Enteritis eosinofílica. Presentación de un caso y revisión de la literatura / Eosinophilic enteritis. Case presentation and literature review

RESUMEN La enteritis eosinofílica consiste en la presencia de infiltrados eosinofílicos en el tracto digestivo. Constituye en la actualidad una entidad rara que puede localizarse en cualquier región del tubo digestivo. Su etiopatogenia se desconoce y en muchas ocasiones se relaciona con antecedentes de atopia. Las manifestaciones clínicas varían en función de las capas afectadas. Se presentó el caso de un paciente de 26 años de edad, con antecedentes de haber sido operado de apendicitis aguda, en el año 2011. Llegó al Cuerpo de Guardia refiriendo dolor intenso, fijo; en fosa iliaca derecha, acompañado de fiebre de 39°C, con escalofríos y síntomas dispéptico. Se orientó ingreso y se le realizó una videoendoscopia, se observó gastritis antral eritematosa exudativa con test para Helicobacter pylori positivo. Además, una videolaparoscopia arrojando presencia de asas delgadas apelotonadas y adherencias no recientes en fosa iliaca derecha. A pesar del tratamiento empleado el paciente continuó con dolor y fiebre, por lo que se decidió indicarle una enteroscopia de doble balón con biopsia de íleon. Se informó que a nivel del colon presentaba una colitis crónica inespecífica y en el íleon una hiperplasia linfoide. El estudio histopatológico confirmó la colitis inespecífica y una eosinofilia moderada en íleon. Se indicó tratamiento con prednisona y mesalazina con mejoría notable del cuadro clínico, fue dado de alta con el diagnóstico de una enteritis eosinofílica, con seguimiento por consulta externa de gastroenterología. En la actualidad se mantiene asintomático (AU).

ABSTRACT Eosinophilic enteritis is the presence of eosinophilic infiltrates in the digestive tract. Currently it is a rare entity than could be located in any region of the digestive tract. Its etiopathogenesis is unknown and is related, in many cases, to antecedents of atopy, Clinical manifestations may vary according to the affected layer. The authors present the case of a patient aged 26 years, with antecedents of having undergone an acute appendicitis surgery in 2011. He arrived to Emergency referring intense, steady pain in the right iliac fossa, accompanied by a 39o C fever, chills and dyspeptic symptoms. He was admitted and a video endoscopy was carried out. An exudative erythematous antral gastritis was observed with a positive test for Helicobacter pylori. In addition, video laparoscopy also showed the presence of thin, lumped loops and no-recent adherences in the right iliac fossa. In spite of the applied treatment, the patient continued with pain and fever, so the doctors indicated a double-balloon enteroscopy with ileum biopsy. It was informed an unspecific chronic colitis at the colon level and a lymphoid hyperplasia in the ileum. The histopathologic study confirmed the unspecific colitis and a moderate eosinophilia in the ileum. A prednisone and mesalazine treatment was indicated with a notable improvement of the clinical characteristics. The patient was discharged diagnosed with a eosinophilic enteritis and follow-up in out-patient consultation of Gastroenterology. Currently he keeps on asymptomatic (AU).

Non-specific colitis among patients with colitis: frequency and relation to inflammatory bowel disease, a prospective study / Colite inespecífica entre pacientes com colite: estudo prospectivo sobre sua frequência e relação com doença inflamatória intestinal

Abstract Background and study aim: The term non-specific colitis refers to an inflammatory condition of the colon that microscopically lacks the characteristic features of any specific form of colitis and is commonly seen in pathology reports of colonoscopy biopsies. In fact, it has been questioned whether it is a separate pathological entity or it is merely an intermediate stage in the course of inflammatory bowel disease. This study was conducted to estimate the prevalence of non-specific colitis among patients with colitis and characterize its natural history over a 6 months year period. Patients and methods: Eighty adult patients presented for colonoscopy were enrolled. In the final analysis they were divided into Group A; the non-specific colitis Group and Group B; the inflammatory bowel disease Group. All patients were subjected to: full history taking, full clinical examination, laboratory investigations: which included stool analysis, CRP, ESR, complete colonoscopy and entire random colon biopsies for histopathological examination. Results: Group A included 67 patients (83.75%) while Group B included 13 (16.25%) patients. Patients with IBD had clinical and laboratory features of inflammation significantly higher than patients with non-specific colitis. Six patients (8.95%) of non-specific colitis group developed histologic features of florid inflammatory bowel disease after 6 months. There were no independent predictors of this conversion. Conclusion: Among our 80 patients with colonoscopy and biopsy 67 (83.75%) were diagnosed as non-specific colitis and out of them 6 patients (8.95%) were reexamined after 6 months and proved to have inflammtory bowel disese this change was not linked to predictive factors.

