Erosive esophagitis secondary to radiotherapy: Case report / Esofagitis erosiva secundaria a radioterapia: reporte de un caso

Abstract Introduction: Erosive esophagitis secondary to radiotherapy is an unusual complication in the oncological treatment of thoracic tumors. This pathological entity is associated with multiple complications, which is a clinical challenge for health workers unfamiliar with the clinical manifestations. Clinical case: A 64-year-old woman with a 3-day clinical picture of chest pain radiating to the epigastrium with 10/10 intensity. On physical examination, she was tachycardic, hypotensive, and with intense pain in the upper hemiabdomen region; she had no signs of peritoneal irritation on deep palpation. Paraclinical tests showed no signs of local or disseminated infection, but endoscopy of the digestive tract reported post-radiation esophagitis. Discussion: Erosive esophagitis after radiotherapy occurs in less than 1 % of cases, and clinical manifestations such as dysphagia, odynophagia, and abdominal pain are common. Initial symptomatic management is preserved, with supportive measures such as intravenous hydration and proton pump inhibitors (PPIs). In case of intolerance to the oral route, therapy with nutritional support is indicated via nasogastric tube or gastrostomy in the most severe cases.

Resumen Introducción: la esofagitis erosiva secundaria a la radioterapia es una complicación inusual del tratamiento oncológico de los tumores torácicos. Esta entidad patológica está asociada con múltiples complicaciones, lo que resulta un reto clínico para los profesionales en salud que están poco familiarizados con las manifestaciones clínicas. Caso clínico: mujer de 64 años con cuadro clínico de 3 días de dolor torácico irradiado al epigastrio con intensidad 10/10. En el examen físico se encontró taquicárdica, hipotensa, con dolor intenso en la región hemiabdominal superior; a la palpación profunda no tenía signos de irritación peritoneal. Los paraclínicos no mostraron signos de infección local o diseminada, pero la endoscopia de vías digestivas reportó esofagitis posirradiación. Discusión: la esofagitis erosiva posterior a la radioterapia se presenta en menos del 1 % de los casos, las manifestaciones clínicas como disfagia, odinofagia y dolor abdominal son frecuentes; el manejo sintomático inicial es conservado, con medidas de soporte como hidratación intravenosa e inhibidores de la bomba de protones (IBP). En caso de intolerancia a la vía oral se indica terapia con soporte nutricional por sonda nasogástrica o gastrostomía en los casos más graves.

Isolation and characterization of the aerobic bacterial microbiota of the esophagus and its probable association with obstructive caseous lesions in green turtles (Chelonia mydas) / Isolamento e caracterização da microbiota bacteriana aeróbia do esôfago e sua provável associação com lesões caseosas obstrutivas em tartarugas-verdes (Chelonia mydas)

Caseous lesions in the esophagus of green turtles (Chelonia mydas) from the coast of Brazil have been described as obstructive lesions and can lead to the death of these animals. However, their etiology remains unclear. The aim of this study was to isolate and characterize the aerobic bacterial microbiota of the esophagus of green turtles (C. mydas) from the Brazilian coast and to verify its possible participation in the etiology of caseous lesions. For this, 42 animals were used, 33 alive and healthy and 9 naturally dead that had esophageal lesions confirmed by necropsy, from Anchieta and Piúma beaches, Espírito Santo. Microbiological tests and morphological evaluation of the esophagus were performed. We isolated 14 different bacterial agents from healthy animal samples, with the prevalence of Pseudomonas aeruginosa being (36.36%), Staphylococcus aureus (33.33%), Aeromonas hydrophila (27.27%), and Vibrio alginolyticus (24.24%). In dead animals, only three distinct agents were isolated: S. aureus (50.00%), A. hydrophila (25.00%), and V. alginolyticus (25.00%). Morphological evaluation revealed a predominance of the lesions at the gastroesophageal junction, with multifocal-to-coalescent distribution, discrete intensity, and absence of obstruction. Ulcerations and caseous exudates, inflammatory infiltrates, parasitic eggs, and giant foreign body cells were also observed as well as bacterial lumps and glandular alterations, such as necrosis, adenitis, and fragments of adult parasites. There was a positive correlation between bacterial lumps and microbiological culture and a negative correlation between bacterial lumps and microbiological culture with parasites. Thus, it was noted that the esophageal aerobic microbiota of C. mydas was predominantly composed of Gram-negative bacteria such as P. aeruginosa, A. hydrophila, and V. alginolyticus, in addition to several enterobacteria and Gram-positive bacteria, such as S. aureus. These agents are opportunists and may be involved in the etiology of caseous esophagitis in association with other pathogens as co-factors working in association or, even in a secondary way.(AU)

