Evaluation of adenosine triphosphate test for cleaning assessment of gastroscopes and the effect on workload in a busy endoscopy center.

OBJECTIVE: Using adenosine triphosphate (ATP) tests to assess manual cleaning of gastroscopes and to determine the associated workload in a busy endoscopy unit. METHODS: Patient-used gastroscopes were sampled before and after cleaning to assess ATP levels, bioburden, and protein. Samples were collected by flushing 20 mL of sterile water through the biopsy port to the distal end. Time spent for reprocessing and performing the ATP test was recorded. RESULTS: Twenty-four samples were collected from 10 gastroscopes. After manual cleaning, 14/24 (58.3%) samples had no microbial growth (mean, 21 colony-forming units/cm2), and in 22/24 (91.7%) samples the protein was undetectable (mean, 0.04 µg/cm2). ATP test was above the cutoff (200 relative light units [RLU]) in 17/24 (70.8%) samples (mean, 498 RLU). After the second cleaning, 11/17 (64.7%) gastroscopes still failed the ATP test (mean, 321.2 RLU). The mean time spent to perform manual cleaning and ATP tests was 16 and 8 minutes, respectively. Hence, each test increased the length of time for cleaning plus testing cleanliness by 50%. CONCLUSION: Further studies regarding the optimal cutoff for ATP tests are needed. ATP tests for cleaning monitoring are easy to perform and provide immediate feedback to the team. However, the increased workload needs to be considered.

[I Brazilian consensus of endoscopic ultrasonography]. / I Consenso Brasileiro de Ecoendoscopia.

BACKGROUND: In the last 20 years, several papers have focused on demonstrating the impact of endoscopic ultrasonography findings on the management of different clinical scenarios in digestive disease. This fact is an indirect evidence of the difficulty of popularization of the method. On other hand, the limited availability of endoscopic ultrasonography in Brazil is a direct evidence of this limitation. This was the rationale for the organization of a consensus meeting on endoscopic ultrasonography. It was aimed to identify the best evidence that support the use of endoscopic ultrasonography in gastroenterology. METHODS: A panel of experts on endoscopic ultrasonography was selected based on the files of the Gastroenterology and Endoscopy Societies and on the registries of endoscope manufacturers. Two members of the meeting selected the relevant topics that were transformed into questions. The topics and the questions were debated among the experts five months before the consensus meeting. The experts were asked to perform systematic reviews in order to answer the questions so it could be possible to grade the answers based on the strength of the evidence. During the two days of the meeting the answers were presented, debated and voted. Consensus was reached when a minimum of 70% of the voters were in agreement. The final consensus report was submitted to the experts' evaluation and approval. RESULTS: Seventy nine questions were debated by the experts at the pre-Consensus meeting. As the result of this debate 85 questions came out and were assigned to the members of the panel. During the Consensus meeting 22 experts debated and voted 85 answers. Consensus was reached for several clinical scenarios for which the impact of endoscopic ultrasonography findings were supported by level 1 evidences: differential diagnosis of subepithelial lesions and thickening of gastric folds, staging and diagnosis of unresectable esophageal cancer, indirect signs of peritoneal involvement of gastric cancer, MALT gastric lymphoma and rectal cancer staging, diagnosis of common bile duct and gallbladder stones, diagnosis of chronic pancreatitis and differential diagnosis of a solid mass in chronic pancreatitis, differential diagnosis of the pancreatic cyst, prediction of the results of the endoscopic treatment of esophageal varices and diagnosis and staging of non-small cell lung cancer. CONCLUSIONS: There are the highest levels of evidences that support the indication of endoscopic ultrasonography for several digestive diseases and even for non-small cell lung cancer.

Use of a homemade nylon loop for the prevention of postpolypectomy bleeding of large pedunculated polyps.

To avoid bleeding after colonoscopic polypectomy, several procedures are being used. We describe a new method that consists of a homemade nylon loop that is applied and tied to the stalk of the pedunculated polyp and after which a conventional polypectomy is done. We have used this method in 15 patients and no complication was observed. The procedure is simple; the loop may be opened to large diameters to make it easier to use for large polyps. It has a low cost and seems to be safe and effective to prevent bleeding after endoscopic polypectomy.

[High resolution chromoendoscopy in the differential diagnosis of neoplastic and non-neoplastic polyps]. / Colonoscopia de alta resolução com cromoscopia no diagnóstico diferencial dos pólipos neoplásicos e não-neoplásicos.