Resumo Introdução e objetivos: O termo colite inespecífica (CI) refere-se a uma condição inflamatória do cólon que microscopicamente não apresenta características de qualquer forma específica de colite; é comumente observada em relatórios patológicos de biópsias de colonoscopia. De fato, tem-se questionado se esta seria uma entidade patológica separada ou apenas um estágio intermediário no curso da DII. Este estudo foi realizado para estimar a prevalência de CI entre pacientes com colite e caracterizar seu curso durante um período de seis meses. Pacientes e métodos: O estudo incluiu 80 pacientes adultos que se apresentaram para colonoscopia. Na análise, os pacientes foram divididos em dois grupos: grupo A (CI) e grupo B (DII) Todos os pacientes foram submetidos a anamnese completa, exame clínico completo e investigações laboratoriais que incluíram análise de fezes, PCR, VHS, colonoscopia completa e biópsias aleatórias de cólon para exame histopatológico. Resultados: Do total de pacientes, 67 foram alocados no grupo A (83,75%) e 13 (16,25%) no grupo B. Os pacientes com DII apresentavam sinais clínicos e laboratoriais de inflamação significativamente maiores do que o observado em pacientes com CI. Seis pacientes (8,95%) do grupo CI desenvolveram características histológicas de DII florida após seis meses. Não foram identificados preditores independentes para essa conversão. Conclusão: Entre os 80 pacientes submetidos a colonoscopia e biópsia, o diagnóstico de CI foi feito em 67 (83,75%); destes, seis pacientes (8,95%) foram reexaminados após seis meses e apresentaram DII, sendo que essa conversão não foi associada a fatores preditivos.

Poliposis gigante de colon como forma de presentación de colitis ulcerativa ideopática. Reporte de caso / Giant polyposis of colon as a presentation form of the idiopathic ulcerative colitis. Case report

RESUMEN La poliposis gigante localizada es una complicación rara de la colitis ulcerativa ideopática de corta evolución. Esta lesión representa un acumulo localizado de pólipos que forman una masa colónica intraluminal de aspecto neoplásico que puede simular un cáncer de colon. Suele presentarse en los adultos jóvenes y es más común en los países desarrollados con una incidencia cada vez mayor. Se presentó un caso de pólipos inflamatorios gigantes (PIG) de recto sigmoides que ingresa como un probable tumor de recto cuyas manifestaciones clínicas fueron semejantes a la de cualquier enfermedad inflamatoria. El paciente desarrolló esta masa inflamatoria sobre una enfermedad inflamatoria intestinal de poco tiempo de evolución clínica, con buena respuesta al tratamiento medicamentoso (AU).

ABSTRACT The located giant polyposis is rare complication of idiopathic ulcerative colitis of short evolution. This lesion is a localized accumulation of polyps forming an intra luminal colon mass of neoplastic aspect that might simulate a colon cancer. It is usually found in young adults, and it is more common in developed countries with a higher and higher incidence. We presented a case of giant inflammatory polyps (PIG as acronym in Spanish) of sigmoid rectum that entered the hospital as a probably rectum tumour, the clinical manifestations of which were similar to others of any inflammatory disease. The patient developed an inflammatory mass on a, intestinal inflammatory disease of short time clinical evolution, with a good answer to the medicinal treatment (AU).

Guía de práctica clínica para el diagnóstico y tratamiento de la colitis ulcerativa en población adulta / Clinical practice guideline for the diagnosis and management of adult patients with Ulcerative Colitis

Objetivo: desarrollar una guía de práctica clínica que permita orientar el diagnóstico de los pacientes con colitis ulcerativa mediante el uso adecuado de criterios clínicos y direccionar la conducta terapéutica en las diferentes etapas de la enfermedad y en los diferentes niveles de atención. Materiales y métodos: esta guía fue desarrollada por un equipo multidisciplinario con apoyo de la Asociación Colombiana de Gastroenterología, el Grupo Cochrane ITS y el Instituto de Investigaciones Clínicas de la Universidad Nacional de Colombia. Se desarrollaron preguntas clínicas relevantes a la entidad y se realizó la búsqueda de guías nacionales e internacionales en bases de datos especializadas. Las guías existentes fueron evaluadas en términos de calidad y aplicabilidad; una de las guías cumplió con los criterios de adaptación y el grupo decidió actualizar la búsqueda, desarrollando de novo las preguntas adicionales contempladas. El Grupo Cochrane realizó la búsqueda sistemática de la literatura. Las tablas de evidencia y recomendaciones fueron realizadas usando la metodología GRADE. Resultados: se desarrolló una guía de práctica clínica, basada en la evidencia, para el diagnóstico y tratamiento de la colitis ulcerativa en adultos en Colombia. Conclusiones: se estableció la importancia para el diagnóstico de la evaluación clínica, endoscópica e histológica y se especificaron las indicaciones para el adecuado tratamiento de los pacientes con colitis ulcerativa, de acuerdo con su severidad y estado de remisión.

Objective: To provide an evidence-based clinical practice guideline for the diagnostic and treatment of ulcerative colitis for patients, caregivers, administrative, and government bodies at all levels of care in Colombia. Materials and Methods: This guide was developed by a multidisciplinary team with the support of the Colombian Association of Gastroenterology, Cochrane STI Group and Clinical Research Institute of the Universidad Nacional de Colombia. Relevant clinical questions were developed and the search for national and international guidelines in databases was performed. Existing guidelines were evaluated for quality and applicability. One of the guidelines met the criteria for adaptation, so the group decided to update the search and develop de novo the additional questions. Systematic literature searches were conducted. The tables of evidence and recommendations were made based on the GRADE methodology. Results: An evidence-based Clinical Practice Guidelines for the management of ulcerative colitis was developed for the Colombian context. Conclusions: The opportune management of ulcerative colitis would have an impact of the disease in Colombia.

