Necrosis esofágica aguda (esófago negro) asociado a neoplasias digestivas / Acute esophageal necrosis (black esophagus) associated with digestive neoplasms

INTRODUCCIÓN. La necrosis esofágica aguda es un síndrome raro que se caracteriza endoscópicamente por una apariencia negra circunferencial irregular o difusa de la mucosa esofágica intratorácica, la afectación es generalmente del esófago distal y la transición abrupta de mucosa normal en la unión gastroesofágica, con extensión proximal variable. CASOS. Se presentan dos casos con diferentes comorbiliades, presentación de signos y síntomas, antecedentes y tratamiento, teniendo en común el diagnóstico a través de endoscopía digestiva alta. RESULTADOS. Caso clínico 1: tratamiento clínico basado en hidratación, suspensión de vía oral, omeprazol intravenoso y sucralfato; mala evolución clínica caracterizada por: disfagia, intolerancia oral y recurrencia del sangrado digestivo alto, se realiza colocación de gastrostomía endoscópica. Caso clínico 2: esófago con mucosa con fibrina y parches de necrosis extensa, se realiza compensación tanto de foco infeccioso pulmonar como hidratación y nutrición, en estudios complementarios se observa masa colónica, con estudio histopatológico confirmatorio de adenocarcinoma de colon en estado avanzado. DISCUSIÓN. La esofagitis necrotizante aguda es una entidad inusual, de baja prevalencia e incidencia, asociada con estados de hipoperfusión sistémica y múltiples comorbilidades que favorezcan un sustrato isquémico. Al revisar los reportes de casos que hay en la literatura médica, los casos que reportamos se correlaciona con las características clínicas, epidemiológicas, endoscópicas y factores de riesgo causales de la enfermedad. La presentación clínica más frecuente es el sangrado digestivo alto, que se debe correlacionar con el hallazgo endoscópico clásico. Nuestro primer caso reportado termina con la colocación de una gastrostomía para poder alimentarse. CONCLUSIÓN. El pronóstico de la necrosis esofágica aguda es malo y se requiere un alto índice de sospecha clínica y conocimiento de esta infrecuente patología para un diagnóstico temprano y un manejo oportuno. Se requiere una evaluación por endoscopia digestiva alta. Es una causa de sangrado gastrointestinal que conlleva tasas altas de mortalidad, principalmente en adultos mayores frágiles. El reconocimiento temprano y la reanimación agresiva son los principios fundamentales para un mejor resultado de la enfermedad.

INTRODUCTION. Acute esophageal necrosis is a rare syndrome that is characterized endoscopically by an irregular or diffuse circumferential black appearance of the intrathoracic esophageal mucosa, the involvement is generally of the distal esophagus and the abrupt transition of normal mucosa at the gastroesophageal junction, with variable proximal extension. CASES. Two cases are presented with different comorbidities, presentation of signs and symptoms, history and treatment, having in common the diagnosis through upper gastrointestinal endoscopy. RESULTS. Clinical case 1: clinical treatment based on hydration, oral suspension, intravenous omeprazole and sucralfate; poor clinical evolution characterized by: dysphagia, oral intolerance and recurrence of upper digestive bleeding, endoscopic gastrostomy placement was performed. Clinical case 2: esophagus with mucosa with fibrin and patches of extensive necrosis, compensation of both the pulmonary infectious focus and hydration and nutrition is performed, in complementary studies a colonic mass is observed, with a confirmatory histopathological study of colon adenocarcinoma in an advanced state. DISCUSSION. Acute necrotizing esophagitis is an unusual entity, with low prevalence and incidence, associated with states of systemic hypoperfusion and multiple comorbidities that favor an ischemic substrate. When reviewing the case reports in the medical literature, the cases we report correlate with the clinical, epidemiological, endoscopic characteristics and causal risk factors of the disease. The most common clinical presentation is upper gastrointestinal bleeding, which must be correlated with the classic endoscopic finding. Our first reported case ends with the placement of a gastrostomy to be able to feed. CONCLUSION. The prognosis of acute esophageal necrosis is poor and a high index of clinical suspicion and knowledge of this rare pathology is required for early diagnosis and timely management. Evaluation by upper gastrointestinal endoscopy is required. It is a cause of gastrointestinal bleeding that carries high mortality rates, mainly in frail older adults. Early recognition and aggressive resuscitation are the fundamental principles for a better outcome of the disease.

