Diagnóstico de divertículo de Meckel mediante cápsula endoscópica / Diagnose of Meckel's diverticulum through endoscopic capsule

Meckel's diverticulum can be present in up to 1.2% of the population. It is usually diagnosed as an imaging finding, but it can present with complications such as digestive bleeding, intestinal obstruction, diverticulitis, ulcers, and perforation, more frequently in childhood or infancy. The diagnosis workup for this condition will depend on their clinical manifestation, the most frequent being gastrointestinal bleeding of obscure origin or small intestinal bleeding. In this context, although capsule endoscopy is the preferred technique, its diagnostic yield for the detection of Meckel's diverticulum is not entirely clear and it has not been compared in a controlled studies with other diagnostic methods. Here we report the diagnosis of a Meckel diverticulum and its intestinal complications by means of capsule endoscopy in a patient with iron deficiency anemia and gastrointestinal bleeding

El divertículo de Meckel puede estar presente en el 1,2% de la población general. Usualmente es diagnosticado como un hallazgo, pero puede presentarse con mayor frecuencia en la niñez o infancia por sus complicaciones como hemorragia digestiva, obstrucción intestinal, diverticulitis, úlceras y perforación. El enfrentamiento diagnóstico de esta condición dependerá de la manifestación clínica, siendo lo más frecuente hemorragia digestiva de origen oscuro o de intestino delgado. En este contexto, si bien la cápsula endoscópica es la técnica de elección, su rendimiento diagnóstico para la detección del divertículo de Meckel no es del todo claro y no ha sido comparado de forma controlada con otras técnicas diagnósticas. En el presente caso se reporta el diagnóstico de un divertículo de Meckel y sus complicaciones intestinales mediante cápsula endoscópica en una paciente con anemia ferropriva y hemorragia digestiva.

Impacto da enteroscopia por cápsula na anemia ferropénica: influência da idade do doente no rendimento diagnóstico / Impact of small bowel capsule endoscopy in iron deficiency anemia: influence of patient'sage on diagnostic yield

ABSTRACT BACKGROUND: Iron deficiency anemia remains one of the main indications to perform small bowel capsule endoscopy. Literature suggests that diagnostic yield is influenced by patient's age but with conflicting results regarding age cutoff. OBJECTIVE: We aimed to clarify the differences in diagnostic yield and incidence of specific findings according to age. METHODS: Retrospective single-center study including 118 patients performing small bowel capsule endoscopy in the study of iron deficiency anemia. Videos were reviewed and small bowel findings that may account for anemia were reported. Incomplete examinations were excluded. Findings were compared between patients ≤60 and >60 years. RESULTS: Patients had a mean age of 58 years old (SD ±17.9) with 69.5% females (n=82). The overall diagnostic yield was 49% (58/118), being higher among patients >60 years (36/60, diagnostic yield 60%) than those ≤60 years (20/58, diagnostic yield 34%), (P<0.01). Angioectasias were more frequent in patients >60 years (45% vs 9%, P<0.01). Patients ≤60 years presented more frequently significant inflammation (Lewis score >135 in 10.3% vs 1.7%, P<0.05) and other non-vascular lesions (24% vs 10%, P=0.04). CONCLUSION: In our cohort small bowel capsule endoscopy diagnosed clinically relevant findings in the setting of iron deficiency anemia in almost half the patients. Diagnostic yield was higher in patients older than 60 years (60%), with vascular lesions being more frequent in this age group. Despite the lower diagnostic yield in patients ≤60 years, significant pathology was also found in this age group, mainly of inflammatory type.

RESUMO CONTEXTO: A anemia ferropénica constitui uma das principais indicações para realização de enteroscopia por cápsula. A literatura sugere que o rendimento diagnóstico é influenciado pela idade do doente, contudo, não é consensual o grupo etário para o qual o rendimento diagnóstico é maior. OBJETIVO: Clarificar as diferenças de rendimento diagnóstico e incidência de achados específicos de acordo com a idade. MÉTODOS: Estudo retrospetivo unicêntrico. Incluídos 118 doentes que realizaram sistematicamente enteroscopia por cápsula no estudo de anemia ferropénica. Todos os vídeos foram revistos e foram reportados os achados no intestino delgado que pudessem ser a causa da anemia ferropénica. Excluídas enteroscopia por cápsula incompletas. Comparados os achados entre doentes com ≤60 e >60 anos. RESULTADOS: Doentes com idade média de 58 anos (SD ±17,9), 69,5% do género feminino (n=82). O rendimento diagnóstico global foi de 49% (58/118), sendo superior em doentes >60 anos (36/60, rendimento diagnóstico 60%) do que em doentes ≤60 anos (20/58, 34%). As angiectasias foram mais frequentemente reportadas em doentes >60 anos (45% vs 9%, P<0,01). Nos doentes com ≤60 anos foi mais frequentemente reportada inflamação significativa (Score de Lewis >135 em 10,3% vs 1,7%, P<0,05) e lesões não vasculares (24% vs 10%, P=0,04). CONCLUSÃO: Na nossa amostra, a enteroscopia por cápsula revelou-se importante no estudo da anemia ferropénica detectando achados relevantes em cerca de metade dos doentes. O rendimento diagnóstico foi maior em doentes com mais de 60 anos (60%), sendo as lesões vasculares mais frequentes neste grupo. Apesar do menor rendimento diagnóstico em indivíduos até aos 60 anos, foi detectada patologia relevante neste grupo, em especial do tipo inflamatório.

