The role of high sensitive C-reactive protein and histopathological evaluation in chronic gastritis patients with or without Helicobacter pylori infection

Abstract Purpose: To evaluate serum levels of high-sensitivity C-reactive protein (hs-CRP) in chronic gastritis patients to predict Helicobacter pylori (HP) infection, inflammatory activity, and precancerous lesions. Methods: A total of 811 patients with upper gastrointestinal symptoms and histopathological diagnosis of chronic gastritis were enrolled in the study. On endoscopy, five gastric biopsies were taken according to Modified Sydney protocol, which were stained with hematoxylin & eosin and Giemsa Results: HP infection was found in 28.6% of patients, being significantly more common in specimens with acute and chronic inflammatory activity. Mucosal atrophy, intestinal metaplasia, and dysplasia were found in 20.2%, 18.8% and 2.7% of biopsy specimens. Mean hs-CRP was 1.9±1.6 mg/dl for males and 2.2±1.9 mg/dl for females. hs-CRP average were significantly higher in patients with severe acute inflammation (p:0.049), in patients with severe chronic inflammation (p:0.015) and in those with HP (p: 0.001) . The severity of HP infection increased significantly with the increased degree of acute inflammation, chronic inflammation and hs-CRP level (p=0.001 for both). Conclusion: Serum hs-CRP level increases in patients with chronic gastritis, it could be an indicator of severity of acute or chronic mucosal inflammation, and presence of HP infection. Therefore, hs-CRP may aid the diagnosis of chronic gastritis, but it is not associated with pre-cancerous lesions.

Endoscopic full-thickness resection for gastric gastrointestinal stromal tumor originating from the muscularis propria

SUMMARY OBJECTIVE: This study retrospectively reviewed 46 cases of gastric gastrointestinal stromal tumors treated by endoluminal endoscopic full-thickness resection (EFR) microsurgery in our gastrointestinal endoscopy center. We aimed to evaluate the EFR for the treatment of gastric gastrointestinal stromal tumors originating from the muscularis propria. METHODS: A total of 46 patients with gastric gastrointestinal stromal tumors originated from the muscularis propria layer from January 2012 to June 2015 were treated with EFR. The patients were followed up with gastroscope and computed tomography (CT) for evaluation of therapeutic effect and safety. RESULTS: EFR was successfully accomplished to remove all tumors in 46 patients. The mean procedure time was 82.5±39.8min (56-188min). Except in 3 leiomyomas, pathological examination confirmed gastrointestinal stromal tumor (GIST) in 43 cases. None of the patients had occurred bleeding, peritonitis and other complications after EFR. Thereafter, all patients were followed up with gastro-scope after 1, 6,12 months. CONCLUSIONS: EFR is effective and safe for patients with gastric gastrointestinal stromal tumors originated from muscularis propria layer and has the advantage of less invasive treatment and higher tumor resection rate. It should be considered for further application.

RESUMO OBJETIVO: Este estudo revisou retrospectivamente 46 casos de tumores gástricos estromáticos gastrointestinais tratados por microcirurgia endoluminal endoscópica de ressecção completa (EFR) em nosso centro de endoscopia gastrointestinal. Pretendemos avaliar a EFR para o tratamento de tumores gastrointestinais estromáticos originários da muscularis própria. MÉTODOS: Um total de 46 pacientes com tumores gástricos estromáticos gastrointestinais originários da camada muscular própria, de janeiro de 2012 a junho de 2015, foi tratado com EFR. Os pacientes foram acompanhados com gastroscópio e tomografia computadorizada (TC) para avaliação de efeitos terapêuticos e segurança. RESULTADOS: A EFR foi realizada com sucesso para remover todos os tumores em 46 pacientes. O tempo médio de procedimento foi de 82,5±39,8 min (56-188 min). Exceto em três leiomiomas, exame patológico confirmou tumor estromal gastrointestinal (Gist) em 43 casos. Em nenhum paciente ocorreu sangramento, peritonite e outras complicações após EFR. Posteriormente, todos os pacientes foram acompanhados com gastroscópio após um, seis e 12 meses. CONCLUSÕES: A EFR é eficaz e segura para pacientes com tumores gastrointestinais originários da camada muscular própria e tem a vantagem de ser um tratamento menos invasivo e com maior taxa de ressecção tumoral. Deve ser considerada para posterior aplicação.

[Retracted Article] Gastric and jejunal histopathological changes in patients undergoing bariatric surgery / [Artigo Retratado] Alterações histopatológicas gástricas e jejunais em pacientes submetidos à cirurgia bariátrica

ABSTRACT BACKGROUND Morbid obesity is a multifactorial disease that is increasingly treated by surgery. OBJECTIVE To evaluate gastric histopathological changes in obese, and to compare with patients who underwent gastrojejunal bypass and the jejunal mucosa after the surgery. METHODS This is an observational study performed at a tertiary public hospital, evaluating endoscopic biopsies from 36 preoperative patients and 35 postoperative. RESULTS In the preoperative group, 80.6% had chronic gastritis, which was active in 38.9% (77.1% and 20.1%, respectively, in the postoperative). The postoperative group had a significant reduction in Helicobacter pylori infection (P=0.0001). A longer length of the gastric stump and a time since surgery of more than two years were associated with Helicobacter pylori infection. The jejunal mucosa was normal in 91.4% and showed slight nonspecific chronic inflammation in 8.6%. CONCLUSION There was a reduction in the incidence of Helicobacter pylori infection in the postoperative group. A longer length of the gastric stump and longer time elapsed since surgery were associated with Helicobacter pylori infection. The jejunal mucosa was considered normal in an absolute majority of patients.