Apendagitis epiploica primaria: Clínica y evolución de 73 casos

La apendagitis epiploica primaria es una enfermedad relativamente infrecuente dentro de los diagnósticos diferenciales del abdomen agudo. Describimos las características clínicas y evolución de una serie de 73 casos de apendagitis epiploica primaria. Se realizó una búsqueda de imágenes ecográficas y tomográficas con diagnóstico de apendagitis en el sistema de información hospitalario electrónico del Hospital Alemán entre abril del 2007 y julio del 2013 y posteriormente se revisaron sus historias clínicas. Se incluyeron 73 casos; la edad promedio fue de 45 años (± 16), 54 (74%) eran varones. El motivo de consulta fue dolor abdominal: en fosa ilíaca izquierda en 65 (el 89% de los casos); en fosa ilíaca derecha en seis (8%) y en otras localizaciones en dos (3%). Se les realizó ecografía abdominal a 44 (60%), tomografía computarizada a 21 (29%), y ambos estudios a 8 (11%). En el 49% de los casos se solicitó interconsulta con el servicio de cirugía. Recibieron tratamiento con antibióticos 15 (21%) pacientes, de los cuales el 73% fue indicado por un médico clínico. Recibieron tratamiento ambulatorio con antiinflamatorios no esteroides 67 (92%); dos requirieron cirugía laparoscópica, dos internación y dos opiáceos. La apendagitis epiploica es infrecuente dentro de los diagnósticos diferenciales de abdomen agudo, pero es una entidad que no debe ser desconocida por los médicos para prevenir intervenciones innecesarias y el uso excesivo de antibióticos.

Primary epiploic appendagitis is a relatively rare disease in the differential diagnosis of acute abdomen, nonetheless it is an entity that should not be ignored by physicians and surgeons in order to prevent unnecessary interventions and overuse of antibiotics. To substantiate this concept a search was conducted at the Hospital Aleman, Buenos Aires between April 2007 and July 2013. The aim was clinical histories containing sonographic and tomographic images with diagnosis of omental appendagitis; and subsequently their electronic medical records were reviewed. The clinical features and outcome of a case series of 73 primary omental appendagitis were selected; the mean age was 45 years (± 16); 54 (74%) were men. Abdominal pain (left lower quadrant in 89% of cases) was the most common symptom. Abdominal ultrasound was performed on 44 (60%) of patients, computed tomography on 21 (29%), and both studies on 8 (11%) of cases in this series. In 49% of cases surgery consultation was requested. Fifteen patients (21%) were treated with antibiotics, 73% of them were prescribed by a clinician. Sixty seven patients (92%) were treated as outpatients with non steroidal anti-inflammatory drugs (NSAIDs); two required laparoscopic surgery, two required hospitalization and two others were treated with opioids. Epiploic apendagitis is uncommon in the differential diagnosis of acute abdomen, but is an entity that should not be ignored by physicians to prevent unnecessary interventions and overuse of antibiotics.

Eosinophilic colitis in infants / Colite eosinofílica em lactentes

OBJECTIVE: To review the literature for clinical data on infants with allergic or eosinophilic colitis. DATA SOURCE: MEDLINE search of all indexes was performed using the words ''colitis or procto-colitis and eosinophilic'' or ''colitis or proctocolitis and allergic'' between 1966 and February of 2013. All articles that described patients' characteristics were selected. DATA SYNTHESIS: A total of 770 articles were identified, of which 32 met the inclusion criteria. The 32 articles included a total of 314 infants. According to the available information, 61.6% of infants were male and 78.6% were younger than 6 months. Of the 314 patients, 49.0% were fed exclusively breast milk, 44.2% received cow's milk protein, and 6.8% received soy protein. Diarrheal stools were described in 28.3% of patients. Eosinophilia was found in 43.8% (115/263) of infants. Colonic or rectal biopsy showed infiltration by eosinophils (between 5 and 25 perhigh-power field) in 89.3% (236/264) of patients. Most patients showed improvement with theremoval of the protein in cow's milk from their diet or the mother's diet. Allergy challenge tests with cow's milk protein were cited by 12 of the 32 articles (66 patients). CONCLUSIONS: Eosinophilic colitis occurs predominantly in the first six months of life and in males. Allergy to cow's milk was considered the main cause of eosinophilic colitis. Exclusion of cow'smilk from the diet of the lactating mother or from the infant's diet is generally an effective therapeutic measure. .

OBJETIVO: Revisão da literatura sobre dados clínicos de lactentes com colite eosinofílica oualérgica. FONTE DOS DADOS: Pesquisa no Medline de todas as indexações com as palavras ''colitis or proc-tocolitis and eosinophilic'' ou ''colitis or proctocolitis and allergic'' entre 1966 e fevereiro de 2013. Foram selecionados todos os artigos que descreviam as características dos pacientes. SÍNTESE DOS DADOS: Foram identificados 770 artigos dos quais 32 preenchiam os critérios de inclusão. Os 32 artigos incluíram o total de 314 lactentes. Conforme as informações disponíveis, 61,6% dos lactentes eram do sexo masculino e 78,6% apresentavam idade inferior a 6 meses. Dos 314 pacientes, 49,0% encontrava-se em aleitamento natural exclusivo, 44,2% recebiam proteína do leite de vaca e 6,8% proteína da soja. Fezes diarreicas foram descritas em 28,3% dos pacientes. Eosinofilia foi encontrada em 43,8% (115/263) dos lactentes. Biópsia retal ou colônica mostrou infiltração por eosinófilos (entre 5 e 25 por campo de grande aumento) em 89,3% (236/264) dos pacientes. A maioria dos pacientes apresentou melhora com a retirada da proteína do leite de vaca da sua dieta ou das suas mães. Teste de desencadeamento com proteína do leite de vaca foi citado em 12 dos 32 artigos (66 pacientes). CONCLUSÕES: Colite eosinofílica ocorre predominantemente nos primeiros seis meses de vida e no sexo masculino. Alergia ao leite de vaca foi considerada a principal causa de colite eosinofílica. Dieta de exclusão do leite de vaca da mãe lactante ou da dieta do lactente é uma medidate rapêutica geralmente eficaz. .

