Avaliação clínica e endoscópica em pacientes com sintomas gastroesofágicos / Clinical and endoscopic evaluation in patients with gastroesophageal symptoms

ABSTRACT BACKGROUND: The gastroesophageal reflux disease (GERD) is the most common esophageal disease in medical practice, and it is suspected according to patients' symptoms. GERD can be classified in erosive esophagitis (EE) according to the presence of upper gastrointestinal endoscopy findings. OBJECTIVE: To evaluate endoscopic findings in patients with symptoms suggestive of GERD comparing epicemiological and risk factors. METHODS: Upper endoscopy reports were examined retrospectively from patients with symptoms of GERD such as heartburn, regurgitation, cough, throat clearing, globus and chest pain. EE was determined based on Los Angeles classification. Comparisons between risk factors in EE and non-EE groups were done with statistical analysis. RESULTS: A total of 984 endoscopic reports were examined and 676 selected for analysis (281 with EE and 395 with non-EE form). Most were female 381 (56.36%) with a mean age of 44.01±15.40 years. Hiatal hernia was present in 47(6.96%) and smoking in 41(6.07%). Univariate logistic regression showed that male (OR=2.24, CI 95%, 1.63-3.06) and hiatal hernia (OR=4.52, CI 95%, 2.30-8.89) were independent predictors of erosions in the EE group. The presence of hiatal hernia (OR=12.04, CI 95%, 3.57-40.62), smoking (OR=8.46, CI 95%, 3.28-31.32) and aged patients (OR=8.01, CI 95%, 2.42-26.49) were also indicated as a risk factor for severe EE (grades C and D of Los Angeles). CONCLUSION Male gender and hiatal hernia were associated with EE. Aged patients, smoking and hiatal hernia were related to severe EE. It is suggested that the risk factors for EE and non-EE types are different. Cohort studies are necessary to identify the exact mechanisms involved in each disease form.

RESUMO CONTEXTO: A doença do refluxo gastroesofágico (DRGE) é uma das doenças digestivas mais comuns na prática médica e deve ser suspeitada de acordo com os seus sintomas clínicos, podendo ser classificada em esofagite erosiva (EE) de acordo com os achados de endoscopia. OBJETIVO: Avaliar os achados endoscópicos em pacientes com sintomas sugestivos de DGRE comparando fatores de risco e epidemiológicos. MÉTODOS: Resultados de endoscopias digestiva foram examinados retrospectivamente de pacientes com sintomas relacionados com DRGE como pirose, regurgitação, tosse, pigarro, globus e dor torácica. EE foi determinada de acordo com a classificação de Los Angeles. Comparação de fatores de risco entre os grupos EE e não-EE foram feitos com análise estatística. RESULTADOS: Um total de 984 endoscopias foram examinadas e 676 endoscopias selecionadas para análise (281 com EE e 395 sem EE). A maioria dos pacientes era do sexo feminino 381 (56,36%) com uma idade média de 44,01±15,40 anos. Hérnia hiatal esteve presente em 47 (6,96%) e tabagismo em 41 (6,07%). Regressão logística uni variada mostrou que sexo masculino (OR=2,24 - IC 95%: 1,63-3,06) e hérnia hiatal (OR=4,52 - CI 95%: 2,30-8,89) foram fatores de risco independentes de EE. A presença de hérnia hiatal (OR=12,04 - CI 95%: 3,57-40,62), tabagismo (OR=8,46 - CI 95%: 3,28-31,32) e pacientes idosos (OR=8,01 - CI 95%, 2,42-26,49) foram fatores de risco no grupo de EE grave (classes C e D de Los Angeles). CONCLUSÃO: Sexo masculino e hérnia hiatal foram associados com EE. Idade avançada, tabagismo e hérnia hiatal foram relacionados à forma grave de EE. É sugerido que os fatores de risco de pacientes com e sem EE sejam diferentes. Estudos de coorte são necessários para identificar os mecanismos exatos envolvidos em cada forma da doença.