Avaliação da expressão da filagrina em biópsias esofágicas de pacientes com esofagite eosinofílica / Evaluation of philagrin expression in esophageal biopsies of patients with eosinophilic esophagitis

Introdução: Mutações do gene da filagrina vêm sendo associadas, classicamente, a alterações da barreira epitelial em doenças alérgicas com comprometimento da pele e das superfícies mucosas. Particularmente na dermatite atópica, a relação entre filagrina, mecanismo fisiopatológico e evolução clínica tem sido demonstrada. Recentemente, alterações da barreira epitelial com redução da expressão da filagrina, também têm sido associadas a mecanismos imunológicos envolvidos na patogênese da esofagite eosinofílica. Devido a disfunções na barreira epitelial, microrganismos e alérgenos são capazes de penetrarem no epitélio da mucosa esofágica, assim como na dermatite atópica. Objetivo: Avaliar a possível correlação da expressão da filagrina com os achados histopatológicos em biópsias esofágicas de pacientes com esofagite eosinofílica. Métodos: A expressão da filagrina foi investigada in situ, por imuno-histoquímica, em biópsias esofágicas nos seguintes grupos: Grupo I, controle (n=8), amostras provenientes de pacientes saudáveis; Grupo II (n=27), amostras provenientes de pacientes com esofagite eosinofílica. Resultados: Os resultados demonstraram uma diminuição da expressão da filagrina na mucosa do esôfago de portadores de esofagite eosinofílica. Adicionalmente, a intensidade da marcação imuno-histoquímica foi menor na mucosa esofágica com maior infiltração de eosinófilos. Conclusão: A diminuição da expressão de filagrina pode ser um fenomeno fisiopatológico associado ao aumento da quantidade de eosinófilos na mucosa esofágica, podendo impactar na evolução clínica da esofagite eosinofílica.

Introduction:Filaggrin gene mutations have been classically associated with changes in the epithelial barrier in allergic diseases involving the skin and mucosal surfaces. Particularly in atopic dermatitis, the relationship between filaggrin, pathophysiological mechanism and clinical evolution hás been demonstrated. Recently, changes in the epithelial barrier with reduced expression of filaggrin have also been associated with immunological mechanisms involved in the pathogenesis of eosinophilic esophagitis. Due to dysfunction in the epithelial barrier, microorganisms and allergens are able to penetrate the epithelium of the esophageal mucosa, as well as in atopic dermatitis. Objective: To evaluated the possible correlation of filaggrin expression with histopathological findings in esophageal biopsies of patients with eosinophilic esophagitis. Methods: Filaggrin expression was investigated in situ by immunohistochemistry in esophageal biopsies in the following groups: Group I, control (n = 8), samples from healthy patients; Group II (n = 27), samples from patients with eosinophilic esophagitis. Results: The results demonstrated a decrease in the expression of filaggrin in the esophageal mucosa of patients with eosinophilic esophagitis. Additionally, the intensity of the immunohistochemical labeling was lower in the esophageal mucosa with greater infiltration of eosinophils. Conclusion: The reduction of filaggrin expression may be a pathophysiological phenomenon associated with an increase in the quantity of eosinophils in the esophageal mucosa, which may impact on the clinical evolution of eosinophilic esophagitis.