protective effect of Echinacea spp. [Echinacea angustifolia and Echinacea purpurea] in a rat colitis model induced by acetic acid

Ulcerative colitis [UC] is a chronic disease that causes an inflammatory condition in the colon. Several cytokines, including tumor necrosis factor alpha [TNF-alpha], interleukin 1beta [IL-1beta] and transforming growth factor beta [TGF-beta] are crucial components of these inflammatory pathways. New therapeutic strategies are needed for improved clinical outcomes in UC and with less adverse effects. That is why alternative therapies such as herbal remedies are increasingly being used with favorable effects in the treatment of UC. Hence, in the present study, we aimed to evaluate the protective effect of Echinacea spp in an experimental rat colitis model induced by acetic acid [AA]. Acetic acid was given via a rectal route to induce acute colitis in rats. Rats were placed in four groups: control, Echinacea, Echinaceacolitis and colitis. Tumor necrosis factor alpha, IL-1beta and TGF-beta levels were measured. Histopathological comparison of the groups was also performed. The disease activity index [DAI] was significantly higher in the colitis group compared to the control, Echinacea and Echinacea-colitis groups [p<0.001]. There was no significant difference between the DAI of control, Echinacea and Echinacea-colitis groups [p>0.07]. The inflammatory mediators IL-1beta and TNF-alpha were significantly elevated in the colitis group compared to the other groups [p<0.007, <0.001 respectively]. Therefore, Echinacea spp. may likely have some therapeutic favorable effects in the management of UC

Colitis eosinofílica / Eosinophilic colitis

La gastroenteritis eosinofílica es una enfermedad rara que se caracteriza por la presencia de eosinofilia hística que afecta diferentes capas de la pared intestinal por lo que desde el punto de vista histológico se clasifica en mucosa, muscular o serosa, según la capa de la pared intestinal en la que predomine el infiltrado. Puede localizarse en cualquier porción del tubo digestivo, pero excepcionalmente en el colon. Se presentó un caso de colitis eosinofílica en un paciente de 26 años de edad con síndrome diarreico crónico. Se exponen datos clínicos y estudios patológicos. Se revisó el tema...

The eosinophilic gastroenteritis is a rare disease characterized by presence of histic eosinophilia involving different layers of the intestinal wall classified from the histological point of view in mucosa, muscular or serous, according to the layer of the intestinal wall with predominance of infiltrate. It may be located in any portion of the digestive tract, but exceptionally in the colon. This the case of eosinophilic colitis in a patient aged 26 with chronic diarrheic syndrome. Clinical data and pathologic studies results are showed. This matter was reviewed...

A Case of Cytomegalovirus Colitis with Endoscopic Finding Resembling Crohn's Disease / 대한소화기학회지

Cytomegalovirus (CMV) colitis is common among immunocompromised patients, and often diagnosed by pathologic confirmation because it is associated with a diverse spectrum of clinical and endoscopic features. However, Crohn's disease has no definitive diagnostic criteria, but longitudinal ulcers and cobble stone appearance are accepted as typical endoscopic features of Crohn's disease. An 83 year-old male with a history of radiotherapy for hypopharyngeal cancer visited our hospital with a complaint of melena for 1 week. His colonoscopic exam showed multiple longitudinal ulcers along the entire colon. Most of the ulcers were longer than 4 cm, these endoscopic findings were suspected as typical endoscopic features of Crohn's disease. Pathologic reports revealed multiple inclusion bodies with CMV on immunohistochemistry. He was finally diagnosed as having CMV colitis, and received a 3 week-course of intravenous ganciclovir. A colonoscopic follow-up showed complete healing of the multiple longitudinal ulcers, and he is doing well now without further treatment.

Clinical Significance of the Large Intestinal Wall Thickening Detected by Abdominal Computed Tomography / 대한소화기학회지

BACKGROUND/AIMS: Bowel wall thickening on CT has been reported to reflect colorectal carcinoma and colitis. The aim of this study was to evaluate the clinical significance of the large intestinal wall thickening on CT. METHODS: Between January 2006 and August 2010, medical records of 815 patients who underwent endoscopy after CT scans within 1 month were reviewed retrospectively. RESULTS: A total of 233 patients were included. The wall thickening was actually associated with abnormal endoscopic findings in 81.1% of the cases. The accuracy rate on diagnosis between CT and endoscopy was 63.5%. The discrepancy in diagnosis was higher in cases with left colon abnormality and short segment lesion. Abdominal pain was significantly more common in cases suspected malignancy on CT compared with colitis (p=0.047). Most of the malignancy diagnosed on CT involved the left side colon and most of the colitis involved the entire colon (p<0.001). The length of lesion was below 5 cm in 86.5% of the malignancy. Malignancy was more common in patients aged over 50 years with hemoglobin below 12 g/dL. The CT findings significantly suggestive of malignancy were lymph node enlargement and length of lesion below 5 cm (p=0.027 and p<0.001). CONCLUSIONS: The large intestinal wall thickening on CT was limited in the differential diagnosis of malignancy and colitis. Additional endoscopic evaluation is needed in patients with bowel wall thickening associated with lymph node enlargement and short segment lesion on CT in order to exclude malignancy.