Descripción del uso de cápsula endoscópica en un hospital público pediátrico / Description of capsule endoscopy use in a pediatric public hospital

INTRODUCCIÓN: La cápsula endoscópica (CE) es a una técnica no invasiva que permite la visualización de la mucosa del intestino delgado. Se utiliza para el diagnóstico de lesiones no accesibles con otros exámenes. El objetivo fue describir la experiencia de uso de CE en un hospital público pediátrico en Chile. PACIENTES Y MÉTODO: Estudio retrospectivo en que se revisaron los casos en que se utilizó CE en el Hospital Dr. Luis Calvo Mackenna desde 2010 hasta la fecha. Se registraron datos demográficos, clínicos, hallazgos, complicaciones, diagnóstico y conducta. RESULTADOS: Se realizaron 20 procedimientos en 16 pacientes, 11 varones (69%), mediana de edad 12 años (rango 3 a 15 años). Las indicaciones incluyeron estudio de poliposis (60%), sospecha de enfermedad de Crohn (20%), hemorragia digestiva de origen desconocido (15%) y anemia de causa desconocida (5%). Diecisiete estudios estaban alterados (85%) y 11 llevaron a un diagnóstico o cambio de conducta clínica (55%). Los hallazgos principales fueron pólipos y erosiones intestinales. No se produjeron complicaciones. CONCLUSIONES: La CE es una técnica útil y segura en niños, factible de realizar en un hospital público pediátrico.

INTRODUCTION: Capsule endoscopy (CE) is a non-invasive technique that allows visualization of small intestine mucosa. It is used for diagnosis of lesions not accessible with other tests. Our goal was to describe the experience using CE in a pediatric public hospital in Chile. PATIENTS AND METHOD: A retrospective study was carried out to review the cases in which CE was used at Dr. Luis Calvo Mac kenna Hospital from 2010 to date. Demographic and clinical data, findings, complications, diagnosis and treatment were recorded. RESULTS: Twenty procedures were performed in 16 patients, 11 men (69%), median age 12 years (range 3 to 15 years). Indications included polyposis study (60%), suspected Crohn disease (20%), obscure gastrointestinal bleeding (15%) and undiagnosed anemia (5%). Seventeen studies were altered (85%) and 11 led to a diagnosis or clinical behavior change (55%). There were no complications. CONCLUSIONS: CE is a useful and safe technique in children, feasible to perform in a pediatric public hospital.

Comportamiento del cáncer gástrico avanzado diagnosticado por videoendoscopia en el Hospital "Faustino Pérez Hernandez", Matanzas / Behavior of advanced gastric cancer diagnosed by video-endoscopy at the Faustino Pérez Hernández Hospital, Matanzas

Introducción: el cáncer gástrico avanzado constituye la segunda causa de muerte por tumores malignos en el mundo. En los últimos cinco años en la provincia de Matanzas existe un incremento de esta patología. Objetivo: determinar el comportamiento clínico epidemiológico del cáncer gástrico avanzado diagnosticado por videoendoscopía, en el departamento de Gastroenterología del Hospital Universitario "Comandante Faustino Pérez Hernández", de Matanzas en el período de enero del 2014 a enero del 2016. Materiales y Métodos: se realizó un estudio observacional, descriptivo y prospectivo en el Departamento de Gastroenterología del Hospital Universitario "Comandante Faustino Pérez Hernández", de Matanzas en el período de enero del 2014 a enero del 2016. El universo los 28 pacientes que presentaron cáncer gástrico avanzado por diagnóstico endoscópico e histológico. Resultados: el grupo de edad más afectado correspondió a los pacientes con 60 años de edad o más (67,9 %). El sexo masculino predominó, un 57,1 %. Los factores de riesgo de mayor incidencia fueron la dieta inadecuada (65 %) y el hábito de fumar (42,9 %). Las manifestaciones clínicas más relevantes fueron la pérdida de peso, la astenia y la acidez. La variedad histica que predominó fue el adenocarcinoma de tipo intestinal y el antro gástrico resultó ser la localización más frecuente. La mayoría de los pacientes tuvieron positivos el test de ureasa para la infección por Helicobacter pylori. (60,7 %). Conclusiones: la infección por Helicobacter pylori constituye una de las principales causas de cáncer gástrico. El diagnóstico y tratamiento precoz de la infección contribuirán a disminuir su incidencia (AU).

Introduction: the advanced gastric cancer is the second reason of death due to malignant cancer in the world. There it is a surge of this disease in the last five years in the province of Matanzas. Objective: to determine the clinical-epidemiologic behavior of advanced gastric cancer diagnosed by video-endoscopy in the Department of Gastroenterology of the Teaching Hospital "Comandante Faustino Pérez Hernández", of Matanzas, in the period from January 2014 to January 2016. Materials and Methods: an observational, descriptive and prospective study of the department of Gastroenterology of the Teaching Hospital "Comandante Faustino Pérez Hernández", of Matanzas, was carried in the period from January 2014 to January 2016. The universe were 28 patients who had advanced gastric cancer according to the endoscopic and histological diagnosis. Outcomes: the most affected age group was the one of the patients aged 60 years and more (67,9 %).The male sex predominated, with 57,1 %. The risk factors with higher incidence were an inadequate diet (65 %) and smoking (42,9 %). The most relevant clinical manifestations were weight loss, asthenia and heartburn. The predominating histological variety was the intestinal type adenocarcinoma and the gastric antrum was the most frequent location. Most of the patients were positive to the urease test for helicobacter pylori (60,7 %). Conclusions: the infection by Helicobacter pylori is one of the main causes of gastric cancer. The precocious diagnosis and treatment of the infection will favor the reduction of its incidence (AU).