Penfigoide de las mucosas a lo largo de los años en nuestro Servicio / Mucous membrane pemphigoid through the years in our Department

Introducción: el penfigoide de las mucosas (PM), antes llamado mucoso, cicatrizal o mucosinequiante, representa un grupo heterogéneo de enfermedades ampollares autoinmunes inflamatorias crónicas que comprometen las mucosas o la piel, con tendencia a dejar secuelas cicatrizales. Existen autoanticuerpos contra distintos componentes de la zona de la membrana basal (BPAG1, BPAG2, integrina α6ß4, laminina 332, colágeno VII, entre otros), por lo que la inmunofluorescencia directa (IFD) es de suma importancia, así como la clínica, para su diagnóstico.Objetivo: realizar una revisión de los casos de PM diagnosticados durante un período de 24 años (enero de 1997- marzo de 2021) en el Sector de Enfermedades Ampollares del Hospital Ramos Mejía para determinar la epidemiología, la clínica y la terapéutica de esta enfermedad.Diseño: estudio retrospectivo descriptivo y observacional, en el que se analizaron las características clínicas e inmunopatológicas de 34 pacientes con diagnóstico de PM atendidos en el Servicio de Dermatología del Hospital Ramos Mejía desde enero de 1997 hasta marzo de 2021. Materiales y métodos: mediante las historias clínicas y los regis-tros iconográficos, se evaluaron las siguientes variables: prevalencia del diagnóstico de PM en los pacientes atendidos en el Sector, sexo, edad, antecedentes personales, mucosas afectadas, tiempo de evolución hasta el diagnóstico, hallazgos en la IFD, seguimiento clínico y tratamientos instaurados. Resultados: se estudió la evolución clínica de 34 pacientes diagnosticados con PM (5,3% del total de pacientes evaluados en el Sector de Patologías Ampollares). El sexo más afectado fue el femenino y la edad promedio en el momento del diagnóstico fue de 64 años. El 70,6% de los pacientes presentaron comorbilidades asociadas como hipertensión e hipotiroidismo. La mayoría refirió algún evento emocional como factor desencadenante. El sitio más comprometido fue la mucosa ocular y la cavidad oral fue la segunda en frecuencia. El tiempo de evolución promedio hasta el momento del diagnóstico fue de 4 años y 11 meses. El hallazgo más frecuente en la IFD fue la IgG lineal. El 17,6% de los pacientes interrumpieron el seguimiento clínico. El tratamiento más utilizado fue el mofetil micofenolato, con el que se obtuvo buena respuesta terapéutica. Conclusiones: el PM es una enfermedad autoinmune infrecuente que compromete las mucosas y, ocasionalmente, la piel. En este estudio, se observó que la principal mucosa afectada fue la conjuntival, a diferencia de lo referido en la bibliografía internacional dermatológica. El diagnóstico interdisciplinario temprano es fundamental para evitar las secuelas irreversibles.