RESUMO CONTEXTO A obesidade mórbida é doença multifatorial cujo tratamento cirúrgico é cada vez mais indicado. OBJETIVO Avaliar alterações histopatológicas gástricas em obesos e comparar com os submetidos à bypass gastrojejunal e a mucosa jejunal após a operação. MÉTODOS Estudo observacional realizado em hospital público terciário avaliando biópsias endoscópicas de 36 pacientes no pré-operatório e 35 no pós-operatório. RESULTADOS: No pré-operatório 80,6% apresentaram gastrite crônica, 38,9% em atividade (77,1% e 20,1%, respectivamente, no pós-operatório). O grupo pós-operatório apresentou diminuição significativa na infecção por Helicobacter pylory (P=0,0001). Maior comprimento do coto gástrico e tempo de operação superior a dois anos associaram-se a infecção por Helicobacter pylori. A mucosa jejunal foi normal em 91,4% e apresentava leve inflamação crônica inespecífica em 8,6%. CONCLUSÃO Houve diminuição da infecção por Helicobacter pylori após a operação. Maior comprimento do coto gástrico e do tempo de operação associaram-se à infecção por Helicobacter pylori. A mucosa jejunal foi considerada normal na maioria absoluta dos pacientes do grupo pós-operatório.

H. Pylori infection, endoscopic, histological aspects and cell proliferation in the gastric mucosa of patients submitted to roux-en-y gastric bypass with contention ring: a cross sectional endoscopic and immunohistochemical study

ABSTRACT Background Morbid obesity treatment through vertical gastroplasty Roux-en-Y gastric bypass initially used a contention ring. However, this technique may create conditions to the development of potentially malign alterations in the gastric mucosa. Although effective and previously performed in large scale, this technique needs to be better evaluated in long-term studies regarding alterations caused in the gastric mucosa. Objective To analyze the preoperative and postoperative endoscopic, histological and cell proliferation findings in the gastric antrum and body mucosa of patients submitted to the Roux-en-Y gastric bypass with a contention ring. Methods We retrospectively evaluated all patients submitted to Roux-en-Y gastric bypass with a contention ring with more than 60 months of postoperative follow-up. We compared the preoperative (gastric antrum and body) and postoperative (gastric pouch) gastric mucosa endoscopic findings, cell proliferation index and H. pylori prevalence. We evaluated cell proliferation through Ki-67 antibody immunohistochemical expression. Results In the study period, 33 patients were operated with the Roux-en-Y gastric bypass using a contention ring. We found a chronic gastritis rate of 69.7% in the preoperative period (gastric antrum and body) and 84.8% in the postoperative (gastric pouch). H. pylori was present in 18.2% of patients in the preoperative period (gastric antrum and body) and in 57.5% in the postoperative (gastric pouch). Preoperative cell proliferation index was 18.1% in the gastric antrum and 16.2% in the gastric body, and 23.8% in the postoperative gastric pouch. The postoperative cell proliferation index in the gastric pouch was significantly higher (P=0.001) than in the preoperative gastric antrum and body. Higher cell proliferation index and chronic gastritis intensity were significantly associated to H. pylori presence (P=0.001 and P=0.02, respectively). Conclusion After Roux-en-Y gastric bypass with contention ring, there was a higher chronic gastritis incidence and higher cell proliferation index in the gastric pouch than in the preoperative gastric antrum and body. Mucosa inflammation intensity and cell proliferation index in the postoperative gastric pouch were associated to H. pylori presence and were higher than those found in the preoperative gastric antrum and body mucosa.

