Mastócitos discriminam esofagite eosinofílica em pacientes pediátricos / Mast cells distinguish eosinophilic esophagitis in pediatric patients

ABSTRACT BACKGROUND: Mast cells exert a substantial role in gastrointestinal allergic diseases. Therefore, it is reasonable to presume that mast cell may aid diagnosis in eosinophilic gastroenteropathy. OBJECTIVE: To evaluate whether mast cell count in the esophageal epithelium can discriminate eosinophilic esophagitis, proton-pump inhibitor (PPI)-responsive eosinophilic esophagitis and gastroesophageal reflux esophagitis. METHODS: Retrospectively we reviewed the files of 53 consecutive patients (age: 7.8 years; range: 8-14 years) with definitive diagnose established during clinical follow up in a universitary outpatient clinic as follow: eosinophilic esophagitis (N=23), PPI-responsive eosinophilic esophagitis (N=15) and gastroesophageal reflux esophagitis (N=15). Eosinophil count in the esophageal epithelium in slides stained with H-E was reviewed and immunohistochemistry for mast cell tryptase was performed. RESULTS: Count of eosinophils/high-power field (HPF) higher than 15 were found in 14 out of 15 reflux esophagitis patients. The mean count of eosinophils/HPF was similar in eosinophilic esophagitis patients and in those with PPI-responsive eosinophilic esophagitis (42 and 39 eosinophils/HPF, respectively, P=0.47). Values of mast cell tryptase (+) were higher in eosinophilic esophagitis [median: 25 mast cells/HPF; range (17-43) ] and in PPI-responsive eosinophilic esophagitis patients [25 (16-32) ], compared to reflux esophagitis [4 (2-14) ], P<0.001. There was no difference between the mean count of mast cells/HPF in the esophageal epithelium of eosinophilic esophagitis patients and PPI-responsive eosinophilic esophagitis patients, respectively, 26 and 24 mast cells/HPF, P=0.391. CONCLUSION: Tryptase staining of mast cells differentiates eosinophilic esophagitis from reflux esophagitis.

RESUMO CONTEXTO: Os mastócitos detêm papel fundamental na resposta imuno-alérgica gastrintestinal. Assim, é razoável admitir que essas células sejam úteis no diagnóstico diferencial das gastroenteropatias eosinofílicas. OBJETIVO: Determinar se a análise quantitativa de mastócitos na mucosa esofágica permite discernir esofagite eosinofílica, esofagite eosinofílica responsiva ao inibidor de bomba de prótons e esofagite péptica por doença de refluxo gastroesofágico. MÉTODOS: Revisamos retrospectivamente os prontuários 53 crianças (idade: 7,8 anos; variação: 8-14 anos), atendidas consecutivamente, num serviço terciário e cujos diagnósticos definitivos estabelecidos após seguimento clínico foram esofagite eosinofílica (N=23), esofagite eosinofílica responsiva ao inibidor de bomba de prótons (N=15) e esofagite péptica por doença de refluxo gastroesofágico (N=15). As amostras histológicas foram revisadas quanto à contagem de eosinófilos na coloração de H-E e processadas para imunoistoquímica da triptase de mastócitos. RESULTADOS: Valores de eosinófilos/campo de maior aumento (CMA; 400X) >15 foram encontrados em 14 dos 15 pacientes com refluxo gastroesofágico. A média de eosinófilos/CMA foi similar nos pacientes com esofagite eosinofílica e com esofagite eosinofílica responsiva ao inibidor de bomba de prótons, respectivamente, 42 e 39 eosinófilos/CMA, P=0,47). Os valores de mastócitos triptase (+) foram superiores no epitélio esofágico dos pacientes com esofagite eosinofílica [mediana: 25 mastócitos/CMA; variação (17- 43) ] e na esofagite eosinofílica responsiva ao inibidor de bomba de prótons [25 (16-32) ], comparados aos pacientes com refluxo gastroesofágico [4(2-14) ], P<0,001. Não houve diferença entre a média de mastócitos/CMA nos pacientes com esofagite eosinofílica comparados aos com esofagite eosinofílica responsiva ao inibidor de bomba de prótons, respectivamente, 26 e 24 mastócitos/CMA, P=0,391. CONCLUSÃO: A coloração para mastócitos pela imunoistoquímica da triptase diferencia as esofagites eosinofílicas da esofagite péptica.

Esofagitis de cambios mínimos y su relación con los bucles capilares papilares intraepiteliales del esófago, en pacientes con enfermedad de reflujo gastroesofágico, usando endoscopios con flexible spectral imaging color enhancement / Minimal change esophagitis and its relation with esophageal intra papillary epithelial capillary loops in patients with gerd using flexible spectral imaging color enhancement endoscopes