Introduction: mucous membrane pemphigoid (MMP), also known as benign mucous membrane pemphigoid, cicatricial or mucosynechial pemphigoid, belongs to an heterogeneous group of chronic inflammatory autoimmune blistering diseases, which involves the mucous membranes (oral, ocular, pharyngeal, nasal, esophageal, laryngeal and anogenital) and/ or skin with tendency to scar formation. There are autoantibodies against different components of the basement membrane zone (BPAG 1- BPAG2, Integrin α6ß4, Laminin 332, Col VII, among others). The direct immunofluorescence (DIF) will be of paramount importance, as well as the clinical diagnosis.Objective: review the cases diagnosed with mucous membrane pemphigoid for 24 years (January 1997- March 2021) in the Blistering Disease Clinic at the Dermatology Department at the Ramos Mejia Hospital to establish the epidemiologic, clinic presentation and available treatments in this pathology.Design: retrospective descriptive and observational study of the clinical and immunopathological characteristics of 34 patients with MMP that were treated at the Blistering Disease Clinic at the Dermatology Department at the Ramos Mejia Hospital between January 1997 and March 2021.Materials and methods: though the medical histories and the photographic registries, we evaluated the following variables: prevalence of MMP within the patients that came to consult at the Blistering Disease Clinic at the Dermatology Department, sex, age, personal history, the affected mucous, evolution time until the diagnosis, direct immunofluorescence findings, clinical follow-ups and treatments.Results: we studied the clinical evolution of 34 patients diagnosed with MMP at our institution (5.3% from the total of patients at the Blistering Disease Clinic).The most affected gender was female and the average age at diagnosis was 64 years. 70.6% presented comorbidities such as hypertension and hypothyroidism. Most of our patients referred an emotional triggering event. The most affected membrane mucous was the ocular one and the oral was the second one. The delay in diagnosis was 4 years and 11 months. Linear deposits of IgG was the most frequent result in the direct immunofluorescence. 17.6% did not continue clinical follow-up. Mycophenolate mofetil was the most used drug with a good therapeutic response. Conclusions: MMP is a rare autoimmune disease that affects mucous membrane and occasionally the skin. In this study, the ocular involvement was the most frequent one, differing with the international reports. The early interdisciplinary diagnosis is essential to avoid irreversible sequelae.

The role of biologics in eosinophilic esophagitis / O papel dos imunobiológicos na esofagite eosinofílica

Eosinophilic esophagitis (EoE) is a chronic inflammation in the esophageal mucosa driven by an antigen-mediated abnormal immune response with apparent increasing prevalence worldwide. Genetically predisposed individuals present with a dysfunctional esophageal barrier and an abnormal immune response mediated by Th2 and IgE against certain allergens. Consequently, esophageal lesions can cause dysmotility, fibrosis and loss of esophageal barrier function. Clinical manifestations are age-related and include symptoms of esophageal dysfunction. Diagnosis is established by specific histological features associated with the presence of at least 15 eosinophils per high-power field. Management of EoE includes control of allergic diseases with diet restrictions and/or pharmacological treatment with proton-pump inhibitors and corticosteroids, not completely effective and limited by possible side effects and impairment of quality of life. Although immunological mechanisms of EoE are still less clear than other allergic diseases, biologic trials indicate some promising perspectives for EoE management. The purpose of this review is to present the current evidence of biologic drugs as options for EoE treatment.

Esofagite eosinofílica (EOE) é uma inflamação crônica da mucosa esofágica com resposta imune antígeno-mediada anormal e com aparente aumento mundial na prevalência. Indivíduos geneticamente predispostos se apresentam com quadro de disfunção da barreira esofágica e uma resposta imune, mediada por TH2 e IGE, anormal contra certos alérgenos. Consequentemente, lesões esofágicas podem causar dismotilidade, fibrose e perda da função de barreira. O quadro clínico apresenta variação conforme idade e inclui sintomas de disfunção esofágica. O diagnóstico é estabelecido por achados histológicos específicos associados à presença de, ao menos, 15 eosinófilos por campo de alta potência. O manejo inclui controle do quadro alérgico com restrição dietética e/ou tratamento medicamentoso com bloqueadores da bomba de prótons e corticosteroides. São tratamentos sem completa efetividade, com efeitos colaterais e prejuízo na qualidade de vida. Ainda que os mecanismos imunológicos da EOE sejam menos claros que as demais doenças alérgicas, novos ensaios com imunobiológicos salientam uma perspectiva promissora de tratamento para a EOE. O objetivo desta revisão é apresentar as atuais evidências de uso de imunobiológicos como uma nova opção de terapêutica para a esofagite eosinofílica.

