Seguridad de la endoscopia y biopsia esofágica en un paciente con esofagitis eosinofílica y enfermedad de Von Willebrand / Safety of esophageal endoscopy and biopsy in a patient with eosinophilic esophagitis and Von Willebrand disease

La esofagitis eosinofílica (EoE) es una enfermedad causada por una respuesta inmune frente a antígenos alimentarios en contacto con la mucosa esofágica; por su parte, la enfermedad de Von Willebrand (EVW) es el trastorno hemorrágico hereditario más común en los seres humanos. La característica central de todos los tipos de EVW, es la presencia de cantidades reducidas o de formas anormales del factor de Von Willebrand (FVW) en el torrente sanguíneo. Debido a que no se han reportado casos previos de EVW tipo 2A asociada a EoE, se describe este caso clínico con el objetivo principal de dar a conocer el hallazgo casual de estas dos patologías, la seguridad de la evaluación por endoscopia de vías digestivas altas y el pronóstico de posibles complicaciones

Eosinophilic esophagitis (EoE) is a disease caused by an immune response against food antigens in contact with the esophageal mucosa; alternatively, Von Willebrand disease (VWD) is the most common inherited bleeding disorder in humans. The central characteristic of all types of VWD is the presence of reduced amounts or abnormal forms of VWF in the bloodstream. Since no previous cases of VWD type 2A associated to EoE have been reported, this clinical case is described with the main objective to present the coincidental finding of these two pathologies, the safety of the evaluation by upper gastrointestinal endoscopy, and the prognosis of possible complications

Esophageal manometry in systemic sclerosis: findings and association with clinical manifestations

SUMMARY INTRODUCTION Systemic sclerosis (SSC) is an autoimmune disorder that affects several organs of unknown etiology, characterized by vascular damage and fibrosis of the skin and organs. Among the organs involved are the esophagus and the lung. OBJECTIVES To relate the profile of changes in esophageal electromanometry (EM), the profile of skin involvement, interstitial pneumopathy (ILD), and esophageal symptoms in SSC patients. METHODS This is an observational, cross-sectional study carried out at the SSC outpatient clinic of the Hospital de Clínicas of the Federal University of Uberlândia. After approval by the Ethics Committee and signed the terms of consent, 50 patients were initially enrolled, from 04/12/2014 to 06/25/2015. They were submitted to the usual investigations according to the clinical picture. The statistical analysis was descriptive in percentage, means, and standard deviation. The Chi-square test was used to evaluate the relationship between EM, high-resolution tomography, and esophageal symptoms. RESULTS 91.9% of the patients had some manometric alterations. 37.8% had involvement of the esophageal body and lower esophageal sphincter. 37.8% had ILD. 24.3% presented the diffuse form of SSC. No association was found between manometric changes and clinical manifestations (cutaneous, pulmonary, and gastrointestinal symptoms). CONCLUSION The present study confirms that esophageal motility alterations detected by EM are frequent in SSC patients, but may not be related to cutaneous extension involvement, the presence of ILD, or the gastrointestinal complaints of patients.

RESUMO INTRODUÇÃO A esclerose sistêmica (ES) é uma doença autoimune que afeta vários órgãos de etiologia desconhecida, caracterizada por dano vascular e fibrose da pele e órgãos. Entre os órgãos envolvidos estão o esôfago e o pulmão. OBJETIVOS Relacionar o perfil das alterações na eletromanometria (ME), o perfil de acometimento da pele, a pneumopatia intersticial (PI) e os sintomas esofágicos em pacientes com ES. MÉTODO Trata-se de um estudo observacional, transversal, realizado no ambulatório de SSC do Hospital das Clínicas da Universidade Federal de Uberlândia. Após aprovação pelo Comitê de Ética e assinatura dos termos de consentimento, 50 pacientes foram inicialmente convidados, de 04/12/2014 a 25/06/2015. Eles foram submetidos às investigações usuais de acordo com o quadro clínico. A análise estatística foi descritiva em porcentagem, média e desvio padrão. O teste Qui-quadrado foi utilizado para avaliar a relação entre ME, tomografia de alta resolução e sintomas esofágicos. RESULTADOS 91,9% dos pacientes apresentaram alterações manométricas. 37,8% tinham envolvimento do corpo esofágico e do esfíncter esofágico inferior. 37,8% tinham IP. 24,3% apresentaram a forma difusa da ES. Não há associação entre alterações manométricas e manifestações clínicas (sintomas cutâneos, pulmonares e gastrointestinais). CONCLUSÃO O presente estudo confirma que as alterações da motilidade esofágica detectadas pela EM são frequentes em pacientes com SSC, mas podem não estar relacionadas ao envolvimento cutâneo, à de DPI ou às queixas gastrointestinais dos pacientes.