La esofagitis de reflujo, es una entidad clínica que forma parte de la enfermedad de reflujo gastroesofágico (ERGE). A pesar que la endoscopia, tiene una excelente especificidad en 90% - 95%, su sensibilidad es sólo del 50%. Más del 50% de los pacientes con síntomas de ERGE han sido diagnosticados como enfermedad por reflujo no erosivo, (ERNE). El análisis más cuidadoso de los estudios publicados, reporta que la mayoría de los pacientes con ERNE tenían pequeños cambios en la mucosa del esófago distal, específicamente proximal a la línea Z; introduciéndose con estos hallazgos el término de esofagitis de cambios mínimos. Pero también cambios característicos de los bucles capilares papilares intraepiteliales (BCPIE) han sido demostrados, en pacientes con esofagitis de cambios mínimos por ERGE. Evaluar y comparar en pacientes con el diagnóstico de ERNE y en pacientes controles, la alteración morfológica de BCPIE en el esófago distal, con la intención de diagnosticar esofagitis de cambios mínimos, utilizando endoscopios de alta resolución con magnificación, cromoscopia electrónica e imagen espectral FICE. Estudio de corte transversal, prospectivo, con un muestreo no probabilístico, de tipo intencional y grupo control, realizado con pacientes que asistieron a la consulta ambulatoria del servicio de Gastroenterología del Hospital Universitario de Caracas y de la Clínica El Ávila, desde mayo de 2007 a noviembre de 2011. De 156 pacientes con diagnóstico de ERNE y 100 pacientes de grupo control. Grupo control: 100 pacientes, 3 pacientes con BCPIE tipo II (1%). Grupo ERNE 156 pacientes, 5 tenían un patrón: Tipo I considerado normal y 151 tenían un patrón de los BCPIE alterado: 146 con patrón de BCPIE Tipo II (96,68%), sensibilidad 97%, especificidad 97%; 5 (3,31%), tenían un patrón de BCPIE Tipo III sensibilidad 5% y especificidad 0%. Los cambios anatómicos encontrados en los BCPIE de la mucosa del esófago, cuando se hace una endoscopia digestiva...

Reflux esophagitis is a clinical entity that is part of Gastroesophageal Reflux Disease (GERD). Although endoscopy has an excellent specificity of 90% -95%, its sensitivity is only 50%. Over 50% of patients with symptoms of GERD have been diagnosed as non-erosive reflux disease (NERD). More careful analysis of the published studies reported that most NERD patients had minor changes in the distal esophageal mucosa, specifically proximal to the Z line; introducing with these findings the term of Minimal Change Esophagitis. Also changes characteristic of Intra Papillary Epithelial Capillary Loops (BCPIE) have been demonstrated in patients with Minimal Change Esophagitis by GERD. To evaluate and compare patients with the diagnosis of NERD and controls, BCPIE morphological alteration in the distal esophagus, with the intention of diagnosing minimal change esophagitis, using high-resolution magnification endoscopes, electronic and spectral imaging chromoscopy FICE. Prospective, cross-sectional study with a non-probability sampling, intentional kind and control group, of patients attending the outpatient clinic of the Department of Gastroenterology, University Hospital of Caracas and of Avila Clinic, from May 2007 to November 2011. Of 156 patients diagnosed with NERD and 100 patients in the control group. Control group: 100 patients, 3 patients with type II BCPIE (1%). NERD group 156 patients, 5 had a pattern: Type I considered normal and 151 had a pattern of altered BCPIE: 146 BCPIE with a Type II pattern (96, 68%), sensitivity 97%, specificity 97%; 5 (3, 31%), had BCPIE with a Type III pattern Sensitivity 5% and Specificity 0%. The anatomical changes found in BCPIE at the esophageal mucosa, when an endoscopy is performed in patients with GERD, allow the diagnosis of Minimal Change Esophagitis. The BCPIE type II pattern is the most frequently found in Minimal Change Esophagitis. The indication of Endoscopy with high definition magnification....

Evaluation of anatomical and functional changes esophageal stump of patients with advanced megaesophagus submitted to subtotal laparoscopic esophagectomy / Avaliação das alterações anatômicas e funcionais do coto esofágico de pacientes portadores de megaesôfago avançado submetidos à esofagectomia subtotal laparoscópica

PURPOSE: Evaluate anatomical and functional changes of the esophageal stump and gastric fundus of patients with advanced megaesophagus, submitted to laparoscopic subtotal esophagectomy. METHODS: Twenty patients with advanced megaesophagus, previously submitted to a videolaparoscopic subtotal esophagectomy , were evaluated. Were conducted: radiological evaluation of the stump esophagus with transposed stomach, electromanometric, endoscopic examination and histopathology of the esophageal stump and gastric fundus, without making gastric tube or pyloroplasty. RESULTS: It was observed that the average height and pressure of the anastomosis, in the electromanometric evaluation, were 23.45cm (±1.84cm) and 7.55mmHg (±5.65mmHg). In patients with megaesophagus III, the pressure of the anastomosis was 10.91mmHg (±6.33mmHg), and pressure from the UES, 31.89mmHg (±14.64mm Hg), were significantly higher than those in grade IV. The pathological evaluation detected mild esophagitis in 35% of patients, moderate in 20% and acanthosis glicogenica in 45%. The examination of the gastric fundus showed that 50% of patients were infected with Helicobacter pylori. Chronic gastritis occurred in 95% of the patients. CONCLUSIONS: The laparoscopic esophagectomy shown to be effective in the treatment of advanced achalasia. The cervical level anastomosis protects the esophageal stump from the aggression resulted from gastric reflux after the esophagectomy.