Dermatomyositis with exfoliation of esophageal mucosa: A case report / 中南大学学报(医学版)

Dermatomyositis (DM) is a kind of idiopathic inflammatory myopathy characterized by chronic proximal skeletal muscle weakness and unique skin lesions. However, DM with exfoliation of esophageal mucosa is rare. A 36-year-old male patient complained of muscular soreness of extremities, dysphagia, and pharyngalgia was diagnosed with DM with exfoliation of esophageal mucosa. After treatment with glucocorticoid, immunosuppressant, acupuncture, and endoscopic submucosal dissection (ESD), the above symptoms were disappeared. During the 3-year follow-up period, the results of routine physical examination, laboratory examination, gastroscopy, and imaging examination were normal. High-dose of corticosteroid is needed in the initial treatment, but it must be reduced regularly to avoid adverse reactions. Acupuncture and ESD are also effective as adjuvant therapy.

Coincidencia de hallazgos endoscópicos e histológicos en el diagnóstico de esófago de Barrett / Coincidence of endoscopic and histological findings in the diagnosis of Barrett's esophagus

Introducción: el esófago de Barrett es una alteración en la cual la mucosa esofágica se transforma desde un epitelio escamoso a un epitelio columnar con metaplasia intestinal. Endoscópicamente esta lesión se corresponde con la presencia de una mucosa columnar de color rojo salmón por encima de la unión gatroesofágica. Para su diagnóstico se requiere de la sospecha endoscópica y la confirmación histológica. Objetivo: determinar los niveles de coincidencia entre los diagnósticos endoscópicos y las características histopatológicas del esófago de Barrett, a partir del análisis de una serie de casos. Métodos: se realizó un estudio retrospectivo, en el Hospital Clínico Quirúrgico "Joaquín Albarrán" de La Habana, Cuba entre enero de 2017 a junio de 2019, obteniéndose los datos de los registros de biopsias e historias clínicas. Se realizaron cálculos de frecuencias absolutas y relativas y, para evaluar la fuerza de coincidencia entre endoscopia e histología, se utilizó el estadístico Chi cuadrado. Resultados: en los 67 casos con diagnóstico endoscópico la coincidencia con histopatológica fue del 44,8%, en el restante 55,2% de los pacientes las lesiones diagnosticadas fue esofagitis crónica (p = 0,005). Conclusiones: el esófago de Barrett es una de las entidades clínicas con una epidemiología de alta variabilidad y su diagnóstico endos-cópicos requiere de la confirmación histológica ya que existe una baja coincidencia entre el diagnóstico endoscópico e histopatológico del EB el cual es el estándar de oro para el diagnóstico de EB.

Background: Barrett's oesophagus is an alteration in which the oesophagal mucosa is transformed from squamous epithelium to co-lumnar epithelium with intestinal metaplasia. Endoscopically this lesion corresponds to the presence of a salmon-red columnar mucosa above the gastroesophageal junction. For its diagnosis, endoscopic suspicion and histological confirmation are required.Objective: To determine the levels of coincidence between the endoscopic diagnoses and the histopathological characteristics of Barrett's oesophagus, from the analysis of a series of cases. Methods: A retrospective study was carried out at the "Joaquín Albarrán" Surgical Cli-nical Hospital in Havana, Cuba, between January 2017 and June 2019, obtaining data from biopsy records and medical records. Absolute and relative frequency calculations were performed and, to evaluate the force of coincidence between endoscopy and histology, the Chi-square statistic was used. Results: In the 67 cases with endoscopic diagnosis, the coincidence with histopathology was 44.8%, in the remaining 55.2% of the patients the lesions diagnosed were chronic esophagitis (p = 0.005). Conclusions: Barrett's oesophagus is one of the clinical entities with the epidemiology of high variability, and its endoscopic diagnosis requires histological confirmation since there is a low coincidence between the endoscopic and histopathological diagnosis of EB which is the gold standard for EB diagnosis.