RESUMO Contexto O tratamento da obesidade mórbida através da gastroplastia vertical com derivação gastrojejunal em Y de Roux inicialmente utilizou o anel de contenção. No entanto, essa técnica pode criar condições para o desenvolvimento de alterações potencialmente malignas na mucosa gástrica. Apesar de eficaz e realizada anteriormente em grande escala, essa técnica precisa ser melhor avaliada em estudos de longo prazo em relação às alterações causadas na mucosa gástrica. Objetivo Analisar os achados endoscópicos, histológicos e da proliferação celular na mucosa do antro e corpo gástricos no pré-operatório e no pós-operatório de pacientes submetidos à derivação gastrojejunal em Y de Roux com anel de contenção. Métodos Avaliamos retrospectivamente todos os pacientes submetidos à derivação gastrojejunal em Y de Roux com anel de contenção e mais de 60 meses de seguimento pós-operatório. Comparamos os achados endoscópicos da mucosa gástrica, o índice de proliferação celular e a prevalência do H. pylori no pré-operatório (antro e corpo gástricos) e no pós-operatório (bolsa gástrica). Avaliamos a proliferação celular pela expressão imuno-histoquímica do anticorpo Ki67. Resultados No período do estudo, 33 pacientes foram operados com a derivação gastrojejunal em Y de Roux usando anel de contenção. Encontramos a taxa de gastrite crônica de 69,7% no período pré-operatório (antro e corpo gástrico) e 84,8% no pós-operatório (bolsa gástrica). O H. pyloriestava presente em 18,2% dos pacientes no período pré-operatório (antro e corpo gástrico) e em 57,5% no pós-operatório (bolsa gástrica). O índice de proliferação celular pré-operatório foi de 18,1% no antro gástrico e 16,2% no corpo gástrico, e de 23,8% na bolsa gástrica no pós-operatório. O índice de proliferação celular pós-operatório na bolsa gástrica foi significantemente maior (P=0,001) do que no antro e corpo gástrico no pré-operatório. O maior índice de proliferação celular e a intensidade da gastrite crônica na bolsa gástrica associaram-se significantemente à presença do H. pylori(P=0,001 e P=0,02, respectivamente). Conclusão Após a derivação gastrojejunal em Y de Roux com anel de contenção, houve maior incidência de gastrite crônica e maior índice de proliferação celular na bolsa gástrica do que no antro e corpo gástricos no pré-operatório. A intensidade da inflamação da mucosa e o índice de proliferação celular encontrados na bolsa gástrica no pós-operatório associaram-se à presença doH. pylori e foram maiores do que os encontrados na mucosa gástrica do antro e corpo gástricos no pré-operatório.

Disección submucosa endoscópica en cáncer gástrico incipiente: experiencia inicial en el Hospital Clínico de la Pontificia Universidad Católica de Chile / Endoscopic submucosal dissection in early gastric cancer: Experience in 16 patients

Background: Endoscopic submucosal dissection (ESD) is a minimally invasive procedure that allows curative treatment of early gastric cancer (EGC) in selected patients. Aim: To report our initial experience with ESD. Material and Methods: Analysis of prospective data from 16 patients aged 61 to 84 years, who underwent ESD between December 2011 and June 2014. Tumor type, operative time, hospitalization length, oncologic outcomes, complications and short-term follow up were registered. Results: En-block resection was achieved in all cases. The median operative time was 135 min (range: 50-320 min). Specimens' median size was 3.5 cm (range: 3-10). All the resections were R0. In 14 patients ESD was considered curative. In two patients, ESD was considered potentially non-curative due to the presence pathological risk factors for lymph-node metastases in the biopsy specimen. Both patients underwent laparoscopic gastrectomy with lymph-node dissection. There was one case of gastric wall perforation that was repaired by laparoscopic suture. There was no mortality. The median follow-up time was 15 months (range: 2-30 months). Conclusions: ESD is a feasible and safe procedure in our institution with good results in this initial experience.

Feasibility of endoscopic submucosal dissection for gastric and colorectal lesions: Initial experience from the Gastrocentro - Unicamp

OBJECTIVE: Endoscopic submucosal dissection is a technique developed in Japan for en bloc resection with a lower rate of recurrence. It is considered technically difficult and performed only in specialized centers. This study sought to report the initial experience from the Gastrocentro - Campinas State University for the treatment of gastric and colorectal lesions by endoscopic submucosal dissection. MATERIALS AND METHODS: The guidelines of the Japanese Association of Gastric Cancer were used as evaluative criteria. For colorectal lesions, the recommended standards proposed by Uraoka et al. and Saito et al. were employed. The practicability of the method, the development of complications and histological analysis of the specimens were evaluated. RESULTS: Sixteen patients underwent endoscopic submucosal dissection from June 2010 to April 2011; nine patients were treated for gastric lesions, and seven were treated for colorectal lesions. The average diameter of the gastric lesions was 28.6 mm, and the duration of resection was 103 min without complications. All lesions presented lesion-free margins. Of the seven colorectal tumors, four were located in the rectum and three were located in the colon. The average size was 26 mm, and the average procedure time was 163 min. Two complications occurred during the rectal resection procedures: perforation, which was treated with an endoscopic clip, and controlled bleeding. One of the lesions presented a compromised lateral margin without relapse after 90 days. Depth margins were all free of lesions. CONCLUSION: Endoscopic submucosal dissection at our institution achieved high success rates, with few complications in preliminary procedures. The procedure also made appropriate lesion staging possible.

Comparative proteomics analysis of chronic atrophic gastritis: changes of protein expression in chronic atrophic gastritis without Helicobacter pylori infection

Chronic atrophic gastritis (CAG) is a very common gastritis and one of the major precursor lesions of gastric cancer, one of the most common cancers worldwide. The molecular mechanism underlying CAG is unclear, but its elucidation is essential for the prevention and early detection of gastric cancer and appropriate intervention. A combination of two-dimensional gel electrophoresis and mass spectrometry was used in the present study to analyze the differentially expressed proteins. Samples from 21 patients (9 females and 12 males; mean age: 61.8 years) were used. We identified 18 differentially expressed proteins in CAG compared with matched normal mucosa. Eight proteins were up-regulated and 10 down-regulated in CAG when compared with the same amounts of proteins in individually matched normal gastric mucosa. Two novel proteins, proteasome activator subunit 1 (PSME1), which was down-regulated in CAG, and ribosomal protein S12 (RPS12), which was up-regulated in CAG, were further investigated. Their expression was validated by Western blot and RT-PCR in 15 CAG samples matched with normal mucosa. The expression level of RPS12 was significantly higher in CAG than in matched normal gastric mucosa (P < 0.05). In contrast, the expression level of PSME1 in CAG was significantly lower than in matched normal gastric mucosa (P < 0.05). This study clearly demonstrated that there are some changes in protein expression between CAG and normal mucosa. In these changes, down-regulation of PSME1 and up-regulation of RPS12 could be involved in the development of CAG. Thus, the differentially expressed proteins might play important roles in CAG as functional molecules.