Retención de cápsula endoscópica como complicación de enteritis actínica: reporte de un caso / Retention of capsule endoscopy as a complication of radiation enteritis: a case report

La cápsula endoscópica es un método, que ha modificado el enfoque diagnóstico de numerosos procesos patológicos en el intestino delgado, sin embargo presenta complicaciones como la retención de la misma. Se estima en la literatura mundial que esta suele ocurrir en menos del 2% de los casos. Femenino de 40 años de edad, con antecedente de cáncer de cuello uterino (2011) en tratamiento con quimioterapia, radioterapia convencional y braquiterapia, que presenta cuadro clínico caracterizado por dolor urente en mesogastrio, y emesis de aspecto biliosos. Ruidos hidroaéreos presentes, dolor a la palpación de mesogastrio sin irritación peritoneal. Radiografía de abdomen y ecosonograma abdominal normales. TAC abdomino pélvica con contraste oral con adecuada progresión de contraste hasta el recto. Se practica gastroscopia y colonoscopia sin evidencia de alteraciones. En vista de persistencia de sintomatología se indica realización de cápsula endoscópica observando en íleon distal, a los 246 minutos del paso duodenal, área muy congestiva, con una úlcera circunferencial friable, que no permite el avance de la misma. Se indica tratamiento médico con laxantes por 72 horas, el cual es infructuoso, por lo cual es llevada a mesa operatoria por presentar signos francos de obstrucción intestinal. Los hallazgos fueron: adherencias en flanco y fosa ilíaca derecha, las cuales fueron liberadas, y segmento de íleon a 10 cm de la válvula ileocecal con inflamación franca, practicándose resección y anastomosis termino-lateral. El estudio histopatológico reportó enteritis crónica activa exulcerada, necrosis fibrinoide de pequeños vasos, y fibrosis en la submucosa. Paciente con post-operatorio exitoso decidiéndose el egreso de la institución. Excelente correlación entre los hallazgos de la cápsula endoscópica y la intervención quirúrgica. Los hallazgos de la cirugía se encuentran relacionados al uso de radioterapia convencional, por lo cual recomendamos la realización de pexia...

Capsule endoscopy is a method that has changed the diagnostic approach to many pathological processes in the small intestine, but it has complications such as retention of the same, is estimated in the literature that this usually occurs in less than 2% cases. Women 40 years of age, with a history of cervical cancer (2011) undergoing chemotherapy, conventional radiation therapy, and brachytherapy, presenting clinical picture characterized by burning pain in midgut, and bilious emesis aspect. Present bowel sounds, tenderness of mesogastrium without peritoneal irritation. Abdominal radiography and abdominal ultrasonography normal. Pelvic CT with oral contrast Abdomino with progression adequate contrast to the rectum. Gastroscopy and colonoscopy was performed without evidence of tampering. In view of the persistence of symptoms embodiment shown in watching endoscopic capsule distal ileum, to 246 minutes of step duodenal study, very congestive area with a circumferential friable ulcer which does not allow the advance thereof. Indicated medical treatment with laxatives for 72 hours being fruitless, operating table being carried by presenting overt signs of intestinal obstruction. The findings were: adhesions flank and right lower quadrant, which were released and ileal segment 10 cm from the ileocecal valve with frank inflammation resection and end-side anastomosis. Histopathological study reported chronic active enteritis exulcerada, fibrinoid necrosis of small vessels, and fibrosis in the submucosa. Postoperative patient deciding successful graduation from the institution. Excellent correlation between the findings of capsule endoscopy and surgery. The findings at surgery are related to the use of conventional radiotherapy, so we recommend an pexia of the organs that are in the radiation field, prior to it, and intestinal transit before indicating capsule endoscopy

Enfoque diagnóstico del sangrado digestivo oscuro / Diagnostic approach to obscure gastrointestinal bleeding

El sangrado digestivo oscuro constituye un reto diagnóstico y terapéutico para el gastroenterólogo debido a la complejidad de su manejo y asociación con elevada morbi-mortalidad. El advenimiento de nuevas herramientas diagnósticas tales como la cápsula endoscópica, enteroscopia asistida por balones y enterografía (TAC, RM), cambiaron de forma definitiva la comprensión y abordaje de esta situación clínica, generando con ello nuevas estrategias diagnósticas y terapéuticas que en la actualidad resultan costo efectivas. Se realizó una revisión bibliográfica en la base de datos Medline (Pubmed) (1995-2013) de los artículos originales publicados en el idioma inglés, tomando en consideración las palabras claves, "sangrado digestivo oscuro", "hemorragia digestiva", "sangrado digestivo oculto", "cápsula endoscópica", "enteroscopia". El objetivo de este artículo consiste en hacer una revisión del abordaje diagnóstico del sangrado digestivo oscuro

Obscure gastrointestinal bleeding is a diagnostic and therapeutic challenge for the gastroenterologist due to the complexity of it´s management and it´s association with high morbidity and mortality. The advent of new diagnostic tools such as capsule endoscopy, balloon assisted enteroscopy and enterography (CT,MR) permanently changed the understanding and approach to this clinical situation, thereby generating new diagnostic and therapeutic strategies that are currently cost effective. We conducted a literature review in Medline (PubMed) (1995 to 2013) of the original articles published in the English language, taking into consideration the key words, "obscure gastrointestinal bleeding," "gastrointestinal bleeding", "occult gastrointestinal bleeding", "capsule endoscopy", "balloon assisted by enteroscopy". The aim of this paper is to give an overview of the diagnostic approach of obscure gastrointestinal bleeding

Papel da cápsula endoscópica na reclassificação da doença inflamatória intestinal em crianças / Role of wireless capsule endoscopy in reclassifying inflammatory bowel disease in children

OBJECTIVE: To evaluate the role of wireless capsule endoscopy in identifying small bowel lesions in pediatric patients with newly diagnosed colonic inflammatory bowel disease (IBD) type unclassified (IBDU), and to assess whether capsule endoscopy findings result in altered patient management. METHODS: Ten pediatric patients recently diagnosed with IBDU through standard investigations were recruited from the pediatric gastroenterology clinic at McMaster Children's Hospital to undergo capsule endoscopy using the Pillcam SB TM (Given Imaging) capsule. Findings consistent with a diagnosis of Crohn's disease required the identification of at least three ulcerations. RESULTS: Three out of ten patients had newly identified findings on capsule endoscopy that met criteria for Crohn's disease. Three more patients had findings suspicious for Crohn's disease, but failed to meet the diagnostic criteria. Three additional patients had findings most consistent with ulcerative colitis, and one had possible gastritis with a normal intestine. Findings from capsule endoscopy allowed for changes in the medical management of three patients. In all ten cases, capsule endoscopy allowed for a better characterization of the type and extent of disease. No adverse outcomes occurred in the present cohort. CONCLUSIONS: This prospective study reveals that wireless capsule endoscopy is feasible, valuable, and non-invasive, offering the ability to potentially better characterize newly diagnosed pediatric IBDU cases by identifying lesions in the small bowel and reclassifying these as Crohn's disease. Further investigation is warranted.