L-arginine-induced esophagitis, report of six cases / Reporte de seis casos de esofagitis inducida por L-arginina

Abstract Background: Drug-induced esophagitis is an uncommon diagnosis in the pediatric population. The following is a report of six adolescents with L-arginine-induced esophagitis. Case reports: All patients were under treatment with L-arginine for short stature. After using the prescribed medication for 1-3 months, all cases started with severe retrosternal pain, odynophagia, and dysphagia. The upper gastrointestinal endoscopies showed ulcers located in the mid esophageal mucosa. Conclusions: In the presence of acute severe odynophagia, dysphagia, and retrosternal pain, drug-induced esophagitis should be considered as a possible diagnosis. Treatment includes liquid diet, pain control, sucralfate, omeprazole, and interruption of L-arginine. In addition, the physician should explain preventive measures focused on patient and family education on the drug side effects and precise instructions on how to take medications, as well as a careful balance of risk and benefits of any medication. At present, there are no clinical trials that support the use of L-arginine in treatment of short stature.

Resumen Introducción: La esofagitis inducida por medicamentos es un diagnóstico poco frecuente en pacientes pediátricos. A continuación, se describe una serie de seis casos de pacientes menores de 15 años con esofagitis inducida por L-arginina. Casos clínicos: Los seis casos se encontraban en tratamiento con L-arginina por talla baja e iniciaron con dolor retroesternal, odinofagia y disfagia de rápida instalación. Cuatro de ellos acudieron al servicio de urgencias por la intensidad de los síntomas. Los hallazgos en la endoscopia del tubo digestivo alto fueron úlceras en la mucosa del esófago a la altura del tercio medio, zona de estrechez natural por la compresión del bronquio izquierdo. Conclusiones: En presencia de odinofagia, disfagia, dolor retroesternal y el antecedente de la ingesta de L-arginina, la esofagitis inducida por fármacos debe considerarse como una posibilidad diagnóstica. El tratamiento está basado en el manejo del dolor, sucralfato, omeprazol, así como la suspensión del medicamento y medidas preventivas centradas en la educación del paciente y los familiares sobre los riesgos y beneficios de un medicamento y la forma correcta de administrarlo.

Esofagite eosinofílica numa consulta de alergia alimentar: caracterização e comparação entre idade pediátrica e idade adulta / Eosinophilic esophagitis at a food allergy appointment: characterization and comparison between pediatric and adult ages

Introdução: Esofagite eosinofílica (EoE) é uma doença inflamatória crônica do esôfago, mediada imunologicamente e caracterizada por sintomas relacionados com disfunção esofágica e infiltração da mucosa esofágica por eosinófilos (Eo). Os objetivos foram caracterizar os doentes com diagnóstico de EoE e analisar as diferenças entre doentes com diagnóstico em idade pediátrica (Cr, < 18 anos) e adulta (Ad, ≥ 18 anos). Métodos: Estudo observacional retrospetivo dos doentes seguidos no serviço de Imunoalergologia, no período de Fev/2009 a Jul/2017, com diagnóstico de EoE. Foram divididos em dois grupos, Cr e Ad, caracterizados de acordo com dados demográficos, história de atopia, sintomas, sensibilizações alimentares, IgE Total, eosinofilia, achados na endoscopia digestiva alta e biópsias. Avaliou-se a correlação entre sensibilização alimentar, clínica grave (ClinG), ou seja, idas ao serviço de urgência ou internamento por complicações de EoE ou histologia grave (HistG), biópsia com Eo > 50 e/ou microabcessos. Resultados: 74 pacientes (81% sexo masculino, média de idades 27±17 anos), 36 Cr e 38 Ad. Os sintomas mais frequentemente reportados foram, no grupo Cr disfagia (73%) e refluxo gastroesofágico (46%), enquanto no grupo Ad impactação (85%) e disfagia (56%). Foram referidos antecedentes de atopia em 96% das Cr, e 67% dos Ad. Em 77% das Cr e 69% dos Ad havia sensibilização alimentar. Os achados endoscópicos mais frequentes no grupo Cr foram estriação (65%) e placas brancas (50%), enquanto que no grupo Ad foram placas brancas (42%) e anéis esofágicos (35%). HistG (46%) associou-se a ClinG (35%), p = 0,001, nas Cr, mas o mesmo não foi objetivado no grupo Ad [ClinG (22%) e HistG (17%), p = 0,5]. Conclusão: Os nossos resultados estão de acordo com o descrito na literatura, observando-se um predomínio do sexo masculino e uma maior frequência de história de atopia e sensibilização alimentar no grupo Cr. As situações graves de impactação e estenose esofágica foram mais frequentes nos Ad, e objetivou-se uma associação de histologia grave com clínica grave, apenas nas Cr.