Prevalencia, características endoscópicas y manejo de las lesiones subepiteliales del tracto gastrointestinal superior / Prevalence, endoscopic characteristics and management of subepitelial lesions of the upper gastrointestinal tract / Prevalência, características endoscópicas e manejo das lesões subepiteliais do trato gastrointestinal superior

Introducción: Las lesiones subepiteliales (LSE) son hallazgos incidentales en las endoscopias. Algunas tienen potencial maligno. Objetivos: Valorar la prevalencia, características endoscópicas y manejo diagnóstico/terapéutico de LSE en video-gastroscopias (VGC). Materiales y métodos: Se incluyeron todas las VGC del periodo enero 2011-junio 2018. Los casos con datos faltantes fueron excluidos. Donde se identificó una LSE se consignó: indicación, edad, sexo, tamaño, ubicación e histología, hallazgos de la ultrasonografía endoscópica (USE), punción-aspiración con aguja fina (PAAF) y resección quirúrgica. Resultados: Se evidenciaron 54 LSE en 7.983 pacientes (0,7 %). 72 % eran mujeres y la indicación más común fue dispepsia (26 %). La localización más frecuente fue en el estómago (74 %). El tamaño medio fue de 16 mm (5-50 mm) y la mitad fueron menores a 10 mm. Siete presentaban mucosa ulcerada, 4 se ubicaban en el cuerpo gástrico y 86 % eran referidos por hemorragia digestiva/anemia. En 26 casos de 54 (48 %) se realizaron biopsias estándar y en 6 de los 54 (11 %) biopsias sobre biopsias, con rendimiento diagnóstico nulo. En un 11 % de ellos se realizó USE, todas mayores de 10 mm: 2 páncreas ectópicos, una lesión compatible con leiomioma, 2 lesiones de la muscular propia (leiomioma/GIST) y 1 compresión extrínseca. No se realizó ninguna PAAF. Todas las LSE fueron manejadas de forma conservadora. Conclusiones: Este es el primer estudio nacional sobre prevalencia de LSE del tracto gastrointestinal superior y resultó comparable al de otras series. El rendimiento diagnóstico de la biopsia fue nulo. En la mayoría de los casos las lesiones se manejaron según las recomendaciones de las guías internacionales.

Introduction: Subepithelial lesions (SELs) are incidental findings in endoscopy procedures. Most are benign, but some have malignant potential. Objectives: To evaluate the prevalence, endoscopic characteristics and diagnostic / therapeutic management of SELs in upper GI endoscopy. Materials and methods: All upper GI endoscopy from January 2011 to June 2018 were included. Cases with missing data were excluded. Indication, age, sex, size, location and histology, findings of endoscopic ultrasound (EUS), fine needle aspiration (FNA) and surgical resection were recorded in patients with SELs. Results: There were 54 SELs in 7983 patients (0.7 %). 72 % were women, and the most frequent indication was dyspepsia (26 %). The most frequent location was stomach (74 %). The average size was 16 mm (5-50 mm), half were less than 10 mm. Seven had ulcerated mucosa, 4 were located in the gastric body and 86 % were referred for digestive hemorrhage/anemia. In 26 of 54 (48 %) standard biopsies and in 6 of 54 (11 %) bite-on-bite biopsy were performed, with no diagnostic yield. In 11 % of the cases EUS was performed, all of them larger than 10 mm: 2 ectopic pancreas, one lesion compatible with leiomyoma, 2 lesions of the muscularis propria (leiomyoma/GIST) and 1 extrinsic compression. No FNA was performed. All SELs were managed conservatively. Conclusions: This is the first national study of the prevalence of SELs in the upper gastrointestinal tract and was comparable to that of other series. Biopsy diagnostic yield was zero. In most cases, lesions were managed according to international guidelines.

Introdução: lesões subepiteliais (LSE) são achadas incidentais em endoscopias. A maioria são benignas, mas algumas têm potencial maligno. Objetivos: Avaliar a prevalência, características endoscópicas e manejo diagnóstico/terapêutico das LSE em vídeo-gastroscopias (VGC). Materiais e métodos: Foram incluídos todas VGC do período de janeiro de 2011 a junho de 2018. Foram excluídos os casos com dados ausentes. Quando uma LSE foi identificada, foram indagados: indicação, idade, sexo, tamanho, localização e histologia, achados da ultrassonografia endoscópica (USE), aspiração por agulha fina (PAAF) e ressecção cirúrgica. Resultados: 54 LSE foram evidenciadas em 7.983 pacientes (0,7 %). 72 % eram mulheres e a indicação mais freqüente foi dispepsia (26 %). A localização mais freqüente foi estômago (74 %). O tamanho médio era de 16 mm (5-50 mm), a metade era menor que 10 mm. Sete tinham mucosa ulcerada, quatro estavam localizadas no corpo gástrico e 86% foram referidos por sangramento/anemia gastrointestinal. Em 26 de 54 (48 %) foram realizadas biópsias padrão e em 6 de 54 (11 %) biópsias sobre biópsias, com um desempenho diagnóstico nulo. Em 11 %, foi realizado uma USE, todas maiores que 10 mm: 2 pâncreas ectópico , uma lesão compatível com leiomioma, 2 lesões musculares (leiomioma/GIST) e 1 compressão extrínseca. Não foi realizada nenhuma PAAF. Todas as LSE foram manejadas de forma conservadora. Conclusões: Este é o primeiro estudo nacional de prevalência de LSE no trato gastrointestinal superior e foi comparável ao de outras séries. O rendimento diagnóstico da biópsia foi nulo. Na maioria dos casos, as lesões foram tratadas de acordo com as recomendações das diretrizes internacionais.