A ocorrência de lesão caseosa no esôfago de tartarugas-verdes (Chelonia mydas) da costa do Brasil tem sido descrita como de caráter obstrutivo e pode causar a morte dos animais. No entanto, sua etiologia permanece pouco esclarecida. Objetivou-se isolar e caracterizar a microbiota aeróbica esofágica das tartarugas-verdes (C. mydas) da costa brasileira e verificar sua possível participação na etiologia das lesões caseosas. Foram utilizados 42 animais, 33 vivos e hígidos e nove mortos naturalmente que apresentavam lesão esofágica confirmada pela necropsia, provenientes de Anchieta e Piúma, Espírito Santo, nos quais foram feitos testes microbiológicos e avaliação morfológica do esôfago. Foram isolados 14 agentes bacterianos diferentes nas amostras de animais saudáveis, com prevalência de Pseudomonas aeruginosa (36,36%), Staphylococcus aureus (33,33%), Aeromonas hydrophila (27,27%) e Vibrio alginolyticus (24,24%). Nos animais mortos, foram isolados apenas três agentes distintos: S. aureus (50,00%), A. hydrophila (25,00%) e V. alginolyticus (25,00%). A avaliação morfológica revelou predominância da lesão em junção gastroesofágica, com distribuição multifocal a coalescente, intensidade discreta e ausência de obstrução. Observou-se ainda ulceração e exsudato caseoso, infiltrado inflamatório, ovos de parasitos e células gigantes do tipo corpo estranho, além de grumos bacterianos e de alterações glandulares, como necrose, adenite e fragmentos de parasitos adultos. Houve correlação positiva dos grumos bacterianos com cultivo microbiológico e negativa dos grumos bacterianos e cultivo microbiológico com parasitos. Assim, nota-se que a microbiota esofágica aeróbica de C. mydas é constituída predominantemente por bactérias Gram-negativas como P. aeruginosa, A. hydrophila e V. alginolyticus, além de diversas enterobatérias e por Gram-positivas, como S. aureus. Esses agentes são oportunistas e podem estar envolvidos na etiologia da esofagite caseosa em associação a outros patógenos como co-fatores agindo em associação, ou mesmo, por via de infecção secundária.(AU)

Guía de práctica clínica Ibero-Latinoamericana sobre la esofagitis cáustica en Pediatría: fisiopatología y diagnóstico clínico-endoscópico (1a Parte) / Ibero-latinamerican clinical practical guidelines on pediatric caustic esophagitis: physiopathology and clinical-endoscopic diagnosis (1st Part)

Resumen: La ingestión de cáusticos representa un grave problema médico-social por las consecuencias devastadoras e irreversibles que puede producir en el tracto digestivo superior. En Iberoamérica no se han publicado datos fidedignos sobre la incidencia o la prevalencia de lesiones inducidas por cáusticos. La información disponible sobre la presentación clínica, diagnóstico, tratamiento y pronóstico se basa en series retrospectivas de casos y, de hecho, su manejo clínico se sustenta en muchos casos fundamentalmente en la opinión de expertos. Recientemente como una iniciativa de la Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición Pediátrica (SLAGHNP) y con la co laboración de colegas de la Sociedad Española de Gastroenterología, Hepatología y Nutrición Pediá trica (SEGHNP), hemos diseñado una Guía de Práctica Clínica (GPC) la cual incluye una serie de enunciados y recomendaciones dirigidos a optimizar la atención a los pacientes y que se basan en la revisión sistemática de la evidencia. En dos (2) manuscritos sucesivos nos hemos enfocado primero, en los aspectos fisiopatológicos y de diagnóstico clínico-endoscópico de la esofagitis cáustica en niños (1a. Parte) y en segundo lugar, en los aspectos más relevantes del tratamiento (2a. Parte). Esperamos esta guía se convierta en una herramienta útil para el clínico en el difícil proceso de toma de decisio nes a la hora de evaluar un paciente posterior a la ingesta de una sustancia cáustica.