OBJETIVO: Avaliar o papel da cápsula endoscópica na identificação de lesões no intestino delgado em pacientes pediátricos com DII inespecífica (DIII) diagnosticada recentemente e avaliar se os achados da cápsula endoscópica resultam em alterações no tratamento dos pacientes. MÉTODOS: Dez pacientes pediátricos recém-diagnosticados com DIII por meio de investigações padrão foram recrutados da clínica de gastroenterologia pediátrica no McMaster Children's Hospital, para serem submetidos a exame com a cápsula endoscópica Pillcam SB TM (Given Imaging). Achados compatíveis com o diagnóstico da doença de Crohn exigiram a identificação de pelo menos três ulcerações. RESULTADOS: De 10 pacientes, três apresentaram achados novos com a cápsula endoscópica que satisfizeram o critério para a doença de Crohn. Outros três apresentaram achados com suspeita de doença de Crohn, porém não atenderam nossos critérios de diagnóstico. Apresentaram achados mais compatíveis com colite ulcerativa outros três pacientes, e um apresentava possível gastrite com intestino normal. Os achados da cápsula endoscópica possibilitaram mudanças no tratamento médico de três pacientes. Em todos os dez casos, a cápsula endoscópica permitiu uma melhor caracterização do tipo e da extensão da doença. Não houve resultado adverso em nossa coorte. CONCLUSÃO: Este estudo prospectivo revela que a cápsula endoscópica é viável, útil e não invasiva, que oferece a possibilidade de melhor caracterização de casos de DIII pediátricos recém-diagnosticados ao identificar lesões no intestino delgado e reclassificá-las como doença de Crohn.

Comparative study of two modes of gastroesophageal reflux measuring: conventional esophageal pH monitoring and wireless pH monitoring / Estudo comparativo de duas modalidades de mensuração do refluxo gastroesofágico: pHmetria esofágica convencional e pHmetria sem cateter

CONTEXT: Esophageal pH monitoring is considered to be the gold standard for the diagnosis of gastroesophageal acid reflux. However, this method is very troublesome and considerably limits the patient's routine activities. Wireless pH monitoring was developed to avoid these restrictions. OBJECTIVE: To compare the first 24 hours of the conventional and wireless pH monitoring, positioned 3 cm above the lower esophageal sphincter, in relation to: the occurrence of relevant technical failures, the ability to detect reflux and the ability to correlate the clinical symptoms to reflux. METHODS: Twenty-five patients referred for esophageal pH monitoring and with typical symptoms of gastroesophageal reflux disease were studied prospectively, underwent clinical interview, endoscopy, esophageal manometry and were submitted, with a simultaneous initial period, to 24-hour catheter pH monitoring and 48-hour wireless pH monitoring. RESULTS: Early capsule detachment occurred in one (4%) case and there were no technical failures with the catheter pH monitoring (P = 0.463). Percentages of reflux time (total, upright and supine) were higher with the wireless pH monitoring (P < 0.05). Pathological gastroesophageal reflux occurred in 16 (64%) patients submitted to catheter and in 19 (76%) to the capsule (P = 0.355). The symptom index was positive in 12 (48%) patients with catheter pH monitoring and in 13 (52%) with wireless pH monitoring (P = 0.777). CONCLUSIONS: 1) No significant differences were reported between the two methods of pH monitoring (capsule vs catheter), in regard to relevant technical failures; 2) Wireless pH monitoring detected higher percentages of reflux time than the conventional pH-metry; 3) The two methods of pH monitoring were comparable in diagnosis of pathological gastroesophageal reflux and comparable in correlating the clinical symptoms with the gastroesophageal reflux.

CONTEXTO: A pHmetria esofágica é considerada o melhor método diagnóstico do refluxo ácido gastroesofágico. Contudo, é bastante incômoda e restringe consideravelmente as atividades cotidianas do paciente. A pHmetria sem cateter foi desenvolvida para contornar tais limitações. OBJETIVO: Comparar as primeiras 24 horas das pHmetrias convencional e sem cateter, posicionadas a 3 cm acima do esfíncter inferior do esôfago, em relação à: ocorrência de falhas técnicas relevantes, capacidade de detecção do refluxo e capacidade de relacionar as queixas clínicas com o refluxo. MÉTODOS: Foram estudados, de modo prospectivo, 25 pacientes encaminhados para pHmetria esofágica, com sintomas típicos da doença do refluxo gastroesofágico, submetidos a entrevista clínica, endoscopia digestiva, manometria esofágica e realização, com período inicial simultâneo, de pHmetrias com cateter por 24 horas e com cápsula por 48 horas. RESULTADOS: Houve queda precoce da cápsula em um paciente (4%) e nenhuma falha técnica na pHmetria com cateter (P = 0,463). As percentagens de tempo de refluxo (total, ortostático e supino) foram mais elevadas na pHmetria sem cateter (P<0,05). Refluxo gastroesofágico patológico foi diagnosticado em 16 (64,0%) pacientes com o cateter e em 19 (76,0%) com a cápsula (P = 0,355). O índice de sintomas foi positivo em 12 (48%) pacientes na pHmetria com cateter e em 13 (52%) na pHmetria sem cateter (P = 0,777). CONCLUSÕES: 1) Não há diferença significante entre as duas modalidades de pHmetria (cápsula vs cateter), em relação à ocorrência de falhas técnicas relevantes durante o exame; 2) A pHmetria sem cateter detecta refluxo em percentagens superiores às detectadas pela pHmetria convencional; 3) Os dois métodos de pHmetria têm capacidades semelhantes de diagnóstico de refluxo gastroesofágico patológico e capacidades semelhantes de relacionar as queixas clínicas com o refluxo gastroesofágico.