Disfunção de múltiplos órgãos causada por corpo estranho no esôfago / Multiple organ dysfunction caused by a foreign body in the esophagus

RESUMO Apresentamos o caso de uma paciente de 71 anos de idade admitida à unidade de terapia intensiva clínica em condição de falência de múltiplos órgãos. Após o quarto dia, com aplicação de todas as modalidades de suporte à vida (estímulo com vasopressores, ventilação mecânica, terapia com diálise contínua, terapia com antibióticos de amplo espectro e outras medidas de suporte), dados inespecíficos fornecidos por acompanhante revelaram que a paciente vinha apresentando dificuldade persistente para deglutir líquidos e alimentos sólidos por alguns dias antes da admissão ao hospital. Após a realização de procedimentos adicionais de diagnóstico radiológico e endoscópico, detectou-se a presença de um corpo estranho no esôfago: um fragmento de fio de aço com cerca de 6 cm de comprimento e dobrado ao meio, que havia penetrado a parede do esôfago e se projetava ao nível da sétima vértebra cervical. Conseguimos remover o corpo estranho por via endoscópica sem maiores complicações e, a seguir, estabilizar nossa paciente, com utilização de medidas terapêuticas adicionais, conforme necessário.

ABSTRACT We present the case of a 71-year-old patient who was admitted to the medical intensive care unit in a state of multiple organ dysfunction. After the fourth day of applying all needed life-saving measures (vasopressor stimulation, mechanical ventilation, continuous dialysis treatment, broad spectrum antibiotic therapy, and other supportive measures), nonspecific heteroanamnestic data revealed that the patient had been having a persistent difficulty in swallowing liquids and food for a few days prior to hospital admission. After performing additional radiological and endoscopic diagnostic procedures, a foreign body was detected; a steel wire that had a length of approximately 6cm and was bent in a half had penetrated the esophagus and was projected into the seventh neckline. We managed to evacuate the foreign body endoscopically without further complications, and we stabilized our patient using additional therapeutic measures as needed.

Pharyngo-ileo-colo-anastomosis with micro-vascular blood supply augmentation for esophago-gastric replacement due to esophago-gastric necrosis after caustic ingestion / Faringo-íleo-colo-anastomose com suprimento sanguíneo microvascular para substituição esofagogástrica por necrose esofagogástrica após ingestão cáustica

ABSTRACT Background : Complete esophago-gastric necrosis after caustic ingestion is a challenging surgical scenario for reconstruction of the upper digestive transit. Aim : To present a surgical technique for reconstruction of the upper digestive tract after total esophagectomy and gastrectomy due to esophageal and gastric necrosis Method: The transit was re-established by means of a pharyngo-ileo-colic interposition with microsurgical arterial and venous anastomosis for augmentation of blood supply. Colo-duodeno-anastomosis and ileo-transverse colic anastomosis were performed for complete digestive transit reconstruction. Result: This procedure was applied in a case of 41 years male attempted suicide by ingesting alkali caustic liquid (concentrated sodium hydroxide). Total necrosis of the esophagus and stomach occurred, which required initially total esophago-gastrectomy, closure at the level of the crico-pharyngeal sphincter and jejunostomy for enteral feeding with a highly deteriorated quality of life . The procedure was performed later and there were no major early and late postoperative complications and normal nutritional conditions were re-stablished. Conclusion: The procedure is feasible and must be managed by multidisciplinary team in order to re-establish a normal quality of life.

RESUMO Racional: A necrose esofagogástrica completa após ingestão cáustica é um cenário cirúrgico desafiador para a reconstrução do trânsito digestivo alto. Objetivo: Apresentar uma técnica cirúrgica para reconstrução do trato digestivo superior após esofagectomia total e gastrectomia por necrose esofágica e gástrica. Método: O trânsito foi restabelecido por interposição faringo-íleo-cólica com anastomose arterial e venosa microcirúrgica com aumento do suprimento sanguíneo. Adicionalmente, anastomose colo-duodeno-anastomótica e íleo-transversa foram realizadas para reconstrução completa do trânsito digestivo. Resultado: Este procedimento foi aplicado em um homem de 41 anos com tentativa de suicídio pela ingestão de líquido cáustico alcalino (hidróxido de sódio concentrado). Ocorreu necrose total do esôfago e do estômago, o que exigiu inicialmente esofagogastrectomia total, fechamento ao nível do esfíncter cricofaríngeo e jejunostomia para alimentação enteral produzindo qualidade de vida altamente deteriorada. O procedimento foi realizado mais tardiamente e não houve maiores complicações pós-operatórias precoces e tardias e condições nutricionais normais foram restabelecidas. Conclusão: O procedimento é viável e deve ser manejado por equipe multidisciplinar a fim de restabelecer a qualidade de vida normal.