Segurança e eficácia do uso de cianoacrilato + coil guiado por ultrassom endoscópico versus técnica convencional de cianoacrilato no tratamento de varizes gástricas: um ensaio clínico randomizado / Safety and efficacy of eus-guided coil plus cyanoacrylate versus conventional cyanoacrylate technique in the treatment of gastric varices: a randomized controlled trial

ABSTRACT BACKGROUND: One of the most feared complications with the use of cyanoacrylate for treatment of gastric varices is the occurrence of potentially life-threatening systemic embolism. Thus, endoscopists are turning towards new techniques, including endoscopic coiling, as a potentially safer and more effective treatment option. However, no studies have been performed comparing the two techniques. OBJECTIVE: This study aims to compare the safety and efficacy of endoscopic ultrasound guided coil and cyanoacrylate injection versus the conventional technique of injection of cyanoacrylate alone. DESIGN: A pilot randomized controlled trial. METHODS: Patients randomized into group I were treated with coil and cyanoacrylate, and those in group II with cyanoacrylate alone. Flow within the varix was evaluated immediately after the treatment session and one month following initial treatment. If thrombosis was confirmed, additional follow-up was performed 4 and 10 months following initial treatment. All patients underwent a thoracic computerized tomography scan after the procedure. RESULTS: A total of 32 patients, 16 in each group, were followed for an average of 9.9 months (range 1-26 months). Immediately after the procedure, 6 (37.5%) group-I patients and 8 (50%) group-II patients presented total flow reduction in the treated vessel (P=0.476). After 30 days, 11 (73.3%) group-I patients and 12 (75%) group-II patients were found to have varix thrombosis. In both groups, the majority of patients required only one single session for varix obliteration (73.3% in group I versus 80% in group II). Asymptomatic pulmonary embolism occurred in 4 (25%) group-I patients and 8 (50%) group-II patients (P=0.144). No significant difference between the groups was observed. CONCLUSION: There is no statistical difference between endoscopic ultrasound guided coils plus cyanoacrylate versus conventional cyanoacrylate technique in relation to the incidence of embolism. However, a greater tendency towards embolism was observed in the group treated using the conventional technique. Both techniques have similar efficacy in the obliteration of varices. Given the small sample size of our pilot data, our results are insufficient to prove the clinical benefit of the combined technique, and do not yet justify its use, especially in light of higher cost. Further studies with larger sample size are warranted.

RESUMO CONTEXTO: Uma das complicações mais temidas com o uso de cianoacrilato para tratamento de varizes gástricas é a ocorrência de embolia sistêmica potencialmente fatal. Assim, os endoscopistas estão se aprimorando com novas técnicas, incluindo o uso de coils endoscópico, como uma opção de tratamento potencialmente mais segura e eficaz. No entanto, nenhum estudo foi realizado comparando as duas técnicas. OBJETIVO: Este estudo tem como objetivo comparar a segurança e eficácia da injeção de coil com cianoacrilato guiados por ultrassom endoscópico versus a técnica convencional de injeção de cianoacrilato. DESIGN: Um ensaio piloto controlado aleatoriamente. MÉTODOS: Os pacientes randomizados para o grupo I foram tratados com coil + cianoacrilato e os do grupo II apenas com cianoacrilato. O fluxo dentro da variz foi avaliado imediatamente após a sessão de tratamento e um mês após o tratamento inicial. Se a trombose foi confirmada, o acompanhamento adicional era realizado em 4 e 10 meses após o tratamento inicial. Todos os pacientes foram submetidos a uma tomografia computadorizada torácica após o procedimento. RESULTADOS: Um total de 32 pacientes, 16 em cada grupo, foram acompanhados por uma média de 9,9 meses (variação de 1-26 meses). Imediatamente após o procedimento, 6 (37,5%) pacientes do grupo I e 8 (50%) pacientes do grupo II apresentaram redução total do fluxo no vaso tratado (P=0,476). Após 30 dias, 11 (73,3%) pacientes do grupo I e 12 (75%) pacientes do grupo II apresentaram trombose da variz. Em ambos os grupos, a maioria dos pacientes necessitou de apenas uma única sessão para obliteração da variz (73,3% no grupo I versus 80% no grupo II). Embolia pulmonar assintomática ocorreu em 4 (25%) pacientes do grupo I e em 8 (50%) pacientes no grupo II (P=0,144). Nenhuma diferença significativa entre os grupos foi observada. CONCLUSÃO Apesar de não haver diferença estatística entre os dois grupos em relação à incidência de embolia neste estudo piloto, observou-se maior tendência de embolia no grupo tratado pela técnica convencional.