Evaluación de un modelo de entrenamiento en cápsula endoscópica / Evaluation of a training model in capsule endoscopy

El proceso de formación y validación de la capacidad individual para analizar imágenes de cápsula endoscópica no ha sido bien estudiado. Evaluar la eficacia de un modelo de entrenamiento rápido en cápsula endoscópica de intestino delgado que permita a endoscopistas sin experiencia en esta técnica, el reconocimiento de lesiones de significación patológica. Se realizó un estudio piloto para validar el diseño de un modelo de entrenamiento rápido. En el estudio participaron 10 endoscopistas. Se seleccionaron 30 video-clips y se estructuraron 2 módulos de reconocimiento al inicio y cierre de la actividad y una sesión didáctica intermedia. En formularios de respuestas múltiples se recogieron las respuestas. Se evaluó la precisión diagnóstica alcanzada antes y después del entrenamiento, midiendo así el impacto en la habilidad de los participantes para detectar lesiones. La precisión diagnóstica de la prueba previa al inicio del programa fue del 51%, frente al 65% en el post-test. Una sesión didáctica corta no parece ser suficiente para lograr el adecuado reconocimiento de las lesiones en cápsula endoscópica, sugiriendo la necesidad de revisar la estructura de los módulos o utilizar este modelo como fase inicial en la enseñanza de la técnica

The validation and training process on the capacity to analyze images in capsule endoscopy has not been studied completely. Evaluate the efficacy of a rapid training model in C.E. in small bowel that allows the inexperienced endoscopist, to be able to recognize relevant lesions with this technique. A pilot study to validate a rapid model training design. Ten endoscopists participated in this study. Thirty videos were selected. Two modules of recognition were structured at the beginning and at the end of the activity, with a didactic session in between. A multiple answer quetionary was used to evaluate the diagnostic accuracy of the endoscopists at the beginning and at the end of training, measuring the impact in the ability to detect lesions using CE. The diagnostic accuracy in the pre-test at the beginning of the program was 51%, compared to 65% in the post-test at the end. Using a short time didactic session is not enough to achieve an appropriate recognition of lesions with capsule endoscopy, suggesting the necessity of structuring new models, or using this one as an initial phase for teaching this technique

Experiencia en el uso de la cápsula endoscópica de intestino delgado en pacientes con sangrado gastrointestinal oscuro / Experience in use of capsule endoscopica of thin intestine in patients with bled dark gastrointestinal

La cápsula endoscópica es un método diagnóstico que evalúa el tracto gastrointestinal de forma no invasiva. La principal indicación del estudio es la determinación del origen del sangrado gastrointestinal oscuro. Dicha entidad clínica se define, como la hemorragia digestiva de causa desconocida, persistente y recurrente, después de una prueba negativa en el estudio endoscópico convencional. (Colonoscopia – endoscopia digestiva superior). Objetivo: Describir hallazgos de la cápsula endoscópica en pacientes con hemorragias digestivas de origen oscuro. Pacientes y Métodos: Estudio descriptivo de corte trasversal. Se evaluaron 19 pacientes con hemorragia digestiva de origen oscuro que acudieron al Servicio de Gastroenterología del centro de cuarto nivel durante el periodo de marzo 2009 – marzo 2010, excluyéndose a pacientes en estado crítico o terminal, y aquellos con clínica de obstrucción intestinal o fistulas. Utilizando plataforma Given Imaging® SB2. Resultados: Se estudiaron 19 pacientes, 14 (73,68%) sexo masculino, 5 (26,31%) sexo femenino, grupo etáreo comprendido entre 29-60 años edad promedio 39.5 años. Indicación: sangrado digestivo oculto: 6 casos (31.57%). Sangrado digestivo oscuro: 13 caso (68.42 %). Hallazgos en 16 pacientes (84.21%): sangrado activo profuso localizado de causa indeterminada (6.25%), úlceras y erosiones (37.5%), lesión de aspecto tumoral sangrante activo (12,5%), angiodisplasia (37.5%), pólipos (6.25%). Tres casos (15,78%) con evaluación limitada por mala preparación. Conclusión: La cápsula endoscópica se considera en la actualidad una herramienta útil para la detección de lesiones en intestino delgado, siendo la principal indicación en la hemorragia gastrointestinal de origen oscuro. Con un rendimiento diagnóstico de 84% en la evaluación de la Hemorragias Digestiva oscura oculta.

The endoscópica capsule is a method diagnosis that evaluates tracto gastrointestinal of noninvasive form. The main indication of the study is the determination of the origin of bled gastrointestinal dark. This clinical organization is defined, like the digestive hemorrhage of cause unknown, persistent and recurrent, after one proves refusal in the conventional endoscópico study. (Colonoscopia - superior digestive endoscopia). Objective: To describe findings of the endoscópica capsule in patients with digestive hemorrhages of dark origin. Patients and Methods: Descriptive study of trasversal cut. 19 patients with digestive hemorrhage of dark origin evaluated themselves that they went to the Service of Gastroenterology of the center of fourth level during the period of March 2009 - March 2010, excluding itself patients in critical or terminal state, and those with intestinal clinic of obstruction or fistulas. Using platform Given Imaging® SB2. Results: 19 patients studied, 14 (73.68%) masculine sex, 5 (26.31%) feminine sex, etáreo group included/understood between 29-60 years age average 39,5 years. Indication: bled digestive hidden: 6 cases (31,57%). Bled digestive dark: 13 case (68,42%). Findings in 16 patients (84,21%): bled active profuse located of indetermine cause (6,25%), ulcers and erosions (37,5%), injury of tumorlike aspect bleeding assets (12.5%), angiodisplasia (37,5%), polyps (6,25%). Three cases (15.78%) with evaluation limited by bad preparation. Conclusion: The endoscópica capsule considers at the present time a useful tool for the detection of injuries in thin intestine, being the main indication in the gastrointestinal he-morrhage of dark origin. With a yield diagnosis of 84% in the evaluation of the Hemorrhages Digestive dark hidden.