Rotinas e condutas em cirurgias para as doenças malignas e benignas do esôfago, estômago e duodeno / Preoperative care in surgeries for the malignant and benign diseases of oesophagus, stomach and duodenum

Resumo: As doenças que acometem o trato digestivo alto, mais precisamente o esôfago, estômago e duodeno revestem-se de grande importância não só devido à relevância epidemiológica (com incidências elevadas e crescentes), mas também pela intensidade dos sintomas e a gravidade das complicações, comprometendo de forma significativa a qualidade de vida dos seus portadores. Nas últimas décadas, os avanços nos cuidados a pacientes portadores de doenças benignas e malignas do aparelho digestivo superior se manifestaram por meio da introdução de novos métodos de diagnóstico e estadiamento, mudanças no paradigma das estratégias perioperatórias e desenvolvimento de novos procedimentos, técnicas e vias de acesso cirúrgicos; ampliando ainda mais o espectro de opções diagnósticas e terapêuticas. Diante do amplo acesso a uma quantidade imensa de informações provida pela medicina atual, o desenvolvimento de protocolos de cuidados pré- e pós-operatórios baseados em evidências, resulta em auxílio na tomada de decisão e certamente também contribui para melhoria dos resultados cirúrgicos. Pela complexidade associada, é imperativo que o seguimento destes pacientes seja realizado em serviços terciários, muitos dos quais também se constituem em hospitais de ensino, com participação contínua de profissionais em treinamento e aprendizado. O presente projeto objetiva à elaboração de manual de rotinas e condutas específicas para o tratamento cirúrgico das doenças malignas e benignas do esôfago, estômago e duodeno; fundamentado em evidências clínicas e com aplicação em hospital de nível terciário. No contexto de hospitais universitários, de ensino e de referência ¿ que contem com equipes médicas, de enfermagem e multidisciplinares, além do envolvimento de alunos e médicos residentes em treinamento ¿ a implementação de protocolos de assistência possui relevância ainda maior, visto que não apenas diferencia e favorece melhores resultados operatórios, menor morbimortalidade e maior sobrevida em geral, mas também uniformiza condutas facilitando o processo de aprendizagem(AU)

Abstract: The diseases that affect the upper digestive tract, the esophagus, stomach and duodenum, are of great importance not only due to the epidemiological relevance (with high and increasing incidence), but also the intensity of the symptoms and the severity of the complications, compromising patients quality of life. Lately, the advances in patients care with benign and malignant diseases of the upper digestive system have consisted in the introduction of new diagnostic methods, changes in the paradigm of perioperative strategies and the development of new procedures, techniques and surgical access; expanding the spectrum of diagnostic and therapeutic options. Given the broad access to a vast amount of information provided by current medicine, the development of pre-and post-operative guidelines based on evidence, results in better decision making and certainly also contributes to improved surgical outcomes. Because of the associated complexity, it is imperative that the follow-up of these patients be performed in tertiary services, many of which also constitute teaching hospitals, with continuous participation of professionals in training and learning. The present project aims the elaboration of a guideline of specific routines and procedures for the surgical treatment of malignant and benign diseases of the esophagus, stomach and duodenum; based on clinical evidence. In the context of university, teaching and reference hospitals - which includes medical, nursing and multidisciplinary teams, as well as the involvement of students and physicians in training - the implementation of assistance protocols will have even greater influence, since it not only favors better overall survival, but also facilitates the learning process(AU)

Esophageal aperistalsis in a patient with lipoid proteinosis

Lipoid proteinosis is a rare disorder with autosomal recessive inheritance, characterized by progressive deposition of hyaline material in the skin, mucous membrane, and different organs of the body, resulting in a multitude of clinical manifestations. A 34-year-old woman presented with hoarseness, dysphagia, eyelid beeding, and acneiform scars on the facial skin and extremities. The patient was diagnosed clinically as having lipoid proteinosis, which was confirmed by laryngeal biopsy. The objective of the present report is to describe this rare entity. This case report also illustrates that lipoid proteinosis may show protean clinical features and yet may remain undiagnosed for many years

Caracterização histopatológica da esofagite eosinofílica em crianças e adolescentes / Histological features of eosinophilic esophagitis in children and adolescents

ABSTRACT BACKGROUND: Eosinophilic esophagitis is an emerging disease featured by eosinophilic esophageal infiltrate not responsive to proton pump inhibitors. OBJECTIVE: To characterize histological features of children and adolescents with eosinophilic esophagitis. METHODS: Cross-sectional study in a tertiary hospital. Biopsies from each esophageal third from 14 patients (median age 7 years) with eosinophilic esophagitis were evaluated. Histological features evaluated included morphometry of esophageal epithelium, esophageal density (per high power field), extracellular eosinophilic granules, eosinophilic microabscesses, surface disposition of eosinophils, epithelial desquamation, peripapillary eosinophilia, basal layer hyperplasia and papillary elongation. RESULTS: Several patients presented a normal esophageal macroscopy in the upper digestive endoscopy (6, 42.8%), and the most common abnormality were vertical lines (7, 50%) and whitish spots over esophageal mucosa (7, 50%). Basal layer hyperplasia was observed in 88.8%, 100% e 80% of biopsies from proximal, middle and lower esophagus, respectively (P=0.22). Esophageal density ranges from 0 to more than 50 per hpf. Extracellular eosinophilic granules (70%-100%), surface disposition of eosinophils (60%-93%), epithelial desquamation (60%-100%), peripapillary eosinophilia (70%-80%) were common, but evenly distributed among each esophageal third. Just one patient did not present eosinophils in the lower third, four in the middle third and four in the upper esophageal third. CONCLUSION: In the absence of hypereosinophilia, other histological features are present in eosinophilic esophagitis and may contribute to diagnosis. Eosinophilic infiltrate is focal, therefore multiple biopsies are needed for diagnosis.