Abstract: Caustic ingestion represents a serious social-medical problem due to the devastating and irreversible consequences it can produce in the upper digestive tract. In Ibero-America, there are no published reliable data on the incidence or prevalence of caustic-induced injuries, and most of the available information on clinical presentation, diagnosis, treatment, and prognosis is based on retrospective clinical series and, indeed, its clinical management is often based primarily on expert opinion. Re cently as an initiative of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) and with the cooperation of the Spanish Society for Pediatric Gastroente rology, Hepatology and Nutrition (SEGHNP), we have designed a Clinical Practice Guideline that include a series of statements and recommendations aimed at optimizing patient medical care which is based on the systematic review of evidence. Two (2) successive papers focused on the evaluation of physiopathological and clinical-endoscopic diagnostic features of caustic esophagitis in children (1st. Paper) and, on the other hand, the most relevant therapeutic considerations (2nd. Paper). We expect this guideline to become a useful tool for the physician in the difficult decision-making process when assessing patients after caustic ingestion.

Actinomicosis esofágica en pacientes con infección por VIH / Esophageal actinomycosis in patients with HIV infection

La patología esofágica es común en pacientes con VIH, frecuentemente debido a Candida, citomegalovirus o virus herpes simple. Sin embargo, la actinomicosis esofágica es una infección rara, incluso en pacientes con infección VIH. Reportamos el caso en un paciente varón de 33 años, con diagnóstico reciente de VIH que acudió a consulta por fiebre, odinofagia, disfagia y dolor retroesternal. La endoscopia digestiva alta evidenció múltiples úlceras esofágicas y el informe histopatológico de la biopsia esofágica describió una esofagitis crónica con presencia de colonias de bacilos PAS positivos, compatibles con Actinomyces, iniciando tratamiento antimicrobiano con evolución favorable. Aunque es una enfermedad no común, cerca de un tercio de los casos de actinomicosis esofágica se presentan en pacientes con infección VIH, y es preciso el estudio endoscópico con toma de biopsia para definir el diagnóstico y manejo apropiado.

Esophageal pathology is common in patients with HIV, frequently due to Candida, cytomegalovirus or herpes virus. However, esophageal actinomycosis is a rare infection, even in patients with HIV. We report the case of a 33-year-old male patient, with a recent diagnosis of HIV who was admitted for fever, odynophagia, dysphagia and retrosternal pain. Upper gastrointestinal endoscopy evidenced multiple esophageal ulcers and the histopathological report of the esophageal biopsy described a chronic esophagitis with colonies of PAS positive bacilli, compatible with Actinomyces, initiating favorable antimicrobial therapy. Although it is an uncommon disease, about one-third of cases of esophageal actinomycosis occur in patients with HIV infection, and endoscopic biopsies are required to define diagnosis and appropriate treatment.

Consecuencias clínicas posgastrectomía vertical tubular: enfermedad por reflujo gastroesofágico / Clinical consequences post tubular vertical gastrectomy: gastroesophageal reflux disease

Varias publicaciones informan un aumento en la tasa de enfermedad por reflujo gastroesofágico (ERGE) después de la gastrectomía vertical tubular (GVT) o en manga a pesar que no existe aún consenso al respecto. El objetivo de este artículo es mostrar nuestra propia experiencia y de la literatura respecto a los aspectos clínicos de la enfermedad por ERGE después de la gastrectomía vertical tubular. Del análisis de nuestros resultados y de los datos de la literatura, los estudios que evalúan la prevalencia de la enfermedad de reflujo gastroesofágico posoperatorio muestran que la GVT puede provocar síntomas de ERGE de novo o empeoramiento de la ERGE preexistente.