Background: Eosinophilic esophagitis (EoE) is an immunologically mediated chronic inflammatory disease of the esophagus characterized by symptoms related to esophageal dysfunction and eosinophilic infiltration in the esophageal mucosa. This study aimed to characterize patients with a diagnosis of EoE and analyze differences between patients with EoE diagnosed at pediatric age (Ch, <18 years) and at adult age (Ad, ≥18 years). Methods: This was a retrospective study of patients with a diagnosis of EoE who were followed in the immunoallergology department from February 2009 to July 2017. Patients were divided into Ch and Ad groups and characterized according to demographic data, history of atopy, symptoms, food sensitization, total IgE, eosinophils (Eo), upper digestive endoscopy (UDE) findings, and biopsy findings. Correlations were assessed between food sensitization, clinical severity (SClin; determined by number of ER visits or hospital admissions for EoE complications), and severe histology (SHist; defined as biopsy with Eo >50 and/or microabscesses). Results: 74 patients (81% male, mean age 27±17 years), 36 Ch and 38 Ad. The most commonly reported symptoms were dysphagia (73%) and gastroesophageal reflux (46%) in the Ch group, and impaction (85%) and dysphagia (56%) in the Ad group. History of atopy was reported in 96% of Ch vs 67% of Ad. Food sensitization was found in 77% of Ch vs 69% of Ad. The most common UDE findings were striation (65%) and white plaques (50%) in the Ch group, and white plaques (42%) and esophageal rings (35%) in the Ad group. SHist (46%) was associated with SClin (35%) in Ch (p=0.001), but not in Ad (SClin [22%] and SHist [17%], p=0.5). Conclusion: Our results are consistent with those reported in the literature, with a male predominance and a higher prevalence of atopy and food sensitization in Ch. Severe impaction and esophageal stenosis were more frequent in Ad, but an association between SHist and SClin was found only in Ch.

Utilização da cromoendoscopia com azul de toluidina mais solução de Lugol para diagnóstico precoce de lesões pré-malignas esofágicas e neoplasias superficiais em pacientes de alto risco / Chromoendoscopy using toluidine blue plus lugol's solution for early diagnosis of esophageal premalignant lesions and superficial neoplasms in high-risk patients

ABSTRACT BACKGROUND: Esophageal cancer is the eighth most common cancer. The prognosis is bleak in patients with advanced stages. Patients with early disease have a better prognosis than those with advanced stage. There are several techniques for the screening of premalignant and superficial lesions including chromoendoscopy. OBJECTIVE: This article aimed to determine the effectiveness of chromoendoscopy with toluidine blue combined with Lugol's solution for diagnosis of esophageal premalignant and superficial neoplastic lesions in high risk patients. METHODS: Routine white light upper endoscopy was performed. Toluidine blue was sprayed from the gastroesophageal junction to 20 cm of the dental arch. Then the uptake dye areas were characterized. Later Lugol's solution was sprayed. Areas with less-intense staining were characterized. Biopsy of the toluidine blue capturing areas and areas with less-intense staining of Lugol's solution were taken. In the cases where lesions were not evidenced after application of dyes, biopsies four quadrants of the esophageal mucosa were taken. The samples were evaluated by a digestive pathologist. RESULTS: Barrett's esophagus was the most common premalignant lesion and the early neoplastic lesion was adenocarcinoma with a sensitivity of 100%, specificity 85.7%, positive predictive value 30%, negative predictive value 100%, positive likelihood ratio 7 negative likelihood ratio 0. CONCLUSION: Chromoendoscopy with toluidine blue combined with Lugol's solution is a useful tool in the screening of esophageal premalignant lesions and superficial neoplasms.