Towards a standard protocol for antimony intralesional infiltration technique for cutaneous leishmaniasis treatment

BACKGROUND Despite its recognised toxicity, antimonial therapy continues to be the first-line drug for cutaneous leishmaniasis (CL) treatment. Intralesional administration of meglumine antimoniate (MA) represents an alternative that could reduce the systemic absorption of the drug and its side effects. OBJECTIVES This study aims to validate the standard operational procedure (SOP) for the intralesional infiltration of MA for CL therapy as the first step before the assessment of efficacy and safety related to the procedure. METHODS The SOP was created based on 21 trials retrieved from the literature, direct monitoring of the procedure and consultation with experts. This script was submitted to a formal computer-aided inspection to identify readability, clarity, omission, redundancy and unnecessary information (content validation). For criterion and construct validations, the influence of critical condition changes (compliance with the instructions and professional experience) on outcome conformity (saturation status achievement), tolerability (pain referred) and safety (bleeding) were assessed. FINDINGS The median procedure length was 12 minutes and in 72% of them, patients classified the pain as mild. The bleeding was also classified as mild in 96.6% of the procedures. Full compliance with the SOP was observed in 66% of infiltrations. Despite this, in 100% of the inspected procedures, lesion saturation was observed at the end of infiltration, which means that it tolerates some degree of modification in its execution (robustness) without prejudice to the result. CONCLUSIONS The procedure is reproducible and can be used by professionals without previous training with high success and safety rates.

Evaluation of percutaneous ethanol injections in benign thyroid nodules / Avaliação do tratamento com injeção percutânea com etanol em nódulos benignos de tireoide

Objective The objective of this study was to evaluate the efficacy and safety of percutaneous ethanol injection (PEI) in the treatment of benign thyroid nodules. Subjects and methods We evaluated 120 patients with benign thyroid nodules. Patients underwent evaluation of serum TSH and free T4, cervical ultrasound, and thyroid scintigraphy (in those with suppressed TSH levels). The application of sterile ethanol 99% was guided by ultrasound, with the injected volume amounting to one-third of the nodule volume. Response was considered complete (reduction of 90%); partial (reduction between 50 and 90%); or none (reduction of < 50%). Autonomous nodules were evaluated for normalization of TSH levels. Results Among the nodules studied, 30.8% were solid, 56.7% were mixed, 12.5% were cystic, and 21.6% were hyperfunctioning. The initial volume of the treated nodules ranged from 0.9 to 74.8 mL (mean 13.1 ± 12.4 mL). We performed 1-8 sessions of PEI, applying an average of 6.2 mL of ethanol for patient. After 2 years of follow-up, 17% of patients achieved a complete response (94% reduction); 53%, a partial response (70% reduction); and 30%, no response. A reduction in the volume of autonomous nodules was noted in 70% of cases, and 54% had a normalized value of TSH. The main side effect is local pain, lasting less than 24 hours in most cases. Conclusion This study showed that PEI is a safe and effective procedure for treatment of benign, solid or mixed thyroid nodules. Most cases resulted in significant reduction in nodule volume, with normalization of thyroid function. Arq Bras Endocrinol Metab. 2014;58(9):912-7 .

Objetivo O objetivo deste estudo foi avaliar a eficácia e segurança da injeção percutânea de etanol (IPE) no tratamento de nódulos tireoidianos benignos. Sujeitos e métodos Foram avaliados 120 pacientes com nódulos benignos de tireoide. Todos realizaram dosagens de TSH, T4 livre, ecografia cervical (US) e cintilografia de tireoide (em pacientes com TSH suprimido). A aplicação de etanol estéril a 99% foi guiada por US e o volume de etanol injetado correspondeu a um terço do volume nodular calculado. A resposta foi considerada completa (redução de 90%); parcial (redução entre 50 e 90%) ou ausência de resposta (redução menor que 50%). Nos nódulos autônomos, foi avaliada a normalização do TSH. Resultados Entre os nódulos estudados, 30,8% eram sólidos, 56,7% eram mistos, 12,5% eram císticos e 21,6%, nódulos hiperfuncionantes. O volume inicial dos nódulos tratados variou de 0,9 a 74,8 mL (média 13,1 ± 12,4 mL). Foram realizadas de 1 a 8 sessões de IPE (média 2,8), com aplicação média de 6,2 mL de etanol por paciente. Após dois anos de seguimento, 17% dos pacientes obtiveram resposta completa (redução de 94%), 53% obtiveram resposta parcial (redução de 70%) e 30% não responderam. Houve redução de volume nos nódulos autônomos em 70% dos casos, e 54% normalizaram o valor do TSH. Os efeitos colaterais registrados foram decorrentes apenas do desconforto no local de aplicação. Conclusão Este trabalho mostrou que a IPE é um procedimento seguro e eficaz para tratamento de nódulos benignos, sólidos ou mistos de tireoide. ...