Several publications report an increase in the rate of gastroesophageal reflux disease (GERD) after surgery, although there is still no consensus on this. The aim of this article is to show our own experience and literature regarding the clinical aspects of GERD disease after tubular vertical gastrectomy. From the analysis of our results and data from the literature, studies evaluating the prevalence of postoperative gastro-oesophageal reflux disease show that GVT can cause symptoms of de novo GERD or worsening of pre-existing GERD.

ENDOSCOPIC CHANGES RELATED TO GASTROESOPHAGEAL REFLUX DISEASE: COMPARATIVE STUDY AMONG BARIATRIC SURGERY PATIENTS / ALTERAÇÕES ENDOSCÓPICAS RELACIONADAS À DOENÇA DO REFLUXO GASTROESOFÁGICO: ESTUDO COMPARATIVO ENTRE OBESOS SUBMETIDOS À CIRURGIA BARIÁTRICA

Background:Obesity is correlated with several comorbidities, including gastroesophageal reflux disease. Its main complications are detectable by endoscopy: erosive esophagitis and Barrett's esophagus.Aim: To correlate erosive esophagitis and hiatal hernia with the degree of body mass index (BMI).Method: Was performed a retrospective analysis of 717 preoperative endoscopic reports of bariatric patients. Fifty-six (8%) presented hiatal hernia, being 44 small, nine medium and five large. Esophagitis was classified by Los Angeles classification.Results: There was no correlation between the presence and dimension of hiatal hernia with BMI. One hundred thirty-four (18.7%) patients presented erosive esophagitis. Among them, 104 (14.5%) had esophagitis grade A; 25 (3.5%) grade B; and five (0.7%) grade C. When considering only the patients with erosive esophagitis, 77.6% had esophagitis grade A, 18.7% grade B and 3.7% grade C. Were identified only two patients with Barrett's esophagus (0,28%).Conclusion: There was a positive correlation between the degree of esophagitis with increasing BMI.

Racional:A obesidade está correlacionada com diversas comorbidades, dentre elas a doença do refluxo gastroesofágico. Ela tem como um de seus principais desencadeantes a hérnia do hiato, e como suas principais complicações a esofagite erosiva e o esôfago de Barrett.Objetivo: Correlacionar o grau do índice de massa corporal (IMC) com a presença e tamanho da hérnia hiatal, e com a presença e gravidade da esofagite erosiva e esôfago de Barrett.Método: Foi realizada análise retrospectiva de laudos endoscópicos pré-operatórios de 717 pacientes submetidos à cirurgia bariátrica. A hérnia de hiato esteve presente em 56 pacientes (8%), sendo que delas 44 eram pequenas, nove médias e cinco grandes. O grau da esofagite obedeceu o preconizado pela Classificação de Los Angeles.Resultados: Não houve correlação entre a presença ou tamanho da herniação hiatal com o IMC. Dos pacientes avaliados, 134 (18,7%) apresentavam esofagite erosiva. Dentre elas 104 (14,5%) eram grau A; 25 (3,5%) grau B e cinco (0,7%) grau C. Considerando-se apenas os portadores de esofagite erosiva, 77,6% eram grau A; 18,7% grau B; e 3,7% grau C. Foram identificados apenas dois casos de esôfago de Barrett (0,28% da amostra total).Conclusão: Observou-se correlação positiva entre o grau de esofagite com o aumento do IMC.