RESUMO CONTEXTO: Esofagite eosinofílica é uma doença emergente caracterizada por infiltrado eosinofílico esofágico não responsivo a inibidores de bomba de prótons. OBJETIVO: Caracterizar os achados histopatológicos de uma coorte de crianças e adolescentes com diagnóstico de esofagite eosinofílica. MÉTODOS: Estudo transversal conduzido em hospital terciário. Biópsias de terços proximal, médio e distal de 14 pacientes (idade mediana 7 anos) com diagnóstico de esofagite eosinofílica. Estudo morfométrico e variáveis histológicas analisadas em fragmentos de biópsias nos terços esofágicos: contagem de eosinófilos/CGA, grânulos eosinofílicos extracelulares, microabscessos eosinofílicos, disposição superficial de eosinófilos, descamação epitelial, eosinofilia peripapilar, hiperplasia da camada basal e alongamento de papilas. RESULTADOS: Vários pacientes apresentaram aspecto macroscópico normal da mucosa esofágica à endoscopia (6, 42.8%), e a anormalidade mais comumente observada foi linhas verticais (7, 50%) e exsudato branco (7, 50%). Hiperplasia da camada basal foi observada em 88,8%, 100% e 80% das biópsias do terço proximal, médio e distal respectivamente (P=0,22); contagem de eosinófilos nos terços variou de 0 a ≥50/CGA, grânulos eosinofílicos extracelulares (70%-100%), disposição superficial de eosinófilos (60%-93%), descamação epitelial (60%-100%), eosinofilia peripapilar (70%-80%), sem diferença estatística entre os terços esofágicos. Ausência de eosinofilia ocorreu raramente em terço distal (uma do distal, quatro do proximal, quatro do médio). CONCLUSÃO: Na ausência de hipereosinofilia, outros achados histopatológicos de inflamação eosinofílica estão presentes. A infiltração eosinofílica apresentou caráter focal, sugerindo-se a realização de múltiplas biópsias de diversos segmentos.

Rol del manejo dietario y farmacológico en la esofagitis eosinofílica / Diet and pharmacological treatment in eosinophilic esophagitis

Eosinophilic esophagitis is an inflammation of the esophagus, causing dysfunction and fibrosis. Dysphagia or food impaction are common symptoms, that do not respond to proton pump inhibitors. Initial management must include an evaluation for food allergies .Emerging data in adults suggest that the elimination of six types of food from the diet can improve symptoms and esophageal eosinophilia. Pharmacological therapy should start with topical use of fluticasone, if lack of response is observed; budesonide is a good next step. The combination of steroids with proton pump inhibitors is reasonable if reflux is suspected to be contributing to symptoms. Further research will be necessary to find the best combination of tailored diets, proton pump inhibitors and steroids to achieve better control of the disease.

La esofagitis eosinofílica es una inflamación del esófago que causa disfunción y fibrosis. La presencia de disfagia o impactación alimentaria son síntomas comunes que no responden al uso de inhibidores de bomba de protones. El manejo inicial debe incluir una evaluación para alergias alimentarias. Datos emergentes en adultos sugieren que una dieta con eliminación de seis alimentos puede mejorar los síntomas y la eosinofilia esofágica. El tratamiento farmacológico debería comenzar con fluticasona tópica; si hay falta de respuesta a esta opción un paso siguiente adecuado es la budesonida. La combinación de esteroides con inhibidores de la bomba de protones es razonable si se sospecha que el reflujo contribuye a la sintomatología. Se requiere conocimiento adicional para encontrar la mejor combinación de dietas individualizadas, esteroides e inhibidores de bomba de protones para conseguir el mejor control de la enfermedad.

Concordancia de hallazgos endoscópicos e histológicos en pacientes con esófago de Barrett / Concordance of endoscopic and histological findings in patients with Barrett's esophagus