Myositis Ossificans of the Elbow after a Trigger Point Injection

Trigger point injection is a simple procedure that is widely performed for relieving pain. Even though there are several complications of trigger point injection, myositis ossificans has not been documented as one of its complications. We treated a patient who suffered from painful limitation of elbow motion and this was caused by myositis ossificans between the insertions of brachialis and supinator muscles after a trigger point injection containing lidocaine mixed with saline, and we also review the relevant medical literature.

Iris depigmentation: an unusual complication of intralesional corticosteroid injection for capillary hemangioma

Intralesional injection of corticosteroids has been used successfully in the treatment of adenexal hemangiomas, with advantages of easy administration, rapid action, repeatability, efficacy and safety. We report a case of an eight-month-old female infant who underwent intralesional corticosteroid injection for capillary hemangioma that had resulted in amblyopia of her left eye from ptosis. Two weeks after the injection, the hemangioma showed some regression but at that point iris depigmentation of the affected eye was noted. The iris depigmentation remained unchanged during her follow-up visit with significant regression of the hemangioma, associated ptosis and astigmatism

Treatment of hepatocellular carcinoma in cirrhotic patients: a prospective randomized study comparing radiofrequency and ethanol injection

Although surgery remains as a gold standard line for management of hepatocellular carcinoma [HCC], many cases are not candidates for surgery due to underlying chronic liver disease and limited functional reserve even with recent advances in the field of surgery. At the same time several local ablative techniques have emerged and proved to be minimally invasive and effective measures for in situ control of HCC, of these techniques, radiofrequency ablation [RFA], and percutaneous ethanol injection [PEI]. The aim of the current study was to evaluate the safety and efficacy of RFA and ethanol injection for the treatment of HCC, to reach a protocol for proper management of unresectable HCC and, also to assess the quality of life before and after each technique. In the current study we had two groups of patients with HCC on top of cirrhosis due to hepatitis C virus [HCV] infection, one of them was subjected to RFA [G 1] and the other [G2] was subjected to PEI as therapeutic modalities for their HCC. As regards GI, it included 30 patients with 36 HCC lesions with a mean size of 3.02 cm which were treated by percutaneous US guided RFA using cooled-tip electrodes with a mean of 1-2 sessions of RFA. Studied patients were followed over variable periods that ranged between 6-18 months with a mean of 11.6 months. The responses to therapy were as follows: Complete ablation in 32 out of 36 lesions [88.8%], partial response in 3 out of 36 lesions [8.3%], recurrence in 3 [8.3%] lesions, and newly developed lesions in 7 cases. G2 included 20 patients with 26 HCC lesions with a mean size of 3cm for which we used PEI modality, we found that 21 out of 26 lesions [80.7%] had complete response, 4 out of 26[15.3%] had partial response and one [3.8%] showed local recurrence, and newly developed lesions were seen in 5 cases. The period of follow up ranged from 4-12 months with a mean of 10 months. As regards survival, one year survival rate was 75% in GI and 80% in G2. We concluded that, both RFA and PEI are safe and effective procedures and result in significant improvement in quality of life in patients with unresectable HCC. RFA showed higher rate of complete necrosis and requires fewer sessions than PET in the management of HCC

Radiología intervencionista hepatobiliar / Hepatic and biliary interventional radiology

La radiología intervencionista (RI) comprende numerosos procedimientos diagnósticos y terapéuticos. El hígado y las vías biliares constituyen por su anatomía y acceso un área singular para la aplicación de múltiples métodos intervencionistas en la patología hepatobiliar. El objetivo del trabajo es presentar nuestra experiencia acumulada en 13 años (1980-1993). En este lapso se realizaron: 313 biopsias percutáneas; 146 drenajes de abscesos u otras colecciones líquidas; 136 procedimientos percutáneos biliares (drenaje percutáneo de la vía biliar, colecistostomía transhepática, litotomía vesicular, colocación de prótesis expandibles, etc.); 83 procedimientos endovasculares (quimioembolización, quimiolipiodol, quimioinfusión y embolización) y 12 alcoholizaciones percutáneas de tumores hepáticos. El trabajo analiza en detalle los resultados obtenidos con cada uno de los procedimientos, sus beneficios, indicaciones, contraindicaciones, las técnicas aplicadas y las complicaciones que se produjeron. Nuestras conclusiones son:1) La RI modificado criterios diagnósticos y terapéuticos en la patología hepatobiliar, tanto clínicos como quirúrgicos. 2) Con una correcta selección de los pacientes la RI proporciona métodos de primera elección frente a otros procedimientos quirúrgicos, aún en el paciente agudo