A Case of Phlebosclerotic Colitis in a Hemodialysis Patient / 대한소화기학회지

Phlebosclerotic colitis is a rare disease of intestinal ischemia caused by calcified peripheral mesenteric veins and a thickened colonic wall, differentiating it from the typical ischemic colitis. A 68-year-old man who was undergoing hemodialysis presented with hematochezia and abdominal pain. Colonoscopic findings showed typical dark purple-colored edematous mucosa. Linear calcifications in the colon were noted on both a plain abdominal radiolography and abdominal computer tomography. These findings suggested that the patient suffered from phlebosclerotic colitis. Following bowel rest and fluid therapy, there was full recovery. We herein report a rare case of phlebosclerotic colitis in a hemodialysis patient and include a review of the relevant literature.

Efeitos do butirato nos níveis de peroxidação lipídica em células da mucosa cólica sem trânsito fecal: estudo experimental em ratos / Effects of butyrate on levels of lipid peroxidation in cells of the colonic mucosa without fecal stream: experimental study in rats

Os ácidos graxos de cadeia curta (AGCC) representam o principal substrato energético para células da mucosa cólica. A derivação intestinal, reduzindo suprimento de AGCC, responsabiliza-se pela colite de exclusão (CE). Aplicação retal de butirato tem sido eficaz no tratamento da doença. Então, o objetivo deste estudo foi avaliar os níveis de lipoperoxidação na mucosa cólica, após aplicação de butirato, em modelo de CE. Vinte seis ratos Wistar foram submetidos à colostomia proximal e fístula mucosa distal. Os animais foram divididos em dois grupos segundo sacrifício ser realizado em duas ou quatro semanas. Cada grupo foi subdividido em dois subgrups segundo intervenção com soro fisiológico ou butirato. O diagnóstico de CE foi estabelecido por estudo histopatológico e os níveis de lipoperoxidação pelos níveis de malondialdeído (MDA). Utilizaram-se os testes de Mann-Whitney e Kruskal-Wallis (significantes quando p<0,05). Após duas semanas, os níveis de MDA foram menores nos segmentos sem trânsito nos animais irrigados com butirato (p=0,006); porém, após quatro semanas foram semelhantes (p=0,08). No cólon sem trânsito irrigado com butirato, os níveis de MDA aumentaram com o tempo de exclusão (p=0,02); enquanto no cólon com trânsito não se modificaram (p=0,86). O butirato reduz os níveis de MDA na mucosa cólica sem trânsito fecal, após duas semanas de derivação; entretanto, a irrigação isolada não é capaz de reduzir os níveis de lipoperoxidação das células mucosas com o progredir do tempo de exclusão intestinal.

The short-chain fatty acids (SCFA) are the main energy substrate for the cells of the colonic mucosa. Diversion of the fecal stream reducing the supply of SCFA is responsible for diversion colitis (DC). Rectal application of butyrate has been demonstrated effective in the treatment of the disease. So the aim of this study was to evaluate the levels of lipid peroxidation in the colon mucosa after application of butyrate in model of DC. Twenty-six rats were submitted to proximal colostomy and distal mucous fistula. The animals were divided into two groups according sacrifice carried out in two or four weeks. Each group was divided into two subgroups according to intervention with saline solution or butyrate. The diagnosis of colitis was established by histopathology and the levels of lipid peroxidation by tissue levels of malondialdehyde (MDA). We used the Mann-Whitney and Kruskal-Wallis, establishing a significance level of 5 percent (significant with p<0.05). After two weeks, the levels of MDA were lower in the segments without fecal stream of animals irrigated with butyrate (p=0.006), but after four weeks were similar (p=0.08). In the colon without fecal stream irrigated with butyrate, MDA levels increased with the time (p=0.02), while in segments with fecal stream MDA not changed. (p=0.86). Butyrate reduces the levels of MDA in the colonic mucosa without fecal stream, after two weeks of derivation. However, the irrigation with the substance is not able to reduce the lipid peroxidation of mucosal cells with increasing time of intestinal exclusion.

Avaliação dos níveis de peroxidação lipídica em células da mucosa cólica após aplicação de enemas com peróxido de hidrogênio: estudo experimental em ratos / Evaluation of lipid peroxidation levels on mucosa colonic cells afther application of hydrogen peroxide in enemas: experimental study in rats

A aplicação de clisteres contendo peróxido de hidrogênio (H2O2) determina o aparecimento de quadros graves de colite, algumas vezes de evolução fatal. É possível que a colite induzida por H2O2 possa ocorrer pela quebra da barreira funcional do epitélio cólico por estresse oxidativo. Objetivo: Avaliar os níveis de peroxidação lipídica em células da mucosa cólica após instilação de H2O2 no reto excluso de trânsito fecal. Método: Vinte seis ratos Wistar machos foram submetidos a colostomia proximal terminal no cólon descendente e fístula mucosa distal. Os animais foram randomizados em dois grupos segundo o sacrifício ter sido realizado duas ou quatro semanas após a derivação intestinal. Cada grupo experimental foi dividido e dois subgrupos segundo aplicação de clisteres, em dias alternados, contendo solução fisiológica a 0,9 por cento ou H2O2 a 3 por cento. O diagnóstico de colite foi estabelecido por estudo histopatológico e os níveis de dano oxidativo tecidual pela dosagem de malondialdeído por espectrofotometria. Os resultados foram analisados com os testes de Mann-Whitney e Kruskal-Wallis, estabelecendo-se nível de significância de 5 por cento (p menor que0,05)