Introducción: se denomina esófago de Barrett(EB) a la sustitución del epitelio esofágico escamoso normal de la zona distal, por un epitelio columnar, confirmado mediante la evaluación histológica con la presencia de células caliciformes que indican la presencia de una metaplasia intestinal especializada, constituyendo un desencadenante del desarrollo de adenocarcinoma esofágico. Existe discrepancia entre la interpretación de los hallazgos endoscópicos e histológicos, debido a que se presentan resultados dispares en operadores dependientes. Si bien el riesgo de progresión a malignidad es bajo,se debe establecer criterios adecuados de vigilancia para un manejo eficiente costo-efectivo.Objetivo: determinar la concordancia existente entre los hallazgos endoscópicos e histológicos en pacientes con EB que acudieron al Servicio de Endoscopía Digestiva del Hospital Central del Instituto de Previsión Social (Asunción, Paraguay)del 2012 al 2014. Materiales y Métodos: estudio observacional descriptivo, retrospectivo, de corte transversal. Se revisaron expedientes clínicos de pacientes. Resultados: se tenía sospecha de EB en 1,54% (265/17.207) de los pacientes, en quienes fueron tomadas muestras de biopsias durante la realización de endoscopía digestiva alta. Hubo confirmación histológica en 32,08% (85/265) de los casos, siendo hallada displasia en 16,47% (14/85), correspondiendo la totalidad a displasia de bajo grado. Por tanto, del total de pacientes la frecuencia de EB fue 0,49% (85/17.207). Conclusión: existe una escasa concordancia entre los hallazgos endoscópicos e histológicos de EB. Es una entidad de baja frecuencia en nuestro medio. No fue encontrado ningún caso que conlleve riesgo significativo de malignidad.

Introduction: Barrett's esophagus(BE) is called to the replacement of normal epithelial squamous esophagic epithelium by columnar epithelium in the distalend, confirmed by histological evaluation with the presence of goblet cells indicating the presence of specialized intestinal metaplasia, constituting a trigger for the development of esophageal adenocarcinoma. There is a discrepancy between the endoscopic interpretation and histological findings, due to the similar results between dependent operators. Although the risk of progression to malignancy is low, it should be establishedadecuate criteria for efficient monitoring and low cost. Objetive: To determine the relation between the endoscopic and histological findings in patients with Barrett's esophagus who were attended the Esophagogastroduodenos copy in the service ofthe Central Hospital of the Social Security, from 2012 to 2014. Materials and Methods: A descriptive, retrospective, observational cross-sectional study;patients clinical records were reviewed. Results: It was suspected to have BE 1.54% (265 / 17,207) of patients in whom biopsies were taken during upper gastrointestinal endoscopy. There were histologically confirmed in 32.08% (85/265) of cases, dysplasia were found in 16.47% (14/85), bring all of them low-grade dysplasia. Therefore, the total frequency of EB patients was 0.49% (85/17,207). Conclusion: There is a low correlation between the endoscopic and histological findings of BE. It is an entity of low frequency in our media. It was not found any case that involves significant risk of malignancy.

Proton Pump Inhibitor-responsive Esophageal Eosinophilia: An Overview of Cases from One University Hospital Center / 대한소화기학회지

BACKGROUND/AIMS: Eosinophilic esophagitis (EoE) is a chronic, immune/antigen-mediated esophageal disease, with eosinophilic infiltration limited to the esophagus. A minority of EoE patients respond well to proton pump inhibitor (PPI) therapy alone, and that condition is labelled PPI-responsive esophageal eosinophilia (PPI-REE). The prevalence of PPI-REE among EoE cases is unknown. We aimed to identify clinical manifestations of PPI-REE, and the proportion of PPI-REE among all EoE cases. METHODS: We reviewed pathology of the 4,075 patients who underwent esophageal biopsy at an institution from March 2003 to July 2015. EoE was diagnosed based on esophageal symptoms and eosinophilic infiltration limited to the esophagus, with ≥15 eosinophils per high-power field. We collected endoscopic and pathologic findings, and clinical features for these patients. RESULTS: Thirteen (0.3%) patients were diagnosed with EoE. Clinical manifestations were dysphagia (30.8%), foreign body sensation (23.1%), regurgitation (23.1%), cough (15.4%), heartburn (15.4%), nausea (7.7%), dyspepsia (7.7%). The endoscopic findings noted were polypoid lesion (23.1%), whitish plaque or exudate (23.1%), linear furrow (7.7%), concentric ring (7.7%), nodularity (7.7%), erosion (7.7%), and normal (30.8%). Of these patients, five had a favorable course with PPI as monotherapy. CONCLUSIONS: The proportion of EoE among all patients undergoing endoscopic biopsy was 0.3%. Of those, PPI-REE comprised 38%. Most of the endoscopic findings were atypical or normal when compared to the typical findings in EoE. In conclusion, patients who present with symptoms related to esophageal dysfunction need esophageal biopsy, regardless of the endoscopic findings. Moreover, patients diagnosed with EoE need to be treated first with PPI alone.

Clinicopathologic Analysis of Proton Pump Inhibitor-Responsive Esophageal Eosinophilia in Korean Patients

BACKGROUND/AIMS: Proton pump inhibitor-responsive esophageal eosinophilia (PPI-REE) is a newly recognized form of eosinophilic esophagitis (EoE) that responds to PPI therapy. It remains unclear whether PPI-REE represents a subphenotype of gastroesophageal reflux disease, a subphenotype of EoE, or its own distinct entity. The aim was to evaluate the clinicopathologic features of PPI-REE. METHODS: Six patients were diagnosed with PPI-REE based on symptoms, endoscopic abnormalities, esophageal eosinophilia with > or =15 eosinophils/high-power field, and a response to PPI treatment. Symptoms and endoscopic and pathological findings were evaluated. RESULTS: The median follow-up duration was 12 months. Presenting symptoms included dysphagia, heartburn, chest pain, foreign body sensation, acid reflux, and sore throat. All patients had typical endoscopic findings of EoE such as esophageal rings, linear furrows, nodularity, and whitish plaques. Three patients had a concomitant allergic disorder, and one had reflux esophagitis. Four patients exhibited elevated serum IgE, and five had positive skin prick tests. All patients experienced symptomatic resolution within 4 weeks and histologic resolution within 8 weeks after starting PPI therapy. There was no symptomatic recurrence. CONCLUSIONS: PPI therapy induced rapid resolution of symptoms and eosinophil counts in patients with PPI-REE. Large-scale studies with long-term follow-up are warranted.