OBJETIVO: Avaliar as alterações anatômicas e funcionais do coto esofágico e fundo gástrico de pacientes com megaesôfago avançado, submetidos à esofagectomia subtotal laparoscópica. MÉTODOS: Vinte pacientes com megaesôfago avançado, previamente submetidos à esofagectomia subtotal videolaparoscópica, foram avaliados. Foram realizados: avaliação radiológica do coto esofágico com o estômago transposto, eletromanometria endoscopia e exame histopatológico do coto esofágico e fundo gástrico,sem fazer tubo gástrico ou piloroplastia. RESULTADOS: Observou-se que a altura média e pressão da anastomose, na avaliação eletromanométrica, foram: 23,45cm (± 1,84cm) e 7,55mmHg (± 5,65mmHg), Em pacientes com megaesôfago III, a pressão da anastomose foi de 10,91mmHg (± 6,33mmHg), e a pressão do ESE, 31,89mmHg (±14,64mmHg) foram significativamente mais elevados do que aqueles em grau IV. A avaliação patológica detectou esofagite leve em 35% dos pacientes, moderada em 20% e acantose glicogênica em 45%. O exame do fundo gástrico mostrou que 50% dos pacientes foram infectados com Helicobacter pylori. Gastrite crônica ocorreu em 95% dos pacientes. CONCLUSÕES: A esofagectomia laparoscópica mostrou-se eficaz no tratamento de acalasia avançada. A anastomose em nível cervical tem um papel protetor para o coto esofágico ao evitar a agressão resultante de refluxo gástrico após a esofagectomia.

Oral stigmatic lesions of gastroesophageal reflux disease (GERD): Informe de un caso / Lesiones en la cavidad bucal en reflujo gastroesofágico

Patients with gastroesophageal reflux may have extra-esophageal manifestations. We report a 46 years old ex-smoker woman presenting with a sensation of burning mouth, xerostomia and glossitis. The patient had a history of heartburn, dysphonia and cough. Mouth examination showed a bad hygiene and abundant accumulation of plaque. Esophageal pH measurement was abnormal. Laryngoscopy showed a posterior laryngeal inflammation and mucous secretion. With these data, a diagnosis of gastroesophageal reflux was reached.

Los pacientes con reflujo gastroesofágico pueden tener manifestaciones extra esofágicas. Presentamos una mujer ex fumadora de 46 años que se presentó con sensación de quemazón en la boca, xerostomia y glositis. La paciente tenía además una historia de pirosis retroesternal, disfonía y tos. El examen bucal mostró una mala higiene bucal con abundante acumulación de sarro. Una medición de pH esofágico fue anormal. La laringoscopia mostró una inflamación laríngea posterior y secreción mucosa. Con estos antecedentes se llegó al diagnóstico de reflujo gastroesofágico.

Sindrome de sandifer: a propósito de la enfermedad por reflujo gastroesofágico en niños / Sandifer syndrome and gastroesophageal reflux in childre

El Síndrome de Sandifer es un trastorno neuroconductual con movimientos de hiperextensión de cuello, cabeza y tronco, con rotación de cabeza, que generalmente se presentan durante o inmediatamente después de la ingesta de alimentos y cesa durante el sueño, secundario a enfermedad por reflujo gastroesofágico. Se caracteriza por esofagitis, anemia por deficiencia de hierro y son confundidos con frecuencia como crisis de origen epiléptico. Lactante masculino de 5 meses referido por movimientos de tónico-clónicos generalizados, de segundos de duración, con una frecuencia de 30 episodios al día, que no ceden con el uso de 3 anticonvulsivantes. Disfagia a alimentos pastosos. Hospitalización al mes de vida por episodio de amenazante de la vida. Estudios neurológicos normales. Paraclínica: anemia microcítica e hipocrómica. Videodeglutoscopia: Disfagia de fase oral leve, disfagia fase esofágica a estudiar (Regurgitación), reflujo faringolaringeo según escala de Belafsky y Larigomalacia grado I; pHmetría de 24 horas con impedancia, puntación de Boix-Ochoa de 26%, durante la colocación de la sonda se observo posición anómala de la cabeza e hiperextensión del dorso. Estudio contrastado de esófago, estómago y duodeno sin anormalidad anatómica. Endoscopia digestiva superior: Esofagitis no erosiva, Hernia hiatal. El Síndrome de Sandifer es una de las presentaciones atípicas de RGE en lactantes. Amerita la evaluación de un equipo multidisciplinario para establecer el diagnóstico. El manejo medico incluyó medidas antireflujo, esomeprazol y técnica de alimentación adecuada con evolución satisfactoria. La diversidad de enfermedades relacionadas con RGE exige el uso de variadas técnicas para lograr diagnósticos más asertivos