Gastritis colágena: presentación de un caso clínico y revisión de la literatura / Collagenous gastritis: presentation of a clinical case and review of the literature

Collagenous gastritis (CG) is an exceptional disease characterized by the deposition of subepithelial collagen band thicker than 10 tm in association with increased inflammatory cell infiltrate of the lamina propria. These histological features seem to overlap with other "collagenous enterocolitides". The pathogenesis and prognosis of CG still remains unclear. CG presentation is seen completely different in two major subsets of patients, children and adults. We report a 38 year-old man with abdominal pain and chronic diarrhea. The upper endoscopy showed a severe gastritis with biopsies that revealed CG, and the colonoscopy was normal with biopsies indicative of collagenous colitis. This characteristic form of clinical presentation in adult patients suggests that subepithelial collagen deposition may be a generalized disease affecting different areas of the gastrointestinal tract. The patient was treated with proton-pump-inhibitors and budesonide, with clinical improvement.

La gastritis colágena (GC) es una enfermedad poco frecuente caracterizada por el depósito subepitelial de colágeno de grosor mayor de 10 um asociado a infiltrado inflamatorio en la lámina propia. Estos hallazgos histológicos son similares a los encontrados en la enterocolitis colágena. La patogénesis y pronóstico de la GC permanece aún desconocida. La presentación clínica de la GC se observa de manera diferente en dos subgrupos de pacientes, niños y adultos. Se presenta el caso de un hombre de 38 años con dolor abdominal y diarrea crónica. La endoscopia digestiva alta mostró una gastritis severa con biopsias que revelaron la presencia de GC y la colonoscopia fue normal con biopsias que mostraron una colitis colágena. Esta forma de presentación clínica en el paciente adulto sugiere que el depósito de colágena subepitelial corresponde a una enfermedad generalizada que puede afectar a diferentes áreas del tracto gastrointestinal. El paciente fue tratado con inhibidores de la bomba de protones y budesonida con mejoría clínica.

Infección por Helicobacter pylori en pacientes sintomáticos con patología gastroduodenal benigna: análisis de 5.664 pacientes / Helicobacter pylori infection in symptomatic patients with benign gastroduodenal diseases: analysis of 5.664 cases

Infection with Helicobacter pylori (H. pylori) is highly prevalent in Chile, but there are no systematic studies in patients with upper gastrointestinal symptoms. Aim: To determine the prevalence of H. pylori infection, according to age, gender and endoscopic pathology in a large sample of patients. Methods: We studied 7,893 symptomatic patients submitted to upper gastrointestinal endoscopy between July 1996 and December 2003 in the context of a screening program of gastric cancer in a high risk population. H. pylori infection was determined by rapid urease test (RUT) in antral mucosa. We excluded 158 patients with gastric cancer (2 percent) and 2,071 patients without RUT. Results: We included 5,664 patients, mean age 50.7 ± 13.9 years, women 72.1 percent. Endoscopic diagnoses were normal in 59.3 percent, erosive esophagitis in 20 percent, gastric ulcer (GU) in 8.1 percent, duodenal ulcer (DU) in 6.4 percent, and erosive gastropathy in 6.2 percent. RUT was positive in 78 percent of patients. After adjusting for age and sex and with respect to patients with normal endoscopy, frequency of H. pylori infection was 86.6 percent in DU (OR 2.1, 95 percent CI 1.5-2.8, p < 0.001); 81.4 percent in GU (OR 1.8, 95 percent CI 1.4-2.4; p < 0.001 ); 79.9 percent in erosive gastropathy (OR 1.4, 95 percent CI 1.03-1.8; p = 0.03) and 77.4 percent in erosive esophagitis (OR 1.1, 95 percent CI: 0.9-1.3; p = NS). The probability of H. pylori infection decreased significantly with age, more markedly in men with normal endoscopy. Conclusions: Prevalence of H. pylori infection is very high in symptomatic Chilean patients and even higher in those with gastroduodenal ulcer or erosions, while in patients with erosive esophagitis is similar to those with normal endoscopy. The frequency of infection decreases with age, probably as a consequence of rising frequency of gastric mucosal atrophy.