Resultados: Os níveis de malondialdeído nos irrigados com SF nos cólons com e sem trânsito fecal após duas e quatro semanas de irrigação foram de: 0,05 mais ou menos 0,006; 0,06 mais ou menos 0,006 e 0,05 mais ou menos 0,03, 0,08 mais ou menos 0,02, respectivamente. Os níveis de malondialdeído nos irrigados com H2O2, nos cólons com e sem trânsito, após duas e quatro semanas de irrigação foram de 0,070 mais ou menos 0,006; 0,077 mais ou menos 0,01 e 0,052 mais ou menos 0,01, 0,08 mais ou menos 0,04, respectivamente. Após duas semanas os níveis de malondialdeído foram maiores nos animais irrigados com H2O2 em relação ao grupo controle (p= 0,007 e p= 0,01, respectivamente). Após quatro semanas não houve diferenças significantes Não ocorreu variação nos níveis de malondialdeído com o decorrer tempo de irrigação. Conclusão: Clisteres com H2O2, podem determinar o aparecimento de colite por ocasionarem estresse oxidativo nas células epiteliais da mucosa intestinal.

The use of rectal enemas with hydrogen peroxide (H2O2) determines the onset of severe colitis, sometimes with fatal evolution. It is possible that H2O2-induced colitis can occur by damage to the functional epithelial barrier of the colon by oxidative stress. Objective: The aim of present study was evaluate the levels of lipid peroxidation in cells of the colonic mucosa after instillation of H2O2 into the rectum excluded from fecal transit. Method: Twenty six male Wistar rats were undergone to proximal terminal colostomy in the descending colon and distal mucous fistula. The animals were randomized in two experimental groups according to the sacrifice was made two or four weeks after diversion of the fecal stream. Each experimental group was divided into two subgroups second application of enemas containing saline solution 0.9 percent or 3 percent H2O2 on alternate days. The diagnosis of colitis was established by histopathology study and the oxidative damage by tissue levels of malondialdehyde quantified by spectrophotometry. The results were analyzed with the Mann-Whitney and Kruskal-Wallis test, adopting a significance level of 5 percent (p less than 0.05).

Results: The levels of malondialdehyde in colon segments irrigated with saline, with and without fecal stream after two and four weeks of irrigation were: 0.05 more or less 0.006, 0.06 more or less 0.006 and 0.05 more or less 0.03, 0.08 more or less 0.02, respectively. The levels of malondialdehyde in colon segments irrigated with H2O2, in the colon with and without fecal stream, after two and four weeks of irrigation were 0.070 more or less 0.006, 0.077 and 0.052 more or less 0.01 more or less 0.01, 0.08 more or less 0.04, respectively . After two weeks the levels of malondialdehyde were higher on animals irrigated with H2O2 than control group (p = 0.007 and p = 0.01, respectively). After four weeks there were no significant differences in malondialdehyde levels related with the time of irrigation. Conclusion: Rectal enemas with H2O2, may determine the onset of colitis by oxidative stress on epithelial cells of intestinal mucosa.

CMV colitis presenting as neoplastic lesions with life-threatening bleeding in an immunocompetent patient

An elderly woman with multiple medical problems developed cytomegalovirus [CMV] colitis following a prolonged hospitalization. She presented life-threatening colonic bleeding mimicking a neoplastic process while the final diagnosis was CMV colitis. This is an uncommon presentation of CMV colitis in an immunocompetent patient needing a high index of suspicion to proceed early with proper diagnosis and therapy

La colonoscopia: ¿es un estudio pre-operatorio indispensable para la restitución del tránsito intestinal en pacientes jóvenes: portadores de colostomía por traumatismo abdominal penetrante? / Colonoscopy: is a necessary pre-operatory study for intestinal transit restitution in young patients carrying a colostomy by penetrating abdominal trauma?

Determinar el impacto de la colonoscopia como procedimiento preoperatorio requisito para la restitución del tránsito intestinal en una población portadora de colostomía por un traumatismo abdominal penetrante. Estudio descriptivo, retrospectivo observacional, donde se evalúan informes de endoscopias digestivas inferiores realizadas por el servicio de Gastroenterología del Hospital General del Oeste "Dr. José Gregorio Hernández" de Caracas, como requisito preoperatorio para la restitución del transito intestinal en pacientes portadores de colostomía por traumatismo abdominal penetrante, en el período comprendido entre enero 2004 y diciembre 2008. De una población total de 46 pacientes, se les realizó una colonoscopia a 34 (73,91%). Los 12 restantes (26,08%), no cumplían con los criterios de inclusión. de los 34 pacientes incluidos para evaluación, 22 (64,70%), presentaron colitis y recidivas por deprivación, 7 (20,59%) con estudio normal y 4 (11,76%) presentaron alguna alteración en la endoscopia digestiva inferior. En este estudio no hay evidencia que sugiera que la realización de una colonoscopia preoperatoria en la cirugía electiva de restitución de tránsito intestinal, evite la aparición de complicaciones, ni permita el diagnóstico de patologías de relevancia en la población estudiada, no teniendo ésta la importancia que se le ha otorgado hasta la actualidad.