Sandifer's syndrome is a neurobehavioral disorder with hyperextension movements of neck, head and trunk, head rotation, which usually occur during or immediately after food intake and ceases during sleep, secondary to gastroesophageal reflux disease. It is characterized by esophagitis, anemia and iron deficiency are often confused as a crisis of epileptic origin. A male infant of 5 months reported by tonic-clonic movements of widespread, lasting seconds, with a frequency of 30 episodes per day, which do not yield with the use of 3 anticonvulsants. Pasty food dysphagia. Hospitalization month of life-threatening episode of life. Normal neurological studies. Paraclinical: hypochromic microcytic anemia. Videodeglutoscopia: mild oral phase dysphagia, esophageal dysphagia to study phase (regurgitation), pharyngolaryngeal reflux as Belafsky and Larigomalacia scale grade I, ph-metry of 24 hours with impedance, Boix-Ochoa score of 26% during the placement of probe was observed abnormal head position and hyperextension of the back. Contrast study of esophagus, stomach and duodenum without anatomical abnormality. Upper gastrointestinal endoscopy: nonerosive esophagitis, hiatal hernia. Sandifer Syndrome is one of the atypical presentations of GER in infants. Warrants evaluation by a multidisciplinary team to establish the diagnosis. The medical management included antireflux measures, esomeprazole and proper feeding technique with satisfactory outcome. The diversity of diseases associated with GER requires the use of various diagnostic techniques to get more assertive

Experimental model of smoking and simulation of reflux with acid and pepsin in rats / Modelo experimental de tabagismo e simulação de refluxo com ácido e pepsina em ratos

PURPOSE: To develop experimental models to evaluate the effects of hydrochloric acid associated with the pepsin instilled in the mucosa of the upper esophagus and the esophagogastric junction of young male rats Wistar, simulating injury caused by gastroesophageal reflux on the mucosa of aero-digestive tract in humans as well as the action of the risk exposure of mucosa to cigarette smoke. METHODS: Fifty young male Wistar rats divided in 5 groups with 10 animals each one, respectively simulating pharyngo-laryngeal reflux and gastroesophageal reflux, pharyngo-laryngeal reflux and smoking, smoking only, gastroesophageal reflux and control group. RESULTS: The histopathologic studies no recorded neoplasias, only mild changes and no significant alterations. The hemo-oximetry (carboxyhemoglobin and methemoglobim) and CO2 concentration confirm that the animals were submitted to high intensity of exposure to carcinogens in tobacco and its derivatives. CONCLUSION: The experimental models were highly efficient, practical, easy to use and economical and can be employed in other similar studies to determine the harmful effects by smoking and reflux.

OBJETIVO: Desenvolver modelos experimentais para avaliar os efeitos do ácido clorídrico associado a pepsina, instilados na mucosa da parte superior do esôfago e da junção esofagogástrica de jovens ratos Wistar, simulando lesão causada por refluxo gastroesofágico na mucosa do trato aero-digestivo em humanos, bem como a ação da exposição ao risco de mucosa, como a fumaça de cigarro. MÉTODOS: Cinqüenta jovens ratos Wistar divididos em cinco grupos com 10 animais cada um, respectivamente, simulando o refluxo faringo-laríngeo e refluxo gastroesofágico, refluxo faringo-laríngeo e tabagismo, tabagismo só, refluxo gastroesofágico e grupo controle. RESULTADOS: os estudos histopatológicos não registraram neoplasias, apenas leves alterações e não significativas. O hemo-oximetria (carboxiemoglobina e metemoglobina) e concentração de CO2 corroboram que os animais foram submetidos a alta intensidade de exposição a substâncias cancerígenas do tabaco e seus derivados. CONCLUSÃO: os modelos experimentais desenvolvidos foram altamente eficientes, práticos, fáceis de usar e econômicos podendo ser empregados em outros estudos semelhantes para determinar os efeitos prejudiciais causados pelo tabagismo e refluxo.

Manometría esofágica en pacientes sometidas a gastrectomía vertical laparoscópica: servicio de cirugía dos / Esophageal manometry in patients undergoing laparoscopic vertical gastrectomy: servicio de cirugia dos

Evaluar mediante manometría, la motilidad esofágica y las características del esfinter esofágico inferior, en pacientes obesos antes y después de ser sometidos a gastrectomía vertical laparoscópica (GVL). Estudio descriptivo, correlacional y prospectivo comparando los hallazgos en la manometria esofágica en el postoperatorio respecto al preoperatorio en 12 pacientes sometidos a GVL. Unidad de Cirugía Endoscópica del Servicio de Cirugía Dos del Hospital Universitario de Caracas. No hubo diferencias estadísticamente significativa en los valores de la manometría esofágica, antes y después del procedimiento, para longitud total e intraabdominal del esfinter esofágico interior (EEI) (p=0,76 y p=0,43 respectivamente), presion de reposo del EEI (p=0,37) y amplitud esofágica distal (p=0,65). Se observó una disminución estadísticamente significativa, en los valores postoperatorios del porcentaje de relación del EEI (p=0.04) y del porcentaje de contracciones peristálticas (p=0.03). Las alteraciones manométricas evidenciadas pueden predisponer o incrementar la enfermedad por reflujo gastroesofágico (ERGE), ya que implican un manor vaciamiento esofágico. Sin embargo el mecanismo por el cual los individuos obesos sometidos a GVL. Desarrollan ERGE es complejo y multifactorial, ya que no obedece únicamente a posibles alteraciones del EEI, sino que esta asociado a otros factores como peristalsis esofágica, vaciamiento gástrico y presión intragástrica.