BACKGROUND: Magnifying colonoscopy brought the possibility of precise histologic diagnosis of colorectal lesions through their surface appearance. Despite the high accuracy of magnifying colonoscopy it is a specialized and expensive equipment not available in most medical centers. Due to these reasons the use of conventional colonoscopy with chromoscopy has been raised because this produce can reproduce most of the information previously obtained by magnifying colonoscopy. AIM: To determine the role of high resolution colonoscopy and indigo carmine chromoscopy for differential diagnosis between neoplastic and non-neoplastic colorectal lesions through measurements of accuracy, sensitivity, specificity, positive and negative predictive values. PATIENTS / METHODS: It was performed a prospective study. Seventy-four colorectal polyps were evaluated in 54 patients. A high resolution Olympus Exera CFQ 160L colonoscope was used. After the identification of the lesions, they were dyed with indigo carmine 0,2% and classified according to Kudo's classification by a single observer. After resection, the polyps were submitted to histopathological examination. RESULTS: The endoscopic findings were compared to histopathologic results. The accuracy of the method was 79,7%, sensibility of 88,8%, specificity of 55%, positive predictive value of 84,2% and a negative predictive value of 64,7%. CONCLUSION: We can conclude that we must be careful to apply high resolution colonoscopy and chromoscopy because adenomatous lesions can be misdiagnosed as non-neoplastic.

Usefulness of early colonoscopy in the diagnosis and treatment of moderate or severe lower gastrointestinal bleeding / Utilidade da colonoscopia precoce no diagnóstico e tratamento do sangramento gastrointestinal baixo moderado ou grave

ABSTRACT A total of 38,686 colonoscopies were performed between January 1985 and December 2012 at Hospital Sírio-Libanês, in São Paulo, Brazil. Two hundred thirty-four patients (0.6%) had acute lower gastrointestinal bleeding of moderate or severe intensity. A definitive diagnosis was possible in 151 cases, 64.5% of these patients.This study was approved by the Institutional Review Board. Medical charts were reviewed.All examinations were done under sedation by the same medical team.The predominant sources of bleeding were colonic diverticula (73 patients; 31%), ischemic or infectious colitis (18 patients; 7.7%) and radiation proctitis (18 patients; 7.7%).A specific therapeutic intervention was performed on 61 of the 151 patients who had the diagnosis confirmed (40.4%), according to the source of bleeding. Most patients with postpolypectomy bleeding were treated with injection of epinephrine (40%) and clipping (40%). Patients with angiodysplasia were treated predominantly with argon plasma coagulation (42%).Injection of epinephrine was the most frequent treatment, regardless of the source of bleeding (34.4%), followed by argon plasma coagulation (31.1%).Control of active hemorrhage was achieved endoscopically in 98.8% of the patients.Our data shows that early colonoscopy in the management of patients with suspected acute lower gastrointestinal bleeding is a useful tool for diagnosis and treatment.

RESUMO No total, 38.686 colonoscopias foram realizadas entre janeiro de 1985 e dezembro de 2012 no Hospital Sírio-Libanês, em São Paulo, Brasil. 234 pacientes (0,6%) sofriam de sangramento gastrointestinal baixo agudo (SGIBA) de intensidade moderada ou grave. Em 151 casos (64,5% desses pacientes) foi possível estabelecer um diagnóstico definitivo.O estudo foi aprovado pelo Comitê de Revisão Institucional. Os prontuários clínicos foram revisados.Todos os exames foram realizados com o paciente sedado e pela mesma equipe clínica.As origens predominantes de sangramento foram divertículos colônicos (73 pacientes; 31%), colite isquêmica ou infecciosa (18 pacientes; 7,7%) e proctite por radiação (18 pacientes; 7,7%).Uma intervenção terapêutica específica foi realizada em 61 dos 151 pacientes com diagnóstico confirmado (40,4%), de acordo com a origem do sangramento. Em sua maioria, os pacientes com sangramento pós-polipectomia foram tratados com injeção de adrenalina (40%) e por clipping (40%). Os pacientes com angiodisplasia foram tratados predominantemente com coagulação com plasma de argônio (42%).O tratamento mais frequentemente administrado foi a injeção de adrenalina, independentemente da origem do sangramento (34,4%), seguida pela coagulação com plasma de argônio (31,1%).O controle da hemorragia ativa foi obtido por via endoscópica em 98,8% dos pacientes. Nossos dados revelam que o uso precoce da colonoscopia no tratamento de pacientes com suspeita de SGIBA é instrumento útil para o diagnóstico e tratamento.