Endoscopic submucosal dissection for the treatment of early esophageal and gastric cancer: initial experience of a western center

BACKGROUND: Endoscopic submucosal dissection is a new Japanese technique characterized by en-bloc resection of the entire lesion irrespective of size, with lower local recurrence when compared to endoscopic mucosal resection. OBJECTIVE: To evaluate the feasibility, early results and complications of the endoscopic submucosal dissection technique for treating early gastric and esophageal cancer at the Endoscopic Unit of Clinics Hospital and Cancer Institute of the São Paulo University. MATERIALS AND METHODS: Twenty patients underwent endoscopic resection using the endoscopic submucosal dissection technique for early gastric or esophageal cancer. The patients were evaluated prospectively as to the executability of the technique, the short-term results of the procedure and complications. RESULTS: Sixteen gastric adenocarcinoma lesions and six esophageal squamous carcinoma lesions were resected. In the stomach, the mean diameter of the lesions was 16.2 mm (0.6-3.5 mm). Eight lesions were type IIa + IIc, four were type IIa and four IIc, with thirteen being well differentiated and three undifferentiated. Regarding the degree of invasion, five were M2, seven were M3, two were Sm1 and one was Sm2. The mean duration of the procedures was 85 min (20-160 min). In the esophagus, all of the lesions were type IIb, with a mean diameter of 17.8 mm (6-30 mm). Regarding the degree of invasion, three were M1, one was M2, one was M3 and one was Sm1. All had free lateral and deep margins. The mean time of the procedure was 78 min (20-150 min). CONCLUSION: The endoscopic submucosal dissection technique was feasible in our service with a high success rate.

Associação entre lesões da mucosa gastroduodenal e Helicobacter Pylori em pacientes com doença hepática crônica / Association between Helicobacter pylori infection and gastroduodenal lesions in patients with chronic liver disease

Contexto: A relação entre a infecção por Helicobacter pylori e lesões da mucosa gastroduodenal em pacientes com doença hepática crônica permanece controversa. Objetivo: Avaliar a presença de lesões da mucosa gastroduodenal e sua relação com Helicobacter pylori em pacientes com doença hepática crônica. Métodos: Estudaram-se 46 pacientes e 27 controles com dispepsia funcional, submetidos a endoscopia digestiva alta. Foram consideradas lesões da mucosa gastroduodenal a gastropatia da hipertensão portal, erosão e úlcera péptica. O Helicobacter pylori foi detectado através de duas amostras de biopsia do antro e do corpo gástrico, pelo método de Giemsa. Resultados: As lesões da mucosa gastroduodenal foram identificadas em 38 (82,6 por cento) pacientes com doença hepática crônica, significantemente mais frequente que nos controles (P = 0,02). A presença de Helicobacter pylori foi observada em 13 (28,2 por cento) dos pacientes com doença hepática e em 17 (62,9 por cento) dos controles. A estimativa de risco mostrou interação significante entre lesão da mucosa e doença hepática crônica (P = 0,04; OR 5,1 IC 95 por cento, 1,6-17,3). Quando associada à presença do Helicobacter pylori, o risco foi mais elevado na ausência da bactéria (P = 0,005; OR 13,0 IC 95 por cento, 1,4-327,9). Conclusão: Pacientes com doença hepática crônica mostram risco aumentado de desenvolver lesões da mucosa gastroduodenal, independente da presença de Helicobacter pylori.

Context: The relationship between Helicobacter pylori infection and gastroduodenal lesions in chronic liver disease remains controversial. Objective: Evaluate the evidence of the role of H. pylori infection in gastroduodenal lesions in patients with chronic liver disease. Methods: Forty-six patients with chronic liver disease were matched with 27 dyspeptic persons for age and sex. The gastroduodenal lesions were portal hypertension gastropathy, erosion and peptic ulcer. All patients underwent upper endoscopy: two biopsies were taken in the antrum and in the gastric body. The biopsies were used for Giemsa staining. Results: A gastroduodenal lesions were found in 38 (82.6 percent) patients with liver disease and was significantly more frequent than among controls (P = 0.002). H. pylori infection was detected at histological assessment in 13 (28.2 percent) patients with chronic liver disease and in 17 (62.9 percent) controls. The odds ratio (OR) showed an interaction statistically significant between gastroduodenal lesions and chronic liver disease (P = 0.04; OR = 5.1; 95 percent CI = 1.6-17.3). When adjusted for the presence of H. pylori OR was significantly with H. pylori negative (OR 13.0 IC 95 percent, 1.4-327.9). Conclusion: Patients with chronic liver disease showed higher risk of developing gastroduodenal lesions regardless of the presence of the H. pylori infection.

Evaluation of gastric histology in children and adolescents with Helicobacter pylori gastritis using the Update Sydney System / Avaliação da histologia gástrica em crianças e adolescentes com gastrite por Helicobacter pylori usando o Sistema de Sydney Atualizado