Impact of prolonged 48-h wireless capsule esophageal pH monitoring on diagnosis of gastroesophageal reflux disease and evaluation of the relationship between symptoms and reflux episodes / Impacto da monitorização prolongada do refluxo por pHmetria sem cateter por 48 horas, no diagnóstico da doença do refluxo gastroesofágico e no estudo da relação entre os sintomas e o refluxo

CONTEXT: Gastroesophageal reflux disease is one of the most common digestive diseases and an important cause of distress to patients. Diagnosis of this condition can require ambulatory pH monitoring. OBJECTIVES: To determine the diagnostic yield of a wireless ambulatory pH monitoring system of 48-hours, recording to diagnose daily variability of abnormal esophageal acid exposure and its symptom association. METHODS: A total of 100 consecutive patients with persistent reflux symptoms underwent wireless pH capsule placement from 2004 to 2009. The wireless pH capsule was deployed 5 cm proximal to the squamocolumnar junction after lower esophageal sphincter was manometrically determined. The pH recordings over 48-h were obtained after uploading data to a computer from the receiver that recorded pH signals from the wireless pH capsule. The following parameters were analyzed: (1) percentual time of distal esophageal acid exposure; (2) symptom association probability related to acid reflux. The results between the first and the second day were compared, and the diagnostic yield reached when the second day monitoring was included. RESULTS: Successful pH data over 48-h was obtained in 95 percent of patients. Nearly one quarter of patients experienced symptoms ranging from a foreign body sensation to chest pain. Forty-eight hours pH data analysis was statistically significant when compared to isolated analysis of day 1 and day 2. Study on day 2 identified seven patients (30.4 percent) that would be missed if only day 1 was analyzed. Three patients (18.7 percent) out of 16 patients with normal esophageal acid exposure on both days, showed positive symptom association probability, which generated an increase in diagnostic yield of 43.4 percent. CONCLUSION: Esophageal pH monitoring with wireless capsule is safe, well tolerated, does not require sedation. The extended 48-h period of study poses an increased yield to diagnose gastroesophageal reflux disease patients.

CONTEXTO: A doença do refluxo gastroesofágico é uma das doenças digestivas mais comuns e importante causa de desconforto para os pacientes. O diagnóstico desta condição clínica pode requerer monitoramento ambulatorial do pH esofágico. OBJETIVOS: Determinar o espectro diagnóstico do sistema de monitoramento ambulatorial do pH esofágico com cápsula telemétrica por um período de 48 horas no diagnóstico da variabilidade diária da exposição ácida anormal e sua associação com sintomas. MÉTODOS: Foram incluídos 100 pacientes adultos, consecutivos, com sintomas relacionados com a doença do refluxo gastroesofágico, que realizaram pHmetria com cápsula telemétrica por 48 horas entre 2004 e 2009. A cápsula foi posicionada e implantada a 5 cm da borda superior do esfíncter esofágico inferior, definida pela manometria esofágica. Foram analisados os seguintes parâmetros: (1) tempos percentuais de exposição ácida no esôfago distal; (2) probabilidade de associação dos sintomas com o refluxo ácido. Foram comparados os resultados entre o 1º e o 2º dia de monitoramento, assim como o eventual ganho diagnóstico obtido após a inclusão do 2º dia no monitoramento. RESULTADOS: Sucesso na obtenção dos dados do pH esofágico durante 48 horas foi obtido em 95 por cento dos pacientes. Aproximadamente 25 por cento dos pacientes apresentaram sintomas relacionados à implantação da cápsula, variando entre sensação de presença de corpo estranho à dor torácica. A análise dos resultados do estudo de 48 horas mostrou-se estatisticamente significante quando comparada com as análises isoladas do dia 1 e do dia 2. O estudo do dia 2 identificou sete pacientes (30.4 por cento) que teriam sido perdidos se somente o dia 1 fosse analisado. Três pacientes (18.7 por cento) dos 16 pacientes com exposição ácida normal no esôfago distal em ambos os dias, apresentaram probabilidade de associação com o sintoma positivo, que gerou incremento no ganho diagnóstico com este método diagnóstico de 43.4 por cento. CONCLUSÕES: O monitoramento do pH esofágico com a cápsula telemétrica é seguro, bem tolerado e não requer sedação. A extensão do período de estudo para 48 horas representa significativo aumento no ganho diagnóstico em pacientes com doença do refluxo gastroesofágico.

Capsula endoscópica y enteroscopia asistida por balones en pacientes con sospecha de enfermedad de intestino delgado métodos complementarios / Capsule endoscopy and balloon enteroscopy in patients with suspected small bowel disease complementary methods

El desarrollo reciente de la cápsula endoscópica (CE) y la enteroscopia asistida por balones (EAPB) ha cambiado el algoritmo diagnóstico de la patología del intestino delgado. La combinación de ambos métodos parece ser una herramienta útil. Mostrar la experiencia con el uso combinado de CE y EAPB en pacientes con sospecha de enfermedades del intestino delgado. 34 pacientes a quienes se les realizó CE y EAPB. El endoscopista conocía el resultado de la CE. Equipos: CE M2A, PillCam SB (Given Imaging), videoenteroscopios doble balón Fujinon EN-450P5, EN-450T5, enteroscopio balón único Olympus SIG Q-180. Se registraron datos demográficos, indicaciones, segmentos evaluados, hallazgos y complicaciones. 34 pacientes (19 mujeres, 15 hombres), edad promedio: 57,67 años. Principales indicaciones: sangrado digestivo oscuro evidente 67,64 %, anemia 11,76%, enfermedad de Crohn 5,88%. La EAPB se realizó por vía anterógrada en 25 pacientes, retrógrada en 4 y combinada en 5. Se detectaron lesiones con CE en 85,29% pacientes, con EAEAPB en 67,64% y con ambos métodos en 52,9%. En 11 pacientes se detectaron lesiones por CE y la EAPB fue normal. En 2 pacientes hubo hallazgos en la EAPB no vistos por la cápsula. Hallazgos mas frecuentes: CE: angioectasias 11, tumor subepitelial ulcerado 2, presencia de sangre 4, úlceras 3. EAPB: angioectasias 9, tumor subepitelial ulcerado 1, ulceras 3, divertículo de Meckel, 1. Terapéutica endoscópica en 13 pacientes y cirugía en 4 con sangrado digestivo. CE y EBU combinadas permiten mejorar el diagnóstico y orientar la conducta terapéutica en pacientes con sospecha de patología del intestino delgado...