RESUMO CONTEXTO: O câncer de esôfago é o oitavo câncer mais comum. O prognóstico é sombrio em pacientes com estágios avançados. Pacientes com doença precoce têm um melhor prognóstico do que aqueles com estágio avançado. Existem várias técnicas para a triagem de lesões pré-malignas e superficiais, incluindo cromoendoscopia. OBJETIVO: Este artigo objetivou determinar a efetividade da cromoendoscopia com azul de toluidina combinada com a solução de Lugol para o diagnóstico de lesões neoplásicas pré-malignas e superficiais esofágicas em pacientes de alto risco. MÉTODOS - A endoscopia de luz branca de rotina foi realizada de forma rotineira. O azul do toluidina foi pulverizado desde a junção gastroesofágica até 20 cm da arcada dentária. As áreas impregnadas pela tintura da tomada foram então caracterizadas. Mais adiante a solução de Lugol foi pulverizada. Áreas com coloração menos intensa foram caracterizadas. Foram realizadas biópsias das áreas de captura de azul de toluidina e áreas com coloração menos intensa da solução de Lugol. Nos casos onde as lesões não foram evidenciadas após a aplicação das tinturas, foram feitas biópsias em quatro quadrantes da mucosa esofágica. As amostras foram avaliadas por um patologista especializado. RESULTADOS: O esôfago de Barrett foi a lesão pré-maligna mais frequente e a lesão neoplásica precoce foi adenocarcinoma com sensibilidade de 100%, especificidade de 85,7%, valor preditivo positivo de 30%, valor preditivo negativo 100%, razão de verossimilhança positiva 7 e razão de verossimilhança negativa 0. CONCLUSÃO: A cromoendoscopia com azul de toluidina combinada com a solução de Lugol é uma ferramenta útil na triagem de lesões pré-malignas esofágicas e neoplasias superficiais.

Disección endoscópica de submucosa en el tratamiento del cáncer precoz de esófago / Endoscopic submucosal dissection in the treatment of early esophageal cancer

Las nuevas tecnologías de imagen con endoscopios de alta resolución y el uso de la cromoscopia asociado al entrenamiento de los endoscopistas han permitido detectar lesiones neoplásicas de esófago en estadios iniciales. Estos avances resultaron en la expansión de las indicaciones del tratamiento endoscópico curativo en pacientes con carcinoma de células escamosas de esófago. En los últimos años se han desarrollado técnicas para la resección endoluminal en bloque de los tumores gastrointestinales precoces, procedimiento denominado disección endoscópica de la submucosa (DES). Inicialmente la DES fue utilizada para tratamiento de tumores gástricos, y posteriormente esta técnica pasó a ser aplicada para tumores de esófago y colorectales. El presente artículo de revisión presenta una descripción de la DES en el manejo de las neoplasias superficiales de esófago, a fin de contribuir para la difusión de este concepto y la incorporación de este procedimiento en Latinoamérica.

The development of high-resolution endoscopes with chromoendoscopy and the education of endoscopists have enabled the detection of early stage esophageal squamous-cell carcinoma (ESCC). Moreover, in recent years there has been an important progress in the management of early gastrointestinal neoplastic lesions after the development in Japan of endoluminal techniques for en-block tumor resection, namely endoscopic submucosal dissection (ESD). The combination of these factors facilitated the expansion of indications for endoscopic minimally invasive curative interventions in selected patients with superficial ESCC. This review article presents a comprehensive overview and detailed description of the ESD procedure for treatment of ESCC in order to facilitate the dissemination of this concept and the incorporation of this new technique in Latin-America.