La enfermedad por reflujo gastroesofágico: su prevalencia en dos muestras de población venezolana con referencia a la presencia de alteraciones endoscópicas y al valor de la biopsia esofágica en el diagnóstico de esta condición / Gastroesophageal reflux disease: prevalence in two samples of venezuelan population with reference to the presence of endoscopic abnormalities and value of esophageal biopsy in the diagnosis of this condition

El objetivo principal de este trabajo fue contribuir a determinar la prevalencia de la Enfermedad por Reflujo Gastroesofágico (ERGE) en nuestro país, y sus objetivos secundarios fueron la determinación del valor de la endoscopia y la biopsia de esófago en el diagnóstico de esta afección. La distribución de un cuestionario validado con elementos clínicos utilizados para el diagnóstico de ERGE entre 337 personas, de 20 a 69 años, con una edad media de 50,9, 62, 84% mujeres (grupo A) y un análisis prospectivo de 335 sujetos, de 15 a 92 años, con una edad media de 50,6, 55,49% mujeres; estudiados minuciosamente mediante historia clínica, esofagogastroduodenoscopia y biopsia de esófago (Grupo B). Se encontró que una proporción considerable de los sujetos evaluados presentaron síntomas de reflujo gastroesofágico (RGE), 65,01%en el Grupo A, 62,08% en el Grupo B, y que de 335 personas en el grupo A, 39,62% presentaron síntomas al menos una vez al mes, 19,81% por lo menos una vez a la semana y 8,57% todos los días. No se encontró una diferencia estadísticamente significativa entre los diferentes grupos de edad. La ERGE parece afectar por igual a todos los estratos de los sujetos objeto de este estudio. Similar a lo que se ha encontrado en otras muestras, la proporción de pacientes con enfermedad por reflujo gastroesofágico no erosiva fue superior a los que presentan enfermedad por reflujo gastroesofágico erosiva (82,70% contra 17,30%). 10% de los sujetos con hallazgos endoscópicos de esofagitis erosiva fueron asintomáticos para RGE. En el Grupo A, sólo 39,52% de los individuos con síntomas de RGE consultó a un médico por este motivo y 55,23% tomaba medicamentos, principal-mente antiácidos, sin prescripción médica. Sólo 39,90% del Grupo B asistieron a consulta por este motivo. Esto significa que aproximadamente 60% de los sujetos con síntomas de RGE no buscan atención médica, aunque, cuando los síntomas fueron más frecuentes y se hicieron presentes a diario...

The primary objective of this paper was to contribute to determine the prevalence of Gastroesophageal Reflux Disease (GERD) in our country, and its secondary goals were the determination of the value of conventional endoscopy and biopsy of the esophagus in the diagnosis of this condition. Two strategies were implemented: the distribution of a validated questionnaire with clinical elements used for the diagnosis of GERD b)etween 337 persons, (20-69 years old, mean age 50,9, 62,84% women (Group A) and a prospective analysis of 335 subjects (15-92 years old, mean age 50.6, 55.49% women, studied with a careful clinical record, esophagogastroduodenoscopy and biopsy of the esophagus (Group B). It was found that a considerable proportion of the subjects evaluated had symptoms of gastroesophageal reflux (GER), (65.01% in Group A, 62.08% in Group B), and that of 335 persons in Group A, 39.62% had symptoms at least one a month, 19.81% al least one a week and 8.57% every day. There was not a significant statistical difference between different groups of age. GERD seems to affect equally all the stratus of the subjects object of this study. Similar to what has been found in other series, the proportion of patients with non erosive gastroesophageal reflux disease was superior to the ones with erosive disease (82.70% vs 17.30%). 10% of subjects with endoscopic findings of erosive esophagitis were asymptomatic for GER. In Group A, only 39.52% of individuals with symptoms of GER visited a physician for this reason, and 55.23% took medications (mainly antacids) without a medical prescription. Only 39.90% from Group B consulted for this reason. It means that approximately 60% of subjects with symptoms of GER do not seek medical attention, although when the symptoms were more frequent and became present daily, 2/3 of the patients sought medical help...