Assess by manometry esophageal motility and the characteristic of the lower esophageal sphincter (LES) in obese patients before and alter laparoscopic vertical gastrectomy (LVG). Descriptive, correlational and prospective investigation, comparing findings in the esophageal manometry in the postoperative compared to the preoperative in 12 patients undergoing LVG. Unit of Endoscopic Surgery of the Hospital Universitario de Caracas, Servicio de Cirugia Dos. There was no statistically significant difference in the values, of esophageal manometry before and alter the procedure, for total and intra-abdominal length of the LES (p=0.76 and p-0.43 respectively), resting LES pressure (p=0.37) and distal esophageal amplitude (p=0,65). There was a statististically significant decrease in postoperative values of the relaxation percentage of the LES (p=0.04) and percentage of peristaltic contractions (p=0.03). Manometric abnormalities that were detected in this study may predispose or increase gastroesophageal reflux disease (GERD), since they imply a lower esophageal emptying rate. However, the mechanism by which obese individuals, that underwent to LVG, develop GERD is complex and multifactorial, and not due solely to alterations of the LES, but is associated to other factors such as esophageal peristalsis, gastric emptying and intragastric pressure.

Eosinophilic esophagitis in patients with typical gastroesophageal reflux disease symptoms refractory to proton pump inhibitor

BACKGROUND: TREATMEN The contribution of eosinophilic esophagitis (EoE) to refractory gastroesophageal reflux disease (GERD) remains unknown. When EoE and GERD overlap, the clinical, endoscopic and histological findings are nonspecific and cannot be used to distinguish between the two disorders. Limited data are available on this topic, and the interaction between EoE and GERD is a matter of debate. AIM: We have conducted a prospective study of adult patients with refractory GERD to evaluate the overlap of reflux and EoE. METHODS: Between July 2006 and June 2008, we consecutively and prospectively enrolled 130 male and female patients aged 18 to 70 years old who experienced persistent heartburn and/or regurgitation more than twice a week over the last 30 days while undergoing at least six consecutive weeks of omeprazole treatment (at least 40 mg once a day). The patients underwent an upper digestive endoscopy with esophageal biopsy, and intraepithelial eosinophils were counted after hematoxylin/eosin staining. The diagnosis of EoE was based on the presence of 20 or more eosinophils per high-power field (eo/HPF) in esophageal biopsies. RESULTS: Among the 103 studied patients, 79 (76.7 percent) were females. The patients had a mean age of 45.5 years and a median age of 47 years. Endoscopy was normal in 83.5 percent of patients, and erosive esophagitis was found in 12.6 percent. Only one patient presented lesions suggestive of EoE. Histological examination revealed >20 eo/HPF in this patient. CONCLUSION: Our results demonstrated a low prevalence of EoE among patients with refractory GERD undergoing omeprazole treatment.

La hernia hiatal y su relación con el reflujo gastroesofágico / Hiatus hernia and its relations with gastro-esophageal reflux

La hernia hiatal (HH) es una condición relativamente frecuente en la población adulta. Su relación con el enfermedad por refl ujo gastroesofágico (ERGE) no está clara. El objetivo de este estudio fue contribuir a defi nir esta asociación. Con éste propósito, realizamos un análisis prospectivo de 335 personas (entre 15-92 años, edad promedio 50,6, 55,49% del sexo femenino). Nuestro estudio consistió en una revisión de las historias clínicas y esofagogastroduodenoscopia (EGD) para determinar presencia de hernia hiatal y de manifestaciones endoscópicas de esofagitis de refl ujo (ER) para determinar si existe o no una relación entre HH y ERGE. Una HH fue encontrada en 104 casos (31,04%), 78 (75%) fueron evidenciadas en pacientes con síntomas de refl ujo gastroesofágico (RGE) y 26 825%) en sujetos asintomáticos para RGE (p= 0.0001). Sin embargo, cuando el hallazgo de HH fue evaluado en pacientes sintomáticos para ERGE 37,50% (72/208 casos) y en aquello sin síntomas 20,47% (26/127 casos), no se encontró diferencia estadística significativa (p >0.05). 40 sujetos (11,94%) de la cantidad total de individuos analizados tuvieron alteraciones endoscópicas de RGE (90%), 36 de ellos con síntomas de RGE (90%) y 4 (10%) asintomáticos para esta condición (diferencia estadísticamente significativa P< 0.0001). La asociación entre HH y hallazgos endoscópicos de RE fue evidenciada en 20 de 40 casos (50%). De ellos, 19 tenían síntomas de RGE (95%). Sólo 1 (5%) fue asintomático de RGE. Hallazgos a la EGD de RE sin HH se encontraron en los otros 20, 17 de ellos (85%) sintomáticos para ERGE y 15% asintomáticos. En ambos subgrupos una diferencia estadísticamente significativa (P < 0-001) fue encontrada entre pacientes con síntomas de RGE y aquellos sin síntomas, reforzando la relación existente entre HH, hallazgos endoscópicos de RE y síntomas de ERGE. HH sin hallazgos endoscópicos de ER fue reportada en 84 individuos, 60 de ellos con síntomas de ERGE (71,42%)...