Effect of the celexoxib in microscopic changes of the esophageal mucosal of rats induced by esofagojejunostomy / Efeito do celecoxibe nas alterações microscópicas da mucosa esofágica de ratos causadas por esofagojejunostomia

OBJECTIVE: To evaluate the protective effect of celecoxib in the esophageal mucosa in rats undergoing esofagojejunostomy. METHODS: Sixty male Wistar rats from the vivarium of the University of Health Sciences of Alagoas were used for the experiment. The animals were divided into four groups: Group I, 15 rats undergoing esofagojejunostomy with the use of celecoxib postoperatively; Group II, 15 rats undergoing esofagojejunostomy without the use of celecoxib; Group III, 15 rats undergoing celiotomy with bowel manipulation; and Group IV, 15 rats without surgery and using celecoxib. The observation period was 90 days. After the death of the animals, the distal segment of the esophagus was resected and sent for microscopic analysis. RESULTS: esofagojejunostomy caused macroscopic and microscopic esophagitis. Esophagitis was equal in both groups I and II. In groups III and IV esophageal lesions were not developed. CONCLUSIONS: celecoxib had neither protective nor inducing effect on esophagitis, but had a protective effect on dysplasia of the animals of group I. .

OBJETIVO: avaliar o efeito do celecoxibe como função protetora na mucosa esofágica, em ratos machos Wistar, submetidos à esofagojejunostomia. MÉTODOS: sessenta animais oriundos do biotério da Universidade de Ciências da Saúde de Alagoas foram utilizados para o experimento. Os animais foram distribuídos em quatro grupos: Grupo I, 15 ratos que foram submetidos à esofagojejustomia e que utilizaram o celecoxibe no pós-operatório, Grupo II, 15 ratos submetidos à esofagojejunostomia sem uso de celecoxibe, Grupo III, 15 ratos submetidos à celiotomia com manipulação de alças, e Grupo IV, 15 ratos sem cirurgia e que utilizaram celecoxibe. O período de observação foi de 90 dias. Após a morte dos animais, o seguimento distal do esôfago foi ressecado e enviado para análise macro e microscópicas. RESULTADOS: a esofagojejunostomia causou esofagite macro e microscópica. A esofagite foi igual tanto no grupo I quanto no II. Nos animais dos grupos III e IV não foram desenvolvidas lesões esofagianas. CONCLUSÕES: o celecoxibe não teve efeito protetor nem indutor nas esofagites, mas obteve efeito protetor nas displasias dos animais do grupo I. .

Esôfago negro: relato de 2 casos / Black esophagus: report of two cases

Esôfago negro, também descrito como necrose esofágica aguda, é definido pelo aspecto enegrecido do esôfago observado à endoscopia digestiva alta. A condição é rara, está presente em pacientes gravemente comprometidos, e habitualmente se manifesta por hemorragia digestiva alta. Os principais fatores de risco envolvidos incluem doença cardiovascular, diabetes mellitus, desnutrição, cirrose hepática e insuficiência renal. Apresenta alta morbidade e mortalidade. Relatamos dois casos de esôfago negro associados à cirrose hepática.

Black esophagus, also described as acute esophageal necrosis is defined by blackish aspect of the esophagus seen at endoscopy. The condition is rare, is present in patients severely compromised, and usually manifests as upper gastrointestinal bleeding. The main risk factors involved include cardiovascular disease, diabetes mellitus, malnutrition, liver cirrhosis, e renal failure. It has high morbidity and mortality. We describe two cases of black esophagus associated with liver cirrhosis.

Myenteric plexus is differentially affected by infection with distinct Trypanosoma cruzi strains in Beagle dogs

Chagasic megaoesophagus and megacolon are characterised by motor abnormalities related to enteric nervous system lesions and their development seems to be related to geographic distribution of distinct Trypanosoma cruzi subpopulations. Beagle dogs were infected with Y or Berenice-78 (Be-78) T. cruzi strains and necropsied during the acute or chronic phase of experimental disease for post mortem histopathological evaluation of the oesophagus and colon. Both strains infected the oesophagus and colon and caused an inflammatory response during the acute phase. In the chronic phase, inflammatory process was observed exclusively in the Be-78 infected animals, possibly due to a parasitism persistent only in this group. Myenteric denervation occurred during the acute phase of infection for both strains, but persisted chronically only in Be-78 infected animals. Glial cell involvement occurred earlier in animals infected with the Y strain, while animals infected with the Be-78 strain showed reduced glial fibrillary acidic protein immunoreactive area of enteric glial cells in the chronic phase. These results suggest that although both strains cause lesions in the digestive tract, the Y strain is associated with early control of the lesion, while the Be-78 strain results in progressive gut lesions in this model.