The recent development of capsule endoscopy (CE) and balloon-assisted enteroscopy (BAE) has changed the diagnostic algorithm of small bowel pathology. The combination of both methods seems to be a useful tool. To show the experience with the combined use of CE and BAE in patients with suspected small bowel diseases. 34 patients who underwent CE and BAE. The endoscopist knew the outcome of the CE. We used the CE M2A, Pillcam (Given Imaging), double balloon videoenteroscopy Fujinon EN-450P5, EN-450T5, single balloon enteroscopy GIS Olympus Q-180. Demographic data, indications, segments evaluated, findings and complications were recorded. 34 patients (19 women, 15 men), average age: 57.67 years. Main indications: evident obscure gastrointestinal bleeding 67.64%, anemia 11, 76%, Crohn’s disease 5.88%. Anterograde BAE was performed in 25 patients, retrograde in 4 and combined in 5 patients. CE lesions were detected in 85.29% patients with BAE in 67.64% and 52.9% in both methods. In 11 patients lesions were detected by CE and the BAE was normal. In 2 patients there were findings in the BAE, not seen by the capsule. Most common finding: CE: 11 angiodysplasia, 2 subepithelial ulcerated tumor, 4 blood presence, 3 ulcers. BAE: 9 angiodysplasia, 1 subepithelial ulcerated tumor, 3 ulcers, 1 Meckel diverticulum. Therapeutic endoscopy was performed in 13 patients and surgery in 4 patients with digestive bleeding. Combined CE and BAE allow improving the diagnostic and orientate the therapeutic behavior in patients with suspected small bowel pathology...

8 años de cápsula endoscopica: progresos y retos / 8 years of capsule endoscopy: progresses and challenges

Desde su introducción en el año 2001, la cápsula endoscópica (CE) ha cambiado el diagnóstico y manejo de la patología del intestino delgado. Evaluar la utilidad clínica de la CE en pacientes con sospecha de enfermedad de intestino delgado. Pacientes a quienes se les realizó CE desde octubre 2001 hasta abril 2009 en dos centros médicos: La Policlínica Metropolitana y el Centro Médico de Caracas. Cápsulas utilizadas: M2A y PillCam SB (Given Imaging). Se registraron datos demográficos, indicaciones, vaciamiento gástrico y tránsito intestinal, hallazgos y complicaciones. 339 pacientes, 180 hombres-159 mujeres. Edad promedio: 56,04 años. Indicaciones: hemorragia digestiva oscura (n=217), diarrea crónica (n=22), enfermedad de Crohn (20), búsqueda de tumores (n=30), dolor abdominal (n=29), enfermedad celíaca (n=5), misceláneos (n=16). Se encontraron lesiones en 78,8% de los pacientes. Hallazgos: angiectasias 28,3%, erosiones 28,6%, úlceras 12,5%, sangrado activo 8% y tumores subepiteliales 4,2%. Al correlacionar los hallazgos con las indicaciones se encontró un porcentaje de concordancia significativo en pacientes con hemorragia digestiva oscura y enfermedad de Crohn. Complicaciones: obstrucción intestinal (n=1), retención (n=6). La CE es un método mínimamente invasivo, bien tolerado, con pocas complicaciones y porcentaje elevado de detección de lesiones, que parece posicionarse para guiar el diagnóstico y tratamiento de patologías como el sangrado digestivo oscuro y la enfermedad de Crohn. Pudimos adaptarnos a la plataforma tecnológica como usuarios y prepararnos para los nuevos avances que se avecinan, creemos que es el momento para dar inicio a un programa de entrenamiento en CE...

Since its introduction in 2001, the endoscopic capsule (EC) has changed the diagnosis and management of small bowel pathology. Objective: To evaluate the clinical benefi t of EC in patients with suspected small bowel disease. Patients who underwent EC from October 2001 to April 2009 at two medical centers, Policínica Metropolitana and Centro Médico de Caracas. Capsules used: M2A and PillCam SB (Given Imaging). Demographic data, indications, gastric emptying and intestinal transit, as well as, fi ndings and complications were recorded. 339 patients, 180 men, 159 women. Average age: 56.04 yearsold. Indications: obscure gastrointestinal bleeding (n = 217), chronic diarrhea (n = 22), Crohn’s disease (n=20), tumor screening (n = 30), abdominal pain (n = 29), celiac disease (n = 5), miscellaneous (n = 16). Lesions were found in 78.8% of patients. Findings: angiectasias 28.3%, erosions 28.6%, ulcers 12.5%, active bleeding 8% and, subepithelial tumors 4.2%. By correlating the fi ndings with the indications we found a signifi cant percentage of concordance in patients with obscure gastrointestinal bleeding and Crohn’s disease. Complications: intestinal obstruction (n=1), retention (n=6). EC is a minimally invasive well tolerated method, with few complications and high percentage of lesions detection, which seems to be positioned to guide the diagnosis and therapy of disorders such as, obscure gastrointestinal bleeding and Crohn’s disease. We were able to adapt to the technological platform as users and prepare for new developments to come; we believe it is time to begin a training program in EC...