Context: Although Helicobacter pylori infection is prevalent in our country, there are few studies evaluating the associated histological abnormalities in children. Objective: To evaluate the histological features of the gastric mucosa in children and adolescents with Helicobacter pylori gastritis. Methods: One hundred and thirty two gastric biopsies from 22 symptomatic patients infected with H. pylori (14F/8M, median age 10 y 5 mo, age range 2 y 11 mo to 16 y 9 mo) were evaluated. Evaluated gastric regions included: antrum (lesser and greater curvature), corpus (lesser and greater curvature), incisura angularis and fundus. Histological examination was performed according to the Updated Sydney System, and regional scores for polymorphonuclear and mononuclear cell infiltrate as well as bacterial density were generated. Results: Fifteen (68.2 percent) patients presented H. pylori-chronic active gastritis, six (27.3 percent) presented antrum-predominant H. pylori-chronic active gastritis, and one (4.5 percent) presented corpus-predominant H. pylori-chronic active gastritis. Polymorphonuclear cell infiltrate and mononuclear cell infiltrate were observed in 93.9 percent and 98.5 percent of the biopsy specimens, respectively. Higher histological scores for polymorphonuclear infiltrate, mononuclear infiltrate, and bacterial density were observed in the gastric antrum. Intestinal metaplasia and gastric atrophy were not identified in any patient. Lymphoid aggregates and lymphoid follicles were observed in the gastric antrum of three (13.6 percent) and seven (31.8 percent) patients, respectively, but they were not related to antral nodularity. Conclusions: Chronic active gastritis was observed in all patients with H. pylori infection. However, antral or corporeal predominance was not observed in most patients.

Contexto: Embora a infecção por Helicobacter pylori seja prevalente em nosso país, há poucos estudos avaliando a histologia gástrica de crianças infectadas. Objetivo: Avaliar as características histológicas da mucosa gástrica de crianças e adolescentes com gastrite por H. pylori. Métodos: Foram avaliadas 132 biopsias gástricas de 22 pacientes sintomáticos infectados por H. pylori (14F/8M, idade mediana 10 anos e 5 meses, variação: 2a 11m a 16a 9m). As regiões gástricas avaliadas foram: antro (pequena e grande curvatura), corpo (pequena e grande curvatura), incisura angular e fundo. A avaliação histológica foi feita de acordo com o Sistema Sydney Atualizado. Foram gerados escores regionais do infiltrado de células polimorfonucleares, de células mononucleares e de densidade bacteriana. Resultados: Quinze (68,2 por cento) pacientes apresentaram gastrite crônica ativa associada a H. pylori, seis (27,3 por cento) apresentaram gastrite crônica ativa com predominância antral associada a H. pylori, e um (4,5 por cento), gastrite crônica ativa com predominância corpórea associada a H. pylori. Infiltrado de células polimorfonucleares e de mononucleares foram observados em, respectivamente 93,9 por cento e 98,5 por cento dos fragmentos de biopsia. Maior escore histológico de infiltrado de células polimorfonucleares, mononucleares e de densidade bacteriana foi observado no antro gástrico. Metaplasia intestinal e atrofia gástrica não foram observadas em nenhum paciente. Agregados linfóides e folículos linfóides foram observados no antro gástrico de três (13,6 por cento) e sete (31,8 por cento) pacientes, respectivamente, mas não foram associados à ocorrência de nodularidade antral. Conclusão: Gastrite crônica ativa foi observada em todos os pacientes com infecção por H. pylori. Na maioria dos pacientes não houve predominância antral ou corpórea da gastrite.

Association between Helicobacter pylori concentration and the combining frequency of histopathological findings in gastric biopsies specimens

BACKGROUND: Helicobacter pylori is the most prevalent infectious agent worldwide. About 90 percent of patients with chronic gastritis are infected with this bacterium. Some studies have shown a association between the H. pylori concentration and the scores of gastritis activity and severity. AIM: To evaluate the association between H. pylori concentration and the combining frequency of findings on histopathological examination. METHODS: Two hundred consecutive gastric endoscopic biopsies diagnosed as chronic gastritis were retrospectively investigated. The Warthin-Starry silver stain was used to study H. pylori and the following parameters were assessed (according to the Sydney system): 1. infiltration by polymorphonuclear cells in chorio and epithelium (activity) graded as mild, moderate and marked; 2. presence of lymphoid follicles; 3. presence of intestinal metaplasia; 4. presence of regenerative cell atypias, graded as mild, moderate and marked; and 5. H. pylori concentration on the mucous covering the foveolar epithelium. RESULTS: The most frequent association was chronic gastritis and activity, regardless of H. pylori concentration. The association of five histopathological findings in the same biopsy has not occurred in the cases of higher concentration of H. pylori. CONCLUSION: Our study has not revealed any association between H. pylori concentration and an increasing in the number of histopathological findings found in the gastric mucosa. Since referring to its presence is much more important than to its concentration.

RACIONAL: O Helicobacter pylori é o agente infeccioso com maior prevalência em todo o mundo. Cerca de 90 por cento dos pacientes com gastrite crônica têm infecção por esta bactéria. Alguns estudos demonstram correlação entre a concentração de H. pylori e o grau de severidade e atividade da gastrite. OBJETIVOS: Avaliar a associação entre a concentração de H. pylori e a freqüência de combinações de alterações no exame histopatológico. MÉTODOS: Foram analisadas, retrospectivamente, 200 biopsias gástricas endoscópicas consecutivas com o diagnóstico de gastrite crônica. A pesquisa de H. pylori foi realizada através da coloração de Warthin-Starry e foram analisados os seguintes parâmetros (segundo o sistema de Sydney): 1. infiltração de polimorfonucleares no cório e no epitélio (atividade), graduada em leve, moderada e acentuada; 2. presença de folículos linfóides; 3. presença de metaplasia intestinal; 4. presença de atipias celulares regenerativas, graduadas em leve, moderada e acentuada; e 5. concentração de H. pylori no muco que recobre o epitélio foveolar. RESULTADOS: A associação mais freqüente foi de gastrite crônica e atividade, independente da concentração de H. pylori. Associação de cinco achados histopatológicos numa mesma biopsia não ocorreu nos casos com maior concentração de H. pylori. CONCLUSÃO: Este estudo não demonstrou associação entre a concentração de H. pylori e aumento no número de alterações histopatológicas encontradas na mucosa gástrica, mostrando ser importante referir sua presença e não sua concentração.