Complicações em colonoscopia / Complications in colonoscopy

A colonoscopia é um exame com possibilidade terapêutica que vem sendo cada vez mais executado. Entretanto, como qualquer procedimento médico, esta modalidade diagnóstica não é isenta de complicações. Estas podem estar relacionadas ao preparo do cólon, à sedação, à analgesia e ao exame colonoscópico propriamente dito. As complicações referentes ao preparo envolvem o jejum e as soluções para limpeza do cólon, que são capazes de ocasionar alterações hidroeletrolíticas que serão mais graves nos pacientes com comorbidades. Durante o exame, alterações dos sinais vitais como hipóxia e hipotensão podem ser induzidas pelos sedativos. Em relação à colonoscopia per si, as complicações estão relacionadas à técnica de exame e aos procedimentos terapêuticos, sendo o sangramento e a perfuração suas principais consequências indesejadas. Neste texto, fazemos uma revisão dos diversos eventos adversos que podem ocorrer na preparação da colonoscopia e nos períodos peri e pós-exame.

The colonoscopy is an diagnostic procedure with the possibility of therapy that is being increasingly performed. However, this diagnostic modality is not free from complications. These may be related to bowel preparation, sedation and analgesia and the colonoscopy itself. Complications related to preparation involve fasting and solutions for cleaning the colon, which are capable to cause electrolytic changes, more severe in patients with co-morbidities. During the examination, changes in vital signs such as hypoxia and hypotension may be induced by sedatives. Regarding the colonoscopy itself, the complications are related to technical examination and therapeutic procedures, with bleeding and perforation its major unintended consequences. In this paper, we review the various adverse events that may occur in preparation for colonoscopy and in the peri-and post-test.

Hemorragia digestiva baixa após biópsia prostática transretal: relato de caso / Rectal haemorrhage after prostate biopsy: a case report

Desde a década de 30, mais especificamente em 1937, Astraldi introduziu a via retal como padrão-ouro para realização de biópsias prostáticas. Desde então, esse procedimento tem se mostrado seguro e com baixas taxas de complicações graves. Em vários estudos publicados recentemente, a hematospermia se mostrou a complicação mais frequente, seguida pela hematúria e em terceiro lugar pelo sangramento retal. Relatamos, neste artigo, o caso de um paciente submetido a biópsias prostáticas por via retal, que evoluiu com sangramento grave, logo após a punção, com repercussão hemodinâmica, necessitando de intervenção endoscópica para bloqueio da hemorragia.

Magnifying colonoscopy: interobserver agreement in the assessment of colonic pit patterns and its correlation with histopathological findings.

BACKGROUND AND STUDY AIMS: Magnifying colonoscopy (MC) is recognized as an aid to the differential diagnosis between neoplastic and nonneoplastic lesions. This study evaluated interobserver agreement of experienced endoscopists in the assessment of colonic pit patterns through the Kudo's classification and correlated morphological aspects with histopathological findings. MATERIALS AND METHODS: A total of 213 magnification chromoendoscopic pictures of colonic lesions were collected from 161 consecutive patients and presented to three independent observers who expressed opinion about predominant pit pattern. All lesions were excised and sent for histopathological study. RESULTS: Kappa statistics showed that the general agreement index with respect to the aspects of the pits was good among the three observers (0.561). Regarding prediction of histopathology according to the pit pattern diagnosis, overall accuracy was 84%, sensitivity was 91.4%, specificity was 67.2%, positive predictive value was 86.6%, and negative predictive value was 79.3%. CONCLUSION: Although the interobserver reproducibility of the colonic pit pattern is good for experienced endoscopists, MC must not be used to replace the histopathological analysis, since it does not differentiate with the necessary safety neoplastic from nonneoplastic lesions.

I Consenso Brasileiro de Ecoendoscopia / I Brazilian Consensus of Endoscopic Ultrasonography