Transthoracic repair of diaphragmatic hiatus hernia with esophageal shortening where laparoscopic abdominal approach does not give satisfactory results.

A 50 year old female patient presented with history of regurgitation of food, heart burn, dyspepsia. Patient was investigated and presence of large hiatus hernia was confirmed on endoscopy, computed tomogram chest and barium swallow. Patient had severe symptoms even with maximum medical management, therefore surgical intervention was planned. Left posterolateral thoracotomy was done through sixth intercostal space. Mobilization of esophagus, reduction of stomach and Belsey Mark IV 270 degree anterolateral fundoplication was done. Patient was discharged on 7th postoperative day. First follow up was I month after the discharge and patient had significant relief from the preoperative problems.

An Overview of Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immune/antigen-mediated esophageal disease affecting both children and adults. The condition is characterized by an eosinophilic infiltration of the esophageal epithelium. Symptoms of esophageal dysfunction include dysphagia, food impaction and symptoms mimicking gastroesophageal reflux disease. Endoscopic examination typically reveals mucosal fragility, ring or corrugated mucosa, longitudinal furrows, whitish plaques or a small caliber esophagus. Histologic findings of >15 eosinophils per high-power field is the diagnostic hallmark of EoE. An elimination diet, topical corticosteroids or endoscopic dilation for fibrostenotic disease serve as effective therapeutic option.

Resultados de la esofaguectomía en 53 pacientes con adenocarcinoma del esófago y Barrett extenso / Results of esophagectomy among patients with esophageal cancer and Barrett esophagus

Background: The incidence of esophageal carcinoma has increased notoriously worldwide. Aim: To assess clinical features, immediate surgical results and long term survival of patients with esophageal carcinoma and Barrett esophagus. Material and Methods: Retrospective review of medical records of all patients operated for esophageal carcinoma, between 1996 y 2011. Results: The records of 53 patients aged 58 +/- 9 years (45 males) were analyzed. The number of operated patients increased from 7 in the period 1968-1983 to 31 in the period 2004-2011. Peritoneal metastases were found in two patients, precluding a resection. Video assisted trans-hiatal approach was the most commonly used technique followed by minimally invasive thoracoscopic and laparoscopic surgery. Transit reconstruction was performed ascending the stomach to the neck in 90 percent of patients. The average length of Barrett esophagus was 7.4 cm and the mean number of excised lymph nodes was 19. Ten patients had an incipient cancer and their five years survival was 80 percent. The survival of those with tumors involving the muscular layer and those with transmural cancer was 25 and 5 percent, respectively. Conclusions: There is an increase in the incidence of esophageal cancer in the last 10 years. The survival after surgery is highly dependent on the invasiveness of the tumor.

Introducción: El adenocarcinoma esofágico es el tumor que ha experimentado el mayor aumento en su incidencia a nivel mundial. Objetivo: Determinar las características clínicas, los resultados inmediatos de la cirugía empleada y la sobrevida a largo plazo. Material y Método: Es un estudio retrospectivo y descriptivo incluyendo a todos los pacientes con adenocarcinoma de esófago entre 1996 y 2011. Se analizó la morbi-mortalidad operatoria y la sobrevida a 5 años. Resultados: Se aprecia un aumento de 10 veces su frecuencia comparada con 40 años atrás. Hay un claro predominio del sexo masculino de 6:1. Dos pacientes no se pudieron resecar por la presencia de metástasis peritoneales. El abordaje principal fue una técnica transhiatal video asistida, seguida de abordaje mini-invasivo toracoscópico y laparoscópico. La reconstitución del tránsito gastrointestinal fue en un 90 por ciento con estómago ascendido hasta el cuello. La morbilidad más frecuente fue la fístula cervical y la mortalidad de 5,7 por ciento. El largo promedio del esófago de Barrett fue de 7,4 cm y el promedio de linfonodos resecados fue de 19. Hubo 10 pacientes con adenocarcinoma incipiente, cuya sobrevida a 5 años fue de 80 por ciento, muy superior al cáncer muscular con sobrevida 25 por ciento y al cáncer transmural con sobrevida de 5 por ciento (p < 0,01). Conclusiones: Se aprecia un enorme aumento del adenocarcinoma esofágico en los últimos 10 años. El abordaje actual que parece ser muy promisorio es la técnica mini-invasiva. La sobrevida a 5 años depende de la profundidad de la infiltración tumoral.

Primary achalasia with pneumoesophagus and bronchopleural fistula causing right lung collapse and bronchiectasis.

A 35-year-old male non-smoker, presented with a history of recurrent respiratory tract infections, associated with intermittent haemoptysis and haematemesis since childhood. His vital parameters were normal with pulse oximetry saturation of 97% on room air. On physical examination, clubbing was observed. Chest auscultation revealed tubular type of bronchial breath sounds over the right hemithorax.