To determine the impact of the colonoscopy as pre-operating procedure as a requirement in the population carrying of colostomy by abdominal penetrating trauma for the restitution of the intestinal transit. Descriptive, retrospective and observational study, where the inferior digestive endoscopy made by the service of Gastroenterology in Hospital General del Oeste "Dr. José Gregorio Hernández", Caracas, was valued as pre-operating requirement in carrying patients of colostomy by abdominal penetrating trauma for the restitution of the intestinal transit, in the period between January 2004 to December 2008. In a population of 46 patients, only 34 (73.91%) were included to do the colonoscopy, the others 12 (26,08%) didn't fulfill the inclusion criteria. Of the 34 patients included, 22 (64.70%) were displayed colitis and rectitis by deprivation, 7 (20.59%) were normal study and 4 (11.76%) presented others alteration in the inferior digestive endocopy. In this study there is not evidence to suggest that the realization of preoperatory colonoscopy for surgery in the restitution of intestinal transit, avoid complications or permit diagnosis of diseases in the study population, doing less important the evidence exposed until present.

Colitis eosinofílica: a propósito de 3 casos y revisión de la literatura / Eosinophilic colitis: report of three cases and literature review

Introducción: Existen afecciones inflamatorias que afectan el colon en forma infrecuente, con amplia variedad en su presentación clínica. Entre ellas, las colitis colágena, indeterminadas, infecciosas, císticas y eosinofílicas, entre otras. La colitis eosinofílica es una enfermedad crónica inflamatoria de etiología desconocida caracterizada por la infiltración masiva de eosinófilos en un segmento del tubo digestivo. Objetivo: Analizar los hallazgos clínicos, histológicos y terapéuticos asociados a la colitis eosinofílica. Diseño: Presentación de casos. Revisión de la literatura. Métodos: Revisión de registros en bases MEDLINE, LILACS y registros de AMA. Pacientes: Se analizaron 3 casos de presentación en los últimos 12 meses. Resultados: Caso 1: femenino, 40 años, dolor abdominal cólico y diarrea. Tomografía Computada: engrosamiento de colon derecho. Colonoscopía: colitis localizada en colon derecho con enantema, congestión sin ulceras. Parasitológico negativo. Caso 2: femenino 26 años, diarrea severa con deshidratación. Parasitológico positivo. Tratamiento con metronidazol sin respuesta. Colonoscopía: pancolitis moderada. Inicia tratamiento con corticoides. Caso 3: femenino 33 años, diarrea, pujo y tenesmo. Perdida de peso. VEDA normal. Colon por enema: dolicocolon. Colonoscopía: tiflitis con ileon normal. Parasitológico negativo. Tratamiento con mesalazina con buena respuesta. Todos tuvieron eosinofilia mayor al 8%. Todas las biopsias fueron del colon derecho y revelaron colitis crónica eosinofílica. Conclusiones: El diagnóstico definitivo es de necesidad para diferenciarlas de enfermedades inflamatorias del colon mediante colonoscopía y biopsia (en especial Enfermedad de Crohn). El tratamiento es sintomático y comprende una variedad de drogas (ketotifeno, corticoides, antihistamínicos, metronidazol, etc.)... (TRUNCADO)

Introduction: There is uncommon colitis with unfrequented presentation. Eosinophilic colitis is an inflammatory chronic bowel disease with unknown etiology. Objective: To evaluate clinical, histological and therapeutic findings and differential diagnosis of chronic eosinophilic colitis. Design: Case report and literature review. Patients: To analyze 3 cases in last 12 months. Results: Case 1: female, 40y, abdominal pain and diarrhea. CT: right colon involvement. Endoscopy: unspecific colitis. Positive Biopsy and negative parasitologic exam. Case 2: female, 26y, severe diarrhea, dehidratation. Positive parasitologic exam. Treatment with metronidazole without reponse. Endoscopy: mild pancolitis with positive biopsy. Treatment with steroids is instaured. Case 3: female, 33y, diarrhea and tenesmus, lost of weight. Upper endoscopy normal, lower endoscopy: cecal inflamation with positive biopsy. Negative parasitologic exam. All patients presented elevated blood eosinophilia and the biopsy were taken from right colon. Conclusions: Symptomatic treatment should be instituted with several drugs according to literature, steroids seems to be the better choice, but with secondary effects. Differential diagnosis should be done always, principally with Crohn’s disease. Current allergic exposition plus environment contamination could represent the physiopathology in some of these cases.

Diagnostic evaluation of patients presenting with bleeding per rectum by colonoscopy