Hiatus Hernia (HH) is a relatively frequent condition in adult population. Its relation with the gastro-esophageal refl ux disease (GERD) is not clear. The purpose of this study was contributing to the definition of this association. With this aim a prospective analysis was performed on 335 people (ranging and age of 15-92, average age of 50.6, 55.49% women). The study was based on reviewing the clinical records and esophagogastroduodenoscopies (EGD) for determining the presence of hiatus hernia and endoscopic manifestations of refl ux esophagitis (RE) as well in order to define if whether a relationship between HH and GERD does exist or does not. One HH was found in out of 104 cases (31.04%), 78 (75%) were evidences in patients with gastro-esophageal refl ux symptoms (GER), and 26 (25%) in GER-asymptomatic subjects (p= 0.0001). However, when assessing the HH finding in GERD-symptomatic patients - 37.50% (72/208 cases) - and in those without symptoms - 20.47% (26/127 cases) - no significant statistical difference was found - (p >0.05). 40 subjects (11.94%) out of the total amount of the analyzed subjects showed endoscopic GER disturbances - (90%). 36 out of them showed GER symptoms (90%) and 4 (10%) were asymptomatic for this condition (statistically significant difference: P< 0.0001). The association between HH and the ER endoscopic findings was evidenced in 20 out of the 40 cases (50%). From them, 19 showed GER symptoms (95%). Only 1 (5%) was GER-asymptomatic. ER’s GED findings without HH were locate in other 20 subjects, where 17 (85%) were GERD-symptomatic and 15% was asymptomatic. A statistically significant difference (P < 0-001) was found in both subgroups among patients with GER symptoms and those without symptoms, thus strengthening the relation existing among HH, the endoscopic findings, and GERD symptoms. HH without RE endoscopic findings was reported in 84 people, 60 of them with GERD symptoms (71.42%) and 24 without symptoms (28.57%)...

Doença do refluxo gastroesofágico / Gastroesophageal reflux disease

A doença do refluxo gastroesofágico (DRGE) é uma condição que se desenvolve quando o refluxo do conteúdo procedente do estômago provoca sintomas desagradáveis e/ou complicações. O seu quadro clínico, em geral, costuma ser bastante simples, representado por pirose e/ou regurgitação (manifestações típicas). As manifestações atípicas (sintomas crônicos laríngeos, asma), entretanto, podem também se apresentar isoladamente, tornando mais difícil a suspeita diagnóstica. As manifestações clínicas da doença não são necessariamente correlacionadas com a gravidade das lesões esofágicas. A DRGE pode ser erosiva (quando erosões são visíveis ao exame endoscópico) ou não erosiva (endoscopia negativa). O exame endoscópico não apresenta sensibilidade elevada, já que em cerca de 50% das vezes as erosões não são vistas durante o procedimento. O método endoscópico permite a realização de biópsias nos casos de complicação, como o esôfago de Barrett, estenose e ulceração. A pHmetria de 24 horas é um método sensível e específico, mas apresenta alguns inconvenientes, entre os quais a incapacidade para reconhecer o refluxo duodenogástrico. Nesse sentido, a combinação da pHmetria com a impedância esofágica pode ser bastante útil. O tratamento clínico é dividido em medidas comportamentais/dietéticas (elevação da cabeceira da cama, perda de peso, suspensão do fumo, evitação de chocolate, alimentos gordurosos etc.) e farmacológicas, estas compreendendo o uso de inibidores da bomba protônica (omeprazol, lansoprazol, pantoprazol, rabeprazol e esomeprazol). As complicações da doença e os pacientes que requerem tratamento contínuo de manutenção, principalmente os mais jovens, consistem nas principais indicações cirúrgicas da DRGE. Usualmente os mais responsivos ao tratamento cirúrgico são os que melhor respondem ao tratamento clínico.

Variation of the intercellular space in the esophageal epithelium in response to hydrochloridric acid infusion in patients with erosive esophagitis

The purpose of this study was to compare esophageal infusion with 0.1 N hydrochloridric acid (HCl) to esophageal infusion with saline in patients presenting with typical gastroesophageal reflux symptoms and erosive esophagitis. METHODS: Upper gastrointestinal endoscopy was performed on 44 prospective subjects, 29 of whom were included in the study. Eighteen patients presented with normal esophagi (Control Group "C"), nine of whom were infused with HCl and nine with saline. Eleven patients presented with erosive esophagitis (Lesion Group "L"), five of whom were infused with HCl and six with saline. Biopsies of the esophageal mucosa were collected before and after infusions. RESULTS: No statistically significant difference was found between the two types of infusions in terms of the dilation of the intercellular space of the esophageal epithelium, regardless of the status of the patient. CONCLUSIONS: Response to HCl infusion cannot be used as a marker for gastroesophageal reflux disease.