Evolução clínica e endoscópica após fundoplicatura para tratamento da doença do refluxo gastroesofágico / Clinical and endoscopic outcome after Nissen fundoplication for gastroesophageal reflux disease

CONTEXTO: O tratamento cirúrgico da doença do refluxo gastroesofágico está indicado para pacientes com doença crônica, associada ou não a complicações. A fundoplicatura é frequentemente indicada em substituição ao uso contínuo dos inibidores de bomba de prótons, para pacientes sem resposta, resposta parcial, ou dependentes de tratamento medicamentoso, ou ainda, quando houver recurrência dos sintomas com a descontinuação das medicações. No período pós-operatório, ocorrências de desmanche da válvula com recurrência da doença do refluxo indicam a necessidade de monitorização do procedimento cirúrgico. A avaliação do funcionamento da válvula, baseada na presença de sintomas, tem se mostrado instrumento ineficaz para essa monitorização. OBJETIVO: Identificar a frequência de anormalidades na válvula antirrefluxo e a frequência de complicações pépticas do esôfago no período de pós-operatório tardio da fundoplicatura em crianças e adolescentes. Métodos - Em estudo transversal, prospectivo e descritivo, em que foram avaliados 45 pacientes (idade = 16 meses a 16,9 anos) que tinham realizado fundoplicatura de Nissen num período de 12 a 30 meses prévios à avaliação. O aspecto da fundoplicatura e da mucosa esofágica foram avaliados por meio de endoscopia digestiva alta e estudo histológico. RESULTADOS: Doentes com encefalopatia crônica corresponderam a 26/45 (57,8 por cento) dos casos. Válvula antirrefluxo intacta foi identificada em 41/45 (91,1 por cento) dos pacientes. A fundoplicatura foi efetiva no tratamento do processo inflamatório esofágico, mesmo quando identificadas subestenose ou estenose de esôfago, no pré-operatório. As complicações identificadas foram esofagite péptica (6/45 pacientes) e necessidade de nova fundoplicatura (2/45 pacientes). A presença de anormalidades na válvula antirrefluxo associou-se ao achado de esofagite péptica (P = 0,005). Dois pacientes receberam o diagnóstico de esôfago de Barrett. CONCLUSÃO: A fundoplicatura...

CONTEXT: The surgical treatment of gastroesophageal reflux disease is indicated in patients with a chronic condition when proton pump inhibitors therapy is ineffective or when symptoms are persistently recurrent. Fundoplication failure occurrence has been detected in some patients and highlights a needing of monitoring esophageal post-surgical condition since that clinical symptoms are not sensitive enough for indicating fundoplication failure. AIMS: To identify the frequency of a disrupted wrap in the postoperative period and to evaluate esophageal complications related with gastroesophageal reflux recurrence in children and adolescents. METHODS: The study was cross-sectional, prospective and descriptive, including 45 patients (16 months-16.9 years) who had undergone Nissen fundoplication in a school hospital. Twenty six patients (57.8 percent) were neurologically impaired. Upper gastrointestinal endoscopy was performed in order to determine fundoplication integrity, endoscopic and histopathological esophageal condition. Upper gastrointestinal endoscopies were performed from 12 up to 30 months after surgery. RESULTS: Patent wrap was identified in 41 patients (91.1 percent). Recurrent peptic esophagitis was found in 6 of 45 patients, 2 of which required a second fundoplication and other two had Barrett esophagus. Endoscopic peptic esophagitis was associated with a defective wrap (P = 0.005). Conclusions - Fundoplication was effective for treating esophagitis, even in patients with previous esophageal stenosis. Endoscopic follow up may detect surgery failure in children undergone anti-reflux surgery even in asymptomatic patients.

Prevenir les risques de lesions oesophagiennes causees par les formes orales de medicaments

N.A.

