con ésta y de 7.05 años con la mínima. Conclusión: En pacientes HIV positivos con diarrea crónica, CD4 menores de 200 células/mm 3 y que inician HAART, las endoscopías digestivas con biopsias constituyen el major método para el diagnóstico etiológico.

Ectasias vasculares del anatro gástrico como causa de sangramiento digestivo crónico: presentación de un caso / Vascular ectasias of the gastric antrum as the cause of chronic digestive hemorrhage: presentation of a case

La hemorragia digestiva es una de las causas que con frecuencia ocupa la atención del gastroenterologoendoscopia, a veces no es fácil el diagnóstico de certeza al no detectarse una hemorragia evidente en el estudio endoscópico alto y por supuesto con una pesquisa radiológica contrastada; en los últimos años se ha incorporado una patología vascular que es responsible de una patología vascular que es evidencia por melenas, cuyo, origen corresponde a las ectasias vasculares que son dilataciones vasculares, que pueden presentarse en el estómago o en el colon derecho en el curso de variadas patologías acompañante, como cirrosis hepática con hipertensión portal, valvulopatía cardíacas y etc. En tal sentido, presentamos un caso, del sexo feminino, de 61 años de edad, con historia de hepatopatía crónica de tipo cirrótica de etiología no precisada (diagnosticada esde 1983), que hace aproximadamente dos años (1996-1997), presenta cuadros de hemorragias digestivas, por lo cual ha sido trasfundida en varias ocasiones al presentar anemia grave. En la duodenoscopía y colonoscopía se observó ectasias vasculares difusas en la región distal del antro y parte del cuerpo gástrico (EVDAG) con signos de hemorragia activa y lesiones similares en el colon pero no sangrantes. La TGP se encuentro normal y los marcadores del virus de la hepatitis B y C fueron negativos. El exámen por imágenes (US) fue normal. No existían antecedente personales ni diagnóstico al egreso fue Ectasia Vascular Difusa del Antro Gástrico y parte del cuerpo gástrico del ciego y colon derecho asociada a cirrosis hepática. Por presentar nuevamente cuadro de hemorragia digestiva alta se reingresa y se decide intervención quirúrgica, realizandose resección gástrica con resultados alentadores. Se analiza el caso y serevisa la entidad.

Gastropatía por Helicobacter Pylori en pacientes pediátricos / Gastropaty by helicobacter pylori in pediatric patients

Se estudiaron veintinueve (29) casos de pacientes pediátricos, que fueron llevados al Servicio de Gastroenterología del Hospital General del Oeste por presentar diversos signos y síntomas del aparato digestivo, siendo el predominante dolor abdominal recurrente. A todos se les realizó estudio clínico, endoscopia del tracto digestivo superior, prueba de la ureasa y biopsia gástrica. Sus edades estaban comprendidas entre los cinco meses y los catorce años. Dieciséis pacientes fueron del sexo femenino y trece del masculino. En dieciséis se hizo el diagnóstico endoscópico de gastritis y la prueba de la ureasa resultó positiva en doce. Desde el punto de vista histopatológico en doce (12) casos se encontró evidencia inequívoca de helicobacter pylori, observándose en la mayoría de ellos una tríada histopatológica constituida por: 1) gastritis crónica superficial activa con plasmocitos e hiperplasia regenerativa típica; 2) hiperplasia vellosa, y 3) dilatación de criptas y/o glándulas. De los doce casos con presencia inequívoca de Helicobacter pylori, nueve presentaron la prueba de la ureasa positiva