Esófago de Barrett: la antesala del adenocarcinoma de esófago / Barrett's esophagus: a risk factor for esophageal adenocarcinoma

El esófago de Barrett (EB) es una complicación frecuente de la enfermedad por reflujo gastroesofágico y es un factor importante en el desarrollo de adenocarcinoma esofágico. El EB es sospechado por los hallazgos en la endoscopia y su diagnóstico se confirma cuando la histología demuestra la presencia de metaplasia intestinal en la mucosa esofágica. Dado que la mayoría de los pacientes con EB no desarrollará cáncer de esófago, es necesario definir nuevas estrategias que ayuden a identificar pacientes de mayor riesgo. Aunque la vigilancia de los pacientes con EB está basada aún en la toma sistemática de biopsias de la mucosa con metaplasia, nuevas técnicas endoscópicas de alta resolución pueden ayudar en el proceso de selección. El tratamiento endoscópico de la displasia en pacientes con EB es una nueva modalidad que espera mayor estudio para precisar su indicación.

Barrett's esophagus (BE) is a common complication of gastroesophageal re flux disease and is a major risk factor in the development of esophageal adenocarcinoma. BE is detected on endoscopy and confirmed when histology shows intestinal metaplasia. The majority of Barretts patients will not develop cancer of the esophagus, so new specific methods of identification of those at risk are needed. Although the surveillance of patients with BE is still based on systematic biopsy sampling of Barrett's mucosa endoscopy.

Relevance of ineffective esophageal motility with erosive and nonerosive gastroesophageal reflux disease.

INTRODUCTION: Ineffective esophageal motility (IEM) is a frequent finding in patients with gastroesophageal reflux disease (GERD). It is responsible for delayed acid clearance as it affects esophageal emptying and saliva transport. Since erosive GERD is a more severe disease than nonerosive GERD, it may be associated with IEM, which delays esophageal clearance. Objective : We investigated the role of IEM in patients with erosive and nonerosive GERD. METHODS: We enrolled 100 patients with heartburn and a primary diagnosis of GERD referred to the GI motility department of RCGLD of Shahid Beheshti University between January 2002 and January 2005. Based on endoscopic findings, the patients were classified into two groups of erosive GERD and nonerosive GERD. Manometry and 24-hour ambulatory pH-metry was performed in all patients. RESULTS: Seventy-seven patients completed the study: 31 (40.3%) with erosive GERD and 46 (59.7%) with nonerosive GERD. IEM was present in 38.7% of patients with erosive GERD and in 28.3% of those with nonerosive GERD (p=0.18). A low lower esophageal sphincter pressure was present in 45.2% of patients with erosive GERD, and in 45.7% of those with nonerosive GERD (p=0.97). Abnormal acid reflux was present in 32.3% and 41.3% of patients with erosive and nonerosive GERD, respectively (p=0.42). CONCLUSION: There was no difference in the prevalence of IEM between patients with erosive and nonerosive GERD. IEM could be an integral part of GERD and may not always be associated with mucosal injury.

Study clinical signs, gastroscopic and oesophageal histopathologic features, pH monitoring 24h in the patients with gastroesophageal reflux disease

Background: pH monitoring 24h is used to diagnose atypical gastroesophageal reflux disease or can be applied to consider surgery for cases poorly respond with medical treatment. Objective: To study clinical signs, gastroscopic and oesophageal histopathologic features, pH monitoring 24h in the patients with gastroesophageal reflux disease (GERD). Subjects and method: The descriptive, cross-sectional study was conducted in patients with gastroesophageal reflux disease treated at Bach Mai Hospital from November 2005 to October 2006. 73 patients with GERD diagnosed according to Romell criteria were underwent gastroscopy and biopsy. 15 patients having extraesophageal manifestations of gastroesophageal reflux disease were underwent gastroesophageal reflux monitoring pH. Results: 31 (42.4%) patients had oesophagitis in which 67.7% grade A, 6.5% grade D and C, 2.7% Barret, and 53.4% having gastritis associated. 61 % oesophagitis and 13.9% Barret were seen on the biopsy. 40% (6/15) patients had abnormal pH monitoring but there was no statistically significant difference in pH monitoring between the group having oesophagitis from those without oesophagitis (p > 0.05). Conclusions: Among 15 patients underwent Ph monitoring, the rate of patients with abnormal pH monitoring was 40%. There was no statistically significant difference of pH monitoring result between patients with or without esophagus lesion.

Doença do refluxo gastroesofágico e a odontologia: uma revisão de literatura / Gastroesophageal reflux disease and dentistry: a literature review

A doença do refluxo gastro-esofágico (DRGE) tem sido apontada na literatura como uma das condições patológicas do trato gastro-intestinal mais prevalentes. Manifestações extra-esofágicas da DRGE podem envolver desordens que afetam a cavidade bucal. O objetivo desta revisão da literatura é trazer à tona os aspectos da DRGE relacionados ao campo de atuação do cirurgião-dentista, envolvendo os mecanismos da gênese da doença e as manifestações extra-esofágicas relacionadas à cavidade bucal. A erosão dentária e a hipertrofia da base da língua têm sido evidenciadas como manifestações da DRGE em trabalhos retrospectivos, transversais e relatos de casos. Embora se observe um volume considerável de trabalhos em relação ao assunto, a evidência científica gerada por estes ainda é extremamente limitada. Nota-se a inexistência de ensaios clínicos longitudinais, controlados e randomizados. No entanto, a impordncia da saliva na integridade do sistema gastrointestinal já é consolidada. Uma ação interdisciplinar entre odontologia e medicina é de valor extremo.