Treatment of gastroesophageal reflux disease

OBJETIVO: Rever a literatura sobre tratamento da doença do refluxo gastroesofágico (DRGE) com ênfase nos aspectos farmacológicos. Identificar particularidades do tratamento farmacológico nas manifestações esofágicas e extra-esofágicas da doença. FONTES DE DADOS: Busca eletrônica na base de dados PubMed/MEDLINE e Cochrane Collaboration. Procurou-se identificar estudos controlados e randomizados publicados a partir de 2000, bem como revisões que representassem consensos e diretrizes publicados nos últimos 10 anos. SíNTESE DOS DADOS: Nenhuma das drogas atualmente usadas no tratamento da DRGE altera comprovadamente o mecanismo principal da doença, ou seja, os relaxamentos transitórios do esfíncter esofágico inferior. O tratamento farmacológico da DRGE com sintomas ou com lesões esofágicas é baseado na inibição da secreção ácida, em particular pelos inibidores da bomba de prótons (IBP). Nas situações em que a hiper-reatividade das vias aéreas inferiores coexiste com sintomas esofágicos da DRGE, a inibição da secreção ácida deve trazer benefícios na condução da doença respiratória se houver uma relação causal; contudo, essa situação não é comum. Quando não coexistem sintomas esofágicos, a pHmetria esofágica de 24 h deve ser realizada previamente ao tratamento farmacológico da DRGE. A melhora dos sintomas respiratórios pode ser tardia em relação aos sintomas esofágicos. A DRGE freqüentemente recorre, e o tratamento farmacológico deve ser repetido ou mantido indefinidamente, conforme a apresentação clínica da doença. CONCLUSÃO: As condutas propostas para o tratamento farmacológico da DRGE na criança são oriundas principalmente de estudos de séries de casos ou de estudos em adultos. Existem poucos estudos controlados e randomizados em crianças. A realização de um número maior desses estudos poderá reafirmar ou introduzir novos aspectos nas condutas propostas.

OBJECTIVE: To review the literature on the treatment of gastroesophageal reflux disease (GERD) with emphasis on pharmacological aspects. To identify particularities of pharmacological treatment of esophageal and extraesophageal manifestations of the disease. SOURCES: Electronic search of the PubMed/MEDLINE and Cochrane Collaboration databases. Controlled and randomized studies published since 2000 and reviews representing consensus positions and directives published within the last 10 years were identified. SUMMARY OF THE FINDINGS: The drugs currently available for the treatment of GERD do not act in the primary mechanism of the disease, i.e., transitory relaxation of the lower esophageal sphincter. Pharmacological treatment of GERD with symptoms or with esophageal injury is based on the suppression of acid secretion, particularly with proton pump inhibitors. When the hyperreactivity of the lower airways coexists with esophageal GERD symptoms, suppression of acid secretions should be of benefit in managing the respiratory disease in the presence of a causal relationship; however, this is not usual. When esophageal symptoms are not present, esophageal 24-hour pH study should be carried out prior to starting pharmacological treatment for GERD. Improvement of respiratory symptoms may be delayed with relation to esophageal symptoms. It is common for GERD to recur and pharmacological treatment should be repeated or continued indefinitely, depending on clinical presentation of the disease. CONCLUSIONS: The strategies that have been proposed for the pharmacological treatment of GERD in children are primarily based on studies of case series or on studies with adults. There have been very few controlled and randomized studies in children. Undertaking a greater number of these studies might reinforce existing aspects or establish new aspects of management.

Frequency of CagA in Helicobacter pylori isolates of patients with peptic ulcer diseases [PUD] and non-ulcer dyspepsia [NUD] at Namazi Hospital, Shiraz, Iran

Data concerning the information on the prevalence and association of the Helicobacter pylori cytotoxinassociated gene A [CagA] with disease is still controversial. The aim of this study was to isolate and identify H. pylori by culture methode from biopsy specimens and its relationship with associated diseases by molecular techniques [PCR]. Gastric biopsy specimens obtained from 220 patients [aged 18 to 68 years] were evaluated for presence of H. pylori using PCR assay on isolates for CagA gene. From 220 patients that included in this study, 120 patients, 51 from PUD [38 duodenal ulcer and 13 gastric ulcer] and 69 from NUD patients [35 gastritis, 18 reflux disease without and 16 with esophagitis] yielded positive for H. pylori culture. Frequency of CagA gene in H. pylori isolated from patients with peptic ulcer diseases [PUD] and non-ulcer dyspepsia [NUD] was 82.3% and 59.4%, respectively. Our data confirmed that CagA gene in H. pylori is a virulence factor with high frequency in PUD. Therefore, we suggest that detection of H. pylori gene expression may contribute in improving the diagnosis and understanding the pathogenesis of H. pylori infections