RACIONAL: Ainda que se reconheça a eficiência da ecoendoscopia para o diagnóstico e até mesmo para o tratamento de várias doenças do aparelho digestivo, a sua inclusão nos algoritmos de decisão clínica em gastroenterologia tem sofrido restrições. Este fato é comprovado indiretamente através da existência de vários estudos que se preocuparam em demonstrar o impacto do exame ecoendoscópio na mudança de condutas e na redução de custos. Outra evidência, esta direta e identificável em nosso meio, é a disponibilidade bastante limitada da ecoendoscopia no Brasil. Neste sentido, quiseram-se identificar as situações clínicas em que o exame ecoendoscópico é eficiente, através de revisões sistemáticas, graduando-se o grau da evidência e a força da recomendação, realizadas pelo grupo envolvido com o método em nosso país, apresentadas e votadas na forma de consenso. MÉTODO: O grupo de médicos que realiza ecoendoscopia foi formado a partir de informações obtidas junto às sociedades de especialidades e aos fabricantes de equipamentos. A lista de tópicos e perguntas relevantes foi formulada por dois membros do consenso (FMF, CMD), discutida com e distribuída aos consensualistas 5 meses antes da reunião de consenso. Foi solicitado que se realizassem, na medida do possível, revisões sistemáticas e que as respostas fossem apresentadas para a votação com o grau de evidência e a força da recomendação. Nos 2 dias da reunião de consenso, as respostas foram apresentadas, debatidas e votadas. Quando, no mínimo, 70 por cento dos votantes concordaram com o texto da resposta, houve consenso. O relatório final foi submetido a apreciação e aprovado por todos os consensualistas. RESULTADOS: Setenta e nove questões foram debatidas na pré-reunião do consenso, resultando 85 questões que foram então distribuídas. Nos 2 dias da reunião do consenso, 22 participantes debateram e votaram as 85 respostas. O impacto causado pelo exame ecoendoscópico foi comprovado por evidências...

BACKGROUND: In the last 20 years, several papers have focused on demonstrating the impact of endoscopic ultrasonography findings on the management of different clinical scenarios in digestive disease. This fact is an indirect evidence of the difficulty of popularization of the method. On other hand, the limited availability of endoscopic ultrasonography in Brazil is a direct evidence of this limitation. This was the rationale for the organization of a consensus meeting on endoscopic ultrasonography. It was aimed to identify the best evidence that support the use of endoscopic ultrasonography in gastroenterology. METHODS: A panel of experts on endoscopic ultrasonography was selected based on the files of the Gastroenterology and Endoscopy Societies and on the registries of endoscope manufacturers. Two members of the meeting selected the relevant topics that were transformed into questions. The topics and the questions were debated among the experts five months before the consensus meeting. The experts were asked to perform systematic reviews in order to answer the questions so it could be possible to grade the answers based on the strength of the evidence. During the two days of the meeting the answers were presented, debated and voted. Consensus was reached when a minimum of 70 percent of the voters were in agreement. The final consensus report was submitted to the experts' evaluation and approval. RESULTS: Seventy nine questions were debated by the experts at the pre-Consensus meeting. As the result of this debate 85 questions came out and were assigned to the members of the panel. During the Consensus meeting 22 experts debated and voted 85 answers. Consensus was reached for several clinical scenarios for which the impact of endoscopic ultrasonography findings were supported by level 1 evidences: differential diagnosis of subepithelial lesions and thickening of gastric folds, staging and diagnosis of unresectable esophageal cancer...

Colonoscopia com magnificação de imagem: análise da variação interobservadores para os padrões de criptas e comparação das imagens endoscópicas com os achados histopatológicos / Magnification colonoscopy images: analysis of variation interobservers for pit patern and comparison of endoscopy and histopatologic findings

A colonoscopia com magnificação de imagem (CMI) é considerada uma técnica que possibilita o diagnóstico diferencial entre lesões colorretais neoplásicas e não-neoplásicas. Este estudo avaliou a variação da concordância interobservadores para os padrões de criptas através de três endoscopistas experientes com a classificação de Kudo, e correlacionou esses aspectos morfológicos com os achados histopatológicos. Um total de 213 imagens de lesões magnificadas (polipóides e planas) forma coletadas de 161 pacientes consecutivos e apresentadas a três observadores independentes que expressaram opinião sobre o padrão de criptas predominante. Todas as lesões foram completamente excisadas e enviadas para estudo histopatológico. A estatística estimada de Kappa mostrou que o índice de concordância geral para padrões de criptas entre os três observadores foi bom (0,561). Com relação aos resultados histapatológicos, quando comparados aos padrões de criptas, observou-se: acuária de 84 por cento; sensibilidade de 91,4 por cento; especifidade de 67,2 por cento; valor preditivo positivo de 86,6 por cento valor preditivo negativo de 79,3 por cento e índice de Kappa de 0,61. Embora a reprodutilidade interobservadores dos padrões de criptas seja boa, a CMI não deve substituir o estudo histopatológico, pois não diferencia com a necessária segurança lesões neoplásicas de lesões não-neoplásicas.