Gastroesophageal reflux disease (GERD) is appointed in the literature as one of the most prevalent gasrrointestinal pathological conditions. Extra-esophageal manifestations of GERD mey involve oral conditions. The aim of this review is to demonstrate aspects of GERD related to dentistry, involving generating mechanisms and the extra-esophageal manifestations related to the oral cavity. Tooth erosion and tongue hypertrophy have been demonstrated in retrospective, cross-sectional and case reports. Although a considerable number or studies in this topic are available, the scientific evidence provided is extremely lirnited. Longitudinal randomized controlled trials are lacking. However, the importance of saliva in this context is definite. An interdisciplinary approach betWeen dentistry and medicine is of extreme importance.

Comparación entre el aspecto endoscópico del cardias, hallazgos manométricos y pHmetría de 24 horas en pacientes con síntomas de reflujo gastroesofágico crónico / Comparison of the endoscopic aspect of the cardia, manometry and 24 hours pH measurement in patients with chronic gastroesophageal reflux

Background: The endoscopic view of the gastric cardia could be related with the manometric competence of the lower esophageal sphincter (LES) and with pathological gastroesophageal reflux. Aim: To compare the endoscopic aspect of the cardia with the results from esophageal manometry and 24 h esophageal pH monitoring. Materials and Methods: The cardia of a group of 150 patients (aged 19 to 72 years, 89 women) with gastroesophageal reflux symptoms was classified as normal or open, during upper gastrointestinal endoscopy. All subjects were subjected to a manometric study to measure LES pressure and determine LES incompetence and to a 24 h esophageal pH measurement. Results: LES pressure was 14.7±6.2 and 8.7±4.2 mmHg in patients with normal and open cardia, respectvively (p <0.001). Likewise, 43 and 79% of patients with normal and open cardia had an incompetent LES, respectively (p <0.001). Pathological acid reflux was present in 43 and 71% of patients with normal or open cardia, respectively (p <0.001). Conclusions: The endoscopic appearance of the cardia can identify patients with pathological gastroesophageal reflux.

Experimental model of gastroesophageal reflux in rats

OBJETIVO: Desenvolver um modelo experimental de refluxo gastroesofágico em ratos. MÉTODOS: Sessenta ratos, Wistar, foram operados e distribuídos em três grupos de vinte animais. Os animais foram submetidos a miectomia total do esôfago em um grupo(A), e em outro grupo foram submetidos a miectomia parcial(B). O terceiro grupo foi o grupo controle(C). Para avaliar o refluxo gastroesofágico realizou-se o estudo radiológico contrastado do esôfago. O estudo anátomo-patológico do esôfago foi utilizado para avaliar esofagite. RESULTADOS: Durante os 30 dias de pós-operatório, 14 animais do grupo A apresentaram refluxo de Bário no esôfago. Em 07 animais do grupo B e em 02 do grupo controle, foram observados a presença de Bário no esôfago. O resultado do histopatológico foi controverso. Observou-se perda ponderal importante nos ratos submetidos a miectomia total, porém não existiu diferença estatística. CONCLUSÃO: A miectomia total realizada no terço inferior do esôfago provocou refluxo gastroesofágico na maioria dos animais.

Efecto del tegaserod sobre el pH y las relajaciones transitorias del esfinter esofágico interior en pacientes con enfermedad de reflujo gastroesofágico / Tegaserod effects in the hP and the transit lower esophageal shincter relaxitions in the gastro esophageal reflux disease patients

Determinar el efecto del tegaserod sobre el número de las relajaciones transitorias del esfínter esofágico inferior (RTEEI) y el número de episodios de reflujo ácido durante las mismas, en el estado de ayuno y postprandial inmediato, en pacientes con enfermedad de reflujo gastro-esofágico (ERGE). Se seleccionaron 10 pacientes con ERGE y esofagitis grado I y II a los cuales se les realizo una manometría inicial de 2 horas (1 h ayuno y 1 h postprandial) para evaluar el número de RTEEI y medir el pH durante las mismas. Posteriormente los pacientes se dividieron en 2 grupos al azar: Grupo A y B. El grupo A tomo tegaserod 6 mg OD por 7 días después placebo por 7 días y el grupo B tomaron placebo durante 7 días y después tegaserod 6 mg OD por 7 días. La manometría fue realizada después de terminar cada periodo de 7 días de tratamiento. Tegaserod redujo significativamente la tasa de RTEEI postprandial de una media de 5 en una hora a 1,1 y la tasa de RTEEI totales de 9,2 en dos horas a 2,2 (p<0,000008 y p<0,00002 respectivamente). La tasa de episodios de reflujo ácido durante las RTEEI en ayuna disminuyeron de una media de 0,8 en una hora a 0,1 y en el periodo postprandial de 1,5 en una hora a 1,1, esta reducción no fue significativa (p<0,62 y p<0,06 respectivamente). El tegaserod tiene la capacidad de disminuir las RTEEI efecto que pudiera ser considerado para ser utilizado como tratamiento en la ERGE