Comparación de cápsula endoscópica esofágica y endoscopia digestiva superior para el diagnóstico de varices esofagicas en Maracaibo Venezuela: reporte preliminar / Comparison between esophageal capsule endoscopy and esophagogastroduodenoscopy for the diagnosis of esophageal varices in Maracaibo Venezuela: preliminary report

La cápsula endoscópica (CE) para intestino delgado inició una revolución tecnológica que se extendió a esófago buscando alternativas para la endoscopia digestiva superior (EDS), “gold standard” en estudio de várices esofágicas (VE) pero invasivas y desagradables sin sedación. Antes de EDS con sedación moderada, 9 pacientes cirróticos de consulta de Hepatología, 6 para seguimiento VE (66.6%) y 3 para despistaje (33.4%) ingirieron PillCam™ESO (Given Imaging). Endoscopista entrenado en CE (ciego a hallazgos EDS pero no a historia del paciente) leyó dos veces los resultados. Se evaluó en imágenes CE y EDS: Presencia-tamaño de várices esofágicas, Riesgo de sangrado, Presencia-grado de Gastropatía Portal Hipertensiva (GPH), várices gástricas. Se aplicaron dos cuestionarios de satisfacción: pre y post procedimiento. CE demostró 88,8% de sensibilidad para determinar tamaño y riesgo de sangrado y 66.6% para GPH. Un hallazgo visto solo por CE, incluyó una várice gástrica. 88% de los pacientes manifestó mayor ansiedad-incomodidad con EDS, prefiriendo CE para futuros procedimientos. A pesar de la eficacia, comodidad y utilidad de CE para seleccionar pacientes para EDS, no creemos que pueda sustituir totalmente a EDS por imposibilidad de tratamiento y costo. Los resultados son prometedores, ampliando la muestra tendremos conclusiones más sólidas...

Endoscopic Capsule (EC) for small bowl is a gastrointestinal breakthrough which extended to esophagus searching for alternatives to esophagogastroduodenoscopy (EGD); “gold standard” for esophageal varices (EV) study (but invasive and uncomfortable without sedation). We report our preliminary EC results in Maracaibo. Before EGD with moderated sedation, 9 cirrhotic patients, 6 (55%) for surveillance and 3 for variceal screening, underwent EC PillCam™ESO (Given Imaging). Endoscopist with EC training (blinded to EGD founds but not to patient’s history) read twice the results. EC and EGD images were evaluated for EV size, bleeding risk, portal hypertensive gastropathy (PHG) grade, gastric varices and other founds. Two satisfaction questionnaires were applied (pre and post procedure). EC showed 88.8% sensibility in determining EV size and bleeding risk and 66.6% sensitivity for PHG. A gastric varice was seen only by EC. 88% of the patients were more anxious and uncomfortable with EGD preferring EC for future procedures. Though EC is efficient, comfortable and useful in deciding which patients would benefi t from EGD we don’t think it will totally replace EGD, due to its cost and impossibility for treatment. Results are promising although bigger samples are necessary for solid conclusions...

Turbinectomia com videoendoscopia e microdebridador / Turbinectomy Assisted by Videoendoscopy and Microdebrider

A obstrução nasal é a queixa mais freqüente em otorrinolaringologia e está associada a. alterações estruturais do septo e da parede lateral do nariz, assim como a afecções inflamatórias crônicas nasossinusais. Atualmente, a cingia nasossinusal permite o tratamento simultâneo destas afecções, com o objetivo de otimizar a permeabilidade nasal. Objetivo: É objetivo deste trabalho expor nossa experiência em turbinectomia de conchas inferior e média com videoendoscopia e microdebridador em 41 casos, como complemento cirúrgico à septoplastia e/ou a cirurgia endoscópica nasossinusal, submetidos a estes procedimentos. Material e métodos: Todas as turbinectomias foram associadas: 51% a septoplastia, 32% a cirurgia endoscópica nasossinusal técnica de Messerklinger e 17% a ambos os procedimentos. A turbinectomia sempre foi parcial, removendo com o microdebridador a mucosa e submucosa da concha, expondo seu suporte ósseo; e, a seguir, a osteotomia parcial, nos casos de hipertrofia óssea. Arcas de sangramento evidentes foram eletrocoaguladas, com controle seguro da hemostasia. Em todos os casos foi colocado tala septal de Neiman com o objetivo de evitar sinéquias nasais. Resultados: Nesta amostra não ocorreu o sangramento nasal no pós-operatório imediato. Sinéquias entre septo e concha média nasal, indesejáveis, ocorreram em 5% (2/41) dos casos. A formação de crostas hemáticas ocorreu nas seis primeiras semanas, obstruindo parcialmente as fossas nasais, e sendo eliminadas com o auxílio de irrigação nasal com solução salina isotônica. Conclusão: A turbinectomia pela videoendoscopia e microdebridador permite melhor controle do procedimento cirúrgico, diminuindo a incidência das complicações pós-operatórias e otimizando a permeabilidade das cavidades nasais.

Nasal obstruction is the most common complaint in ENT consultations and is associated with septal deviation or deformities of the lateral wall of the nose, as well as chronic inflammatory diseases of the sinus and nasal cavities. Today the modern functional sinus surgery allows the ore step management of structural deformities of the nose and of inflammatory diseases of nasal and paranasal cavities providing good respiratory function. Aim: The aim of this work is to expose our experience in turbinectomies powdered by video-endoscopy and soft tissue shaver. The turbinectomies were a supplementary procedure of nasal surgeries in 41 patients with nasal obstruction. Material and methods: The turbinectomies were associated: 51% with nasal septum surgery, 32% with functional endoscopic sinus surgery (FESS) and 17% with both procedures. The turbinectomy was always partial removing all the soft tissue with the microdebrider, exposing the bone framework and then, cutting it partially, as conservative as we could do. Bleeding areas were stopped by electrocoagulation. In all cases a septal nasal splint of Neimann was sutured in order to avoid nasal sinequiae between the septum and the nasal lateral wall for 10 days. Results: In this sample, we didn't observe nasal bleeding after surgery. Nasal sinequia between the nasal septum and the middle turbinate occurred in 5% (2/41) cases. Nasal crusting was common in the first six weeks after surgery, causing nasal obstruction; they were relieved by buffered isotonic saline nasal washings, twice a day. Conclusion: Turbinectomy powdered by video-endoscopy and microdebrider allows a better control of this surgical procedure, lowering the rate of pos-operative complications and enhancing the respiratory nasal flow.