Rectal bleeding is a manifestation of lower gastrointestinal bleed, which means bleeding from a site distal to ligament of Treitz. Annual incidence of this problem has been estimated to be 20% and mortality as 11%. Patients complaining of haematochezia are suspected of having lower GI bleeding and proctosigmoidoscopy followed by colonoscopy is the examination of choice for diagnosis and treatment. Previous evidence suggested that in our country, frequencies of different aetiologies of lower GI bleed are different from the West. This study validated the previous findings. The Objective of this study was to determine the causes of rectal bleeding in adult patients at Military Hospital, Rawalpindi. One hundred and five adult patients with visible rectal bleed, irrespective of their gender were selected by non-probability convenient sampling from general medical OPD and general medical wards. Patients with suspected upper GI source of bleeding; haemorrhoidal bleed and acute infectious diarrhoea were excluded from the study. All patients were subjected to fibre-optic colonoscopy after necessary preparation and findings were recorded. Biopsies taken from suspected lesions were clinically indicated. Diagnosis was based on colonoscopic and histopathologic findings. A total of 105 patients [77 male and 28 female] with mean age 41.04 yrs were part of the study. Colonoscopy showed abnormal findings in 85 [84%] patients. The commonest diagnosis was ulcerative colitis, which was found in 48 [46%] patients. It was followed by colorectal carcinoma, 11 [10%] patients, and non-specific colitis, 9 [8%] patients. Other less frequent findings were colonic diverticuli, 7 [6%] patients, solitary rectal ulcer, 5 [4%] patients, colonic polyps in 3 [2.5%] patients and one case each of telangiectasia and Crohn's disease. Colonoscopy has very high diagnostic yield and would be recommended in the workup of patients presenting with bleeding per rectum. Ulcerative colitis was the leading cause of bleeding per rectum in this study; while infrequent findings of Crohn's disease, polyps and diverticuli indicate that these are uncommon in this region

Hemorrhagic Colitis due to Escherichia coli O157 Infection in a Patient with Takayasu's Arteritis / 대한소화기학회지

Escherichia coli (E coli) O157 may cause abdominal pain and diarrhea followed by hematochezia. Most of cases resolve spontaneously after several days. Takayasu's arteritis affects medium- and large-sized arteries, aortic arch and its branch, and rarely affects inferior mesenteric artery. In case of Takayasu's arteritis with hematochezia, we must distinguish among ulcerative colitis, ischemic colitis, and infectious colitis with Takayasu's arteritis. We report a case of 17-year-old woman who suffered from hemorrhagic colitis by E. coli O157, and combined with leg claudication and abdominal pain by Takayasu's arteritis that affected abdominal aorta and inferior mesenteric artery. Sigmoidoscopy showed edematous, hyperemic mucosa and superficial ulcerations in the sigmoid colon. Abdominal CT scan showed diffuse submucosal edema, narrowing of distal abdominal aorta and inferior mesenteric artery. Hematochezia disappeared after the conservative treatment and leg claudication and abdominal pain disappeared after the aortic angioplasty.

Cytomegaloviral colitis in HIV positive patients: endoscopic findings / Colite por citomegalovírus em pacientes HIV positivo: aspectos endoscópicos

BACKGROUND: Diarrhea in seropositive human immunodeficiency virus patients is one of the most important and disabling symptoms, and often decreases their quality of life. Cytomegalovirus colitis is among the principal causes of this symptom and colonoscopy is the gold standard examination to diagnose it. AIM: To define the main endoscopic findings in seropositive human immunodeficiency virus patients with cytomegalovirus colitis. METHODS: Two hundred and forty-three colonoscopies were performed in 200 seropositive human immunodeficiency virus patients with diarrhea associated or not to abdominal pain or gastrointestinal bleeding, over 10-year period, whom 51 patients were diagnosed with cytomegalovirus colitis. Full length colonoscopy with ileum intubation was always tried and multiple biopsies of all segments examined, including endoscopically normal segments, were attempted. All diagnoses were confirmed by histologic and immunohistochemical studies. RESULTS: Total colonoscopy was possible in 98.03 percent and ileum intubation in 88.23 percent of these cytomegalovirus colitis patients. At colonoscopy, a heterogeneous ulcerative pattern was presented in 72.54 percent, an inflammatory process of the mucosa in 21.56 percent and 5.88 percent of the patients mucosa was endoscopically normal. CONCLUSION: Full length colonoscopy with ileum intubation and multiples biopsies of all segments, even when they are endoscopically normal, have always to be attempted in cases of seropositive human immunodeficiency virus patient with diarrhea.

RACIONAL: Diarréia em pacientes soropositivos para o vírus da imunodeficiência adquirida é um dos sintomas mais importantes e debilitantes e freqüentemente reduz sua qualidade de vida. Colite por citomegalovírus está entre as principais causas desse sintoma e a colonoscopia é o exame padrão-ouro para seu diagnóstico. OBJETIVO: Definir os principais achados endoscópicos em pacientes HIV+ com colite por citomegalovírus. MÉTODO: Duzentas e quarenta e três colonoscopias foram realizadas em 200 pacientes HIV+ com diarréia associada ou não à dor abdominal ou sangramento gastrointestinal, em período de 10 anos, dos quais 51 pacientes foram diagnosticados com colite por citomegalovírus. Colonoscopia total com entubação ileal foi sempre tentada e múltiplas biopsias de todos os segmentos, incluindo segmentos endoscopicamente normais, foram realizadas. Todos os resultados foram confirmados por estudos histológicos e imunoistoquímicos. RESULTADOS: A colonoscopia total foi possível em 98,03 por cento e entubação ileal em 88,23 por cento dos pacientes com colite por citomegalovírus. Nestes pacientes, identificou-se padrão ulcerativo heterogêneo em 72,54 por cento, processo inflamatório da mucosa em 21,56 por cento e mucosa de aspecto normal em 5,93 por cento das colonoscopias. CONCLUSÃO: Podemos concluir que colonoscopia total com entubação ileal com múltiplas biopsias de todos os segmentos, mesmo quando são endoscopicamente normais, têm que ser sempre realizadas em casos de pacientes HIV+ com diarréia.