Duodenal gastric metaplasia and Helicobacter pylori infection in patients with diffuse nodular duodenitis

Whether the regression of gastric metaplasia in the duodenum can be achieved after eradication of Helicobacter pylori is not clear. The aim of the present study was to investigate the relationship between H. pylori infection and gastric metaplasia in patients with endoscopic diffuse nodular duodenitis. Eighty-six patients with endoscopically confirmed nodular duodenitis and 40 control patients with normal duodenal appearance were investigated. The H. pylori-positive patients with duodenitis received anti-H. pylori triple therapy (20 mg omeprazole plus 250 mg clarithromycin and 400 mg metronidazole, all twice daily) for one week. A control endoscopy was performed 6 months after H. pylori treatment. The H. pylori-negative patients with duodenitis received 20 mg omeprazole once daily for 6 months and a control endoscopy was performed 2 weeks after treatment. The prevalence of H. pylori infection was 58.1 percent, and the prevalence of gastric metaplasia was 57.0 percent. Seventy-six patients underwent endoscopy again. No influence on the endoscopic appearance of nodular duodenitis was found after eradication of H. pylori or acid suppression therapy. However, gastric metaplasia significantly decreased and complete regression was achieved in 15/28 patients (53.6 percent) 6 months after eradication of H. pylori, accompanied by significant improvement of other histological alterations. Only mild chronic inflammation, but not gastric metaplasia, was found in the control group, none with H. pylori infection in the duodenal bulb. Therefore, H. pylori infection is related to the extent of gastric metaplasia in the duodenum, but not to the presence of diffuse nodular duodenitis.

Resultados inmediatos y tardíos de la miotomía de Heller laparoscópica en pacientes con acalasia esofágica / Laparoscopic Heller myotomy for esophageal achalasia

Background: Achalasia is characterized by an incomplete relaxation of the lower esophageal sphincter. The best treatment is surgical and the laparoscopic approach may have good results. Aim: To assess the results of laparoscopic Heller myotomy among patients with achalasia. Material and methods: Prospective study of patients subjected to a laparoscopic Heller myotomy between 1995 and 2004. Clinical features, early and late operative results were assessed. Results: Twenty seven patients aged 12 to 74 years (12 females) were operated. All had disphagia lasting for a mean of 32 months. Mean lower esophageal sphincter pressure ranged from 18 to 85 mmHg. Eight patients received other treatments prior to surgery but symptoms persisted or reappeared. The preoperative clinical score was 7. No patient died and no procedure had to be converted to open surgery. In a follow up of 21 to 131 months, all patients are satisfied with the surgical results and the postoperative clinical score is 1. Only one patient with a mega esophagus maintained a clinical score of six. Conclusions: In this series of patients, laparoscopic Heller myotomy was an effective and safe treatment for esophageal achalasia.

cagA positive Helicobacter pylori in Brazilian children related to chronic gastritis

Helicobacter pylori is a spiral-shaped Gram-negative bacterium. It colonizes the gastric mucosa of humans and persists for decades if not treated. Helicobacter pylori infection affects more than half of the world's population and invariably results in chronic gastritis. The cagA gene is present in about 60 to 70 percent of H. pylori strains; it encodes a high-molecular-weight protein (120 to 140 kDa) and several investigators have noted a correlation between strains that possess cagA and the severity of gastric mucosal inflammation. We examined the relation between cagA status in H. pylori strains and chronic gastritis with inflammatory processes in children from Marília, São Paulo, Brazil. One-hundred-twenty-one children were analyzed histopathologically and by polymerase chain reaction (PCR) to detect H. pylori and cagA. We then looked for an association between cagA presence and inflammatory infiltration. Using histology and PCR, we found 47 percent H. pylori positive infection; 29 children were diagnosed with chronic gastritis, while 28 showed normal mucosa by histopathological analysis. CagA presence was genotyped in both groups, and an inflammatory infiltrate was studied in all infected children with chronic gastritis. We found cagA strains in 20 of 29 (69 percent) children with chronic gastritis and 18 of 28 (64 percent) with normal mucosa, demonstrating a strong relationship between the strains and the inflammatory process. We found a positive association between an inflammatory process associated with H. pylori of cagA+ strains and chronic gastritis development.