Colonoscopy with magnified view is the most reliable nonbiopsy method for distinguishing non-neoplastic from neoplastic colorectal lesions. This study analysed lhe interobserver concordance in diagnosis of pit patem, with 3 experients endoscopists using Kudo Classification and correlating the this aspects with histological ones. A total of 213 magnificated images injuries (polipoides and plain) had been collected of 161 independent observing patients consecutive and presented tres that had expressed opinion on the predominant standard of criptas. All the injuries had been completely ressected and send for histopatológico study. The analysis esteem statistics of Kappa showed that the indice of general agreement for standards of criptas between the 3 observers was 84 percent; sensitivity 91.4 percent; specificity 67.2 percent positive preditivo value 86.6 percent; negative preditivo value 79.3 percent; e index of Kappa of 0,61 percent. Although the interobserver reproduction of pit patern are good, the image for colonoscopia with magnificação, does not have to substitute the histopatologic study, therefore it does not differentiate with the necessary security neoplastic injuries of non neoplastic.

Colonoscopia de alta resoluçäo com cromoscopia no diagnóstico diferencial dos pólipos neoplásicos e näo-neoplásicos / High resolution chromoendoscopy in the differential diagnosis of neoplastic and non-neoplastic polyps

RACIONAL: Com o advento da colonoscopia com magnificaçäo de imagem, tem se mostrado possível a identificaçäo da natureza histopatológica das lesöes colorretais através de suas características da forma que as glândulas se abrem na superfície da mucosa (PITS). Apesar de ser método com alto índice de acurácia para o diagnóstico diferencial entre lesöes neoplásicas e näo-neoplásicas, trata-se de equipamento especializado, de custos elevados, näo disponível na grande maioria dos centros médicos. Diante dessa realidade, a colonoscopia convencional com cromoscopia vem adquirindo espaço, pois acredita-se que pode reproduzir grande parte das informações obtidas até entäo pela colonoscopia com magnificaçäo de imagem. OBJETIVO: Determinar o papel da colonoscopia de alta resoluçäo com cromoscopia no diagnóstico diferencial entre pólipos neoplásicos e näo-neoplásicos através dos seguintes índices estatísticos: acurácia, sensibilidade, especificidade, valores preditivos positivo e negativo. PACIENTES E MÉTODO: Realizou-se estudo prospectivo, onde foram avaliadas 74 lesöes polipóides colorretais em 54 pacientes. Foi utilizado o colonoscópio Olympus Exera CFQ 160L de alta resoluçäo. Após identificadas, as lesöes foram coradas com índigo carmim 0,2 por cento e analisadas conforme classificaçäo descrita por Kudo, por um único examinador. Após ressecados, os pólipos foram encaminhados para estudo anatomopatológico. RESULTADOS: Os achados endoscópicos foram comparados com os resultados histopatológicos. A acurácia do método foi de 79,7 por cento, sensibilidade de 88,8 por cento, especificidade de 55 por cento, valor preditivo positivo de 84,2 por cento e valor preditivo negativo de 64,7 por cento. CONCLUSÄO: Pode-se concluir que se deve ter cautela na aplicaçäo clínica da colonoscopia de alta resoluçäo com cromoscopia, pois lesöes adenomatosas podem ser interpretadas como näo-neoplásicas

Aplicaçäo do ultra-som endoscópico na avaliaçäo dos tumores vilosos do reto / The endoscopic ultrasound application at the avaliation of the rectal villous tumor

Um dos mais importantes e decisivos aspectos no tratamento dos tumores vilosos do reto (TVR) é a presença de adenocarcinoma invasivo, o quel necessita de uma abordagem mais agressiva. O ultra-som endoscópico (USE) permite um estadiamento local apropriado, diminuindo os índices de sub ou superestadiamento, evitando uma abordagem terapêutica inicial inadequada.Entre junho de 1997 a outubro de 2000, doze pacientes com diagnóstico de TVR foram submetidos ao USE, a fim de se estabelecer a profundidade de invasäo da lesäo na parede retal. Houve concordância diagnóstica em 11 de 12 casos: 10, onde o USE mostrou lesões restritas à mucosa e 1 com invasäo da gordura peri-retal. No caso discordante, com suspeita de invasäo da submucosa, houve um superestadiamento, quando na realidade o tumor se restringia à mucosa. Essa experiência inicial permite concluir que o USE tem grande sensibilidade e pode ser importante na definiçäo do estadiamento dos TVR