role of helicobacter pylori in esophagitis and peptic ulcer disease in Iraq

The objectives of this study are to determine the prevalences of Helicobacter pylori [H.pylori] infection in symptomatic, but endoscopically normal patients as well as in patients with endoscopically and histologically proven esophagitis, gastritis, duodenitis, duodenal ulcer, and gastric ulcer. The study extended over the period November 1999 through June 2000. Biopsy specimens were harvested from intact areas of gastric antral mucosa, duodenal bulb, gastric body and lower third of esophagus of each one of 200 patients undergoing eseophago-gastro-duodenoscopy in endoscopy unit of Tikrit General Hospital [TGH], Salahuddin Governorate, Tikrit City, Iraq. The biopsies were submitted for histopathological, cultural and biochemical investigations. Seven biopsy samples were taken from each patient. Written consent was taken from each patient. The patients were pooled from various districts of the governorate. Results:Helicobacter pylori was detected in antral biopsies of the following categories of patients: in 73.9% of patients with endoscopic gastritis, in 75% of patients with gastric ulcers, in 86% of patients with endoscopic duodenitis, in 88.6% of patients with duodenal ulcers and in 57.7% of patients with endoscopic esophagitis, but absent in all patients with totally normal endoscopies. Although H.pylori has no role in the development of esophagitis, it is a prevalent pathogen and is associated with many gastro-intestinal diseases and has an important role in the pathogenesis of peptic ulcer disease and gastritis in our district

El compromiso del esófago en la enfermedad HIV/SIDA / The compromise of esophagus in HIV/AIDS diseases

Esophageal disease is a common complication in patients infected with human immunodeficiency virus type-1 (HIV-1). Dysphagia, odynophagia and retrosternal pain are the most common symptons associated with the esophageal compromise. Esophageal candidiasis, the most frequent opportunistic infection, may occur in patients with long-standing infection or may be a manifestation of the seroconversion. Cytomegalovirus and Herpes simplex virus are more likely to produce esophageal ulcers or erosions. HIV itself may be responsible for ulcerative esophagitis. Neoplasms as Kaposi's sarcoma, are an infrequent cause of symptomatic disease. Barium esophagography and specially upper endoscopy are the most commonly employed diagnostic modalities for the evaluation of symptomatic patients. Endoscopy may be warranted to make a rapid diagnosis such that specific therapy will not be delayed. The use of a combination of histologic, cytologic, mycologic and virologic studies is necessary to provide an etiologic diagnosis of these lesions.

Pattern of gastroesophageal reflux in children

Gastroesophageal reflux disease is a common health problem in children worldwide. There are no published data on this disease in children from Saudi Arabia. The objective of this study is, therefore, to report on the pattern of gastroesophageal reflux disease in Saudi children. Retrospective review of all children referred to the Pediatric Gastroenterology Division at King Khaled University Hospital in Riyadh. The diagnosis was confirmed in 85 children, all but 2 were Saudi nationals, and the male to female ratio was 1.6. The median age of onset of symptoms was 10 months, whereas the median age at referral was 20 months. The pattern of clinical presentation indicates that vomiting is the most common presentation occurring in 82% of the children, followed by respiratory disease in 38%. An underlying condition was found in 41% of the children, [35/85] the most common of which was neurological impairment. Peptic esophagitis was present in 51.5% of the children who underwent endoscopy. The median duration of follow up was 6 months. Good response to medical therapy was documented in 72% of normal children and 27% of those with underlying disease. All of the 23 children who had fundoplication in our institution had one or more of the underlying disorders. Gastroesophageal reflux disease is a common problem in Saudi children. The overall pattern in this report is similar to descriptions in the literature. Prospective multicenter studies are needed to confirm this pattern and to provide more focused descriptions of other aspects of the disease

Esofagite herpética / Herpetic esophagitis

Relata-se caso de um paciente de 19 anos, portador de Linfoma Não-Hodgkin em tratamento quimioterápico que desenvolveu Esofagite Herpética. São discutidas as diversas manifestações clínicas e endocópicas, revisando-se a literatura