Alteraciones genéticas en gastritis crónica: Estudio de inestabilidad microsatelital y pérdida de la heterocigocidad / Genetic changes in chronic gastritis: study of microsatellite instability and loss of heterozygosity

Background: Multifocal chronic gastritis, associated to intestinal metaplasia, is considered a preneoplastic lesion, closely associated to intestinal type gastric cancer. Aim: To study the frequency of microsatellite instability (MSI) and loss of heterozygosity (LOH) in areas of chronic gastritis and intestinal metaplasia in gastric biopsies of patients without cancer. Material and methods: Gastric biopsy samples from 34 patients without cancer (22 with multifocal atrophic gastritis and 12 with diffuse antral gastritis), were studied. Glands from areas of chonic gastritis and intestinal metaplasia and lymphocytes, were collected using laser microdissection of paraffin embedded samples. The analysis of 15 mono and dinucleotide microsatellites was used to assess LOH and MSI. Results: LOH and MSI were found in some of the markers in 55% (12/22) and 59% (13/22) of cases with intestinal metaplasia, respectively. Only one of 12 areas with diffuse atrophic gastritis had MSI and a different area had LOH (p <0.05 or less, when compared with areas of multifocal atrophic gastritis). Three areas of normal epithelium in patients with multifocal atrophic gastritis, also had alterations. Most of these alterations were concordant with adjacent areas with intestinal metaplasia. Conclusions: LOH and MSI was found in areas of intestinal metaplasia in more than half of the studied cases and in few areas of atrophic gastritis without intestinal metaplasia. These findings suggest that genotypic alterations may precede phenotypic modifications and that intestinal metaplasia is a preneoplastic lesion (Rev Méd Chile 2003; 131: 1365-74).

Participación de interleuquina-8 en patología gástrica en niños / Interleukin-8 expression in gastric pathology in children

Introducción: Interleuquina (IL)-8 ha sido involucrada en las respuestas inflamatoria de la infección por H. pylori. Objetivo: Evaluar la presencia y niveles de IL-8, y su correlación con factores demográficos, presencia de H. pylori, daño histológico asociado, y evolución de la infección, en niños chilenos con H. pylori. Métodos: En forma prospectiva, 50 niños con indicación de endoscopía, fueron enrolados previo consentimiento parental. Las biopsias antrales fueron analizadas para: detección de H. pylori mediante ureasa, tinción histológica, detección de IL-8 por ELISA, expresado como pg de citoquina/mg de proteína total. Resultados: La edad promedio fue de 13,9 ñ 2,6 años (media ñ 1 DE). No hubo asociación entre edad, sexo, nivel socioeconómico y el nivel de IL-8 (p = 0,3). Los 37 niños infectados con H. pylori presentaron niveles de IL-8 mayores que los niños no infectados (311,1 vs 79,9 pg/ml, p < 0,05). La intensidad del infiltrado inflamatorio (p = 0,0022), la actividad determinada por polimorfonucleares (p = 0,027) y la presencia de desdiferenciación foveolar (p = 0,00003), se correlacionaron con la presencia de IL-8. La expresión de IL-8 en mucosa antral fue mayor en niños con gastritis crónica y especialmente en aquellos con úlcera duodenal al ser comparado con el grupo normal (p < 0,005 y p < 0,0005, respectivamente), pero no hubo diferencia entre los niños infectados con H. pylori con gastritis sola (351 pg/mg) comparados con los que presentaban ulceración duodenal (375 pg/mg). Conclusiones: El mayor nivel de IL-8 en niños con úlcera duodenal puede representar un mayor nivel de activación inflamatoria local o ser un marcador de mayor virulencia bacteriana

Factores geográficos socioeconómicos en la orientación de patología gastroduodenal asociada a la infección por helicobacter pylori / Geographic and socioeconomic factors in the orientation of Helicobacter pylory-associated gastroduodenal pathology

It is highly probable that nutritionally-related geographic and socioeconomic factors may modulate the conversion of early stages of Helicobacter pylori-associated chronic active gastritis (chronic superficial gastritis [CSG] and chronic deep gastritis [CDG]) to chronic atrophic gastritis (CAG). The factors would be diets low in antioxidant vitamins and other micronutrients. In regions of the world and population groups with high socioeconomic level in which these modulating factors are absent, chronic active gastritis tends to stay in its early stages of CSG or CDG and to predispose to duodenal ulcer. On the contrary, in regions and population groups with low socioeconomic level in which the modulating factors are present, the frequency of CAG increases markedly. When CAG becomes severe and diffuse, hypochlorhydria ensues. Hypochlorhydria decreases the predisposition to duodenal ulcer, while CAG, a precancerous lesion, predisposes to gastric cancer of the intestinal type. The real role of the modulating factors already mentioned could be elucidated doing a multicentric study to determine endoscopically and histologically, in large series of dyspeptic patients from various regions of the world and with different socioeconomic levels, prevalence rates of duodenal ulcer, gastric ulcer, gastric cancer, Helicobacter pylori-associated CAG and intestinal metaplasia of the gastric mucosa, and to correlate these prevalence rates with blood levels of antioxidant capacity and related micronutrients. Latin America, because of its diversity in regions, geographic characteristics and population socioeconomic levels, seems to be the ideal place to conduct a study of that type. If the study could be performed, it would undoubtedly constitute an important contribution to a better understanding of Helicobacter pylori-associated gastroduodenal pathology.