Gastrointestinal involvement due to graft-versus-host disease / Compromiso gastrointestinal por enfermedad de injerto contra huésped

Abstract Graft-versus-host disease is a common complication after stem cell transplantation. The digestive tract is affected in many patients who suffer from it, with consequences that can be fatal. The proper approach, which includes endoscopic studies, allows ruling out differential diagnoses and managing the disease early.

Resumen La enfermedad de injerto contra huésped es una complicación frecuente después del trasplante de células madre. El tracto digestivo se afecta en una gran proporción de los pacientes que la sufren, con consecuencias que pueden llegar a ser fatales. El abordaje adecuado, que incluye el uso de estudios endoscópicos, permite descartar diagnósticos diferenciales y brindar un manejo temprano de la enfermedad.

Gastric disorders of cattle in western Rio Grande do Sul State, Brazil / Distúrbios gástricos de bovinos no Oeste do Rio Grande do Sul

A retrospective study of gastric disorders in autopsied cattle in the Western region of Rio Grande do Sul State, was performed. The exam reports of bovine necropsy of the Veterinary Pathology Laboratory, Unipampa, were analyzed in the period from 2010 to 2018. All cases in which death was primarily caused by disturbance in the gastric chambers were included. During the period evaluated, 141 cattle were necropsied. Of those, 25 had gastric disorders. Of those, 53% had alterations in the rumen, followed by abomasum (17%), involvement of two chambers (13%) and reticulum (9%). Most cases corresponded to beef cattle raised in an extensive system and most them for calf production and fattening with an average age of approximately three years. The cases occurred in farms of four different municipalities. Bullous bloat by excessive Trifolium repens ingestion was the gastric disturbance with the highest number of dead cattle observed in this study, especially in irrigated áreas of livestock farms. Cases such as lactic acidosis, ruminal alkalosis due to excessive urea ingestion and Baccharis coridifolia poisoning were also important gastric disturbances in necropsied cattle, associated especially with poor management and period of scarcity of good quality fodder. Cases of Clostridium perfringens infection were also observed in young cattle suggesting that it is an important infectious agent in the evaluated cattle herds, also showing failures in vaccination of the herds. As observed, gastric disturbances in cattle in the western region of Rio Grande do Sul have several causes. Metabolic/toxic and infectious disturbances were important causes of mortality in the herds, inducing considerable economic losses. Based on this study, it is clear that the majority of outbreaks or isolated cases occurred due to errors in the management of the properties and the vast majority of them could have been avoided with improvements in the technical qualification of the workers and simple adjustments in the farming methods. It is also emphasized the importance of the conclusive diagnosis to control these disorders, once after the orientation to the producers, was observed significant decrease in cattle losses in the farms.(AU)

Foi realizado estudo retrospectivo dos distúrbios gástricos em bovinos necropsiados na região Oeste do Rio Grande do Sul. Foram analisados os relatórios de exame de necropsia de bovinos do Laboratório de Patologia Veterinária (LPV) da Universidade Federal do Pampa (Unipampa), Rio Grande do Sul, no período de 2010 a 2018. Foram incluídos todos os casos nos quais a morte foi causada primariamente pelo distúrbio nas câmaras gástricas. De um total de 141 bovinos necropsiados, 25 corresponderam a distúrbios gástricos. Dentre esses, 53% apresentaram alterações no rúmen, seguido de abomaso 17%, acometimento concomitante de duas câmaras 13% e retículo 9%. A maioria dos casos ocorreram em bovinos de corte criados em sistema extensivo e a maioria destinados à produção de bezerros e engorda com média de idade de aproximadamente três anos. Os casos ocorreram em propriedades rurais de quatro municípios da região Oeste do estado. O timpanismo bolhoso por ingestão excessiva de Trifolium repens foi o distúrbio gástrico com maior número de bovinos mortos observados nesse estudo, especialmente em propriedades com criação de animais em áreas de irrigação. Casos como acidose láctica, alcalose ruminal por intoxicação por ureia e intoxicação por Baccharis coridifolia também foram importantes distúrbios gástricos nos bovinos necropsiados e percebeu-se sua associação a falhas no manejo e à época de escassez de forragem de boa qualidade. Foram observados ainda casos de infecção por Clostridium perfringens em bovinos jovens o que sugere também tratar-se de um importante agente infeccioso nos rebanhos bovinos avaliados, demonstrando ainda falhas na vacinação dos rebanhos. Conforme observado, diversos são os distúrbios gástricos em bovinos na região Oeste do Rio Grande do Sul, tendo como importantes causas de mortalidades os distúrbios metabólicos/tóxicos e infecciosos, induzindo consideráveis perdas econômicas. Com base nesse levantamento, percebe-se que a maioria dos surtos ou casos isolados estudados ocorreram por erros no manejo nas propriedades e, na sua grande maioria, poderiam ter sido evitados com especialização da mão de obra e ajustes simples. Ressalta-se ainda a importância do diagnóstico conclusivo para controle desses distúrbios, uma vez que, após a orientação aos produtores, observou-se significativa diminuição das perdas de bovinos nas propriedades.(AU)

Tumores neuroendocrinos del tracto gastroenteropancreático. Estudio multicéntrico / Neuroendocrine tumors of the gastroenteropancreatic tract. A multicentric study

Introducción: Los tumores neuroendocrinos del tracto gastroenteropancreático constituyen un grupo infrecuente de neoplasias, de diagnóstico tardío y tratamiento complejo. Objetivo: Caracterizar clínica, macroscópica e histopatológicamente los tumores neuroendocrinos del tracto gastro enteropancreático. Material y Método: Se realizó un estudio observacional descriptivo de corte transversal, con 54 pacientes con diagnóstico histopatológico de estas neoplasias, confirmados por inmunohistoquímica, diagnosticados en el Instituto de Gastroenterología, Instituto Nacional de Oncología y Radiobiología y el Hospital Clínico-Quirúrgico Hermanos Ameijeiras, en el período 2008-2014. Resultados: El sexo femenino (66,7 por ciento y el grupo de edad de 50-69 años (48,1 por ciento), fueron los más frecuentes. La manifestación clínica más reportada fue el dolor abdominal (87 por ciento), seguido de las diarreas (16.7 por ciento), y del íctero (14.8 por ciento). Los tumores fueron más frecuentes en intestino delgado (31,5 por ciento) y páncreas (27,8 por ciento). La lesión endoscópica polipoidea se observó en 88,9% de los pacientes. La mayoría de los tumores midieron menos de 2 cm. Los tumores grado 1 y 2 tuvieron igual comportamiento en cuanto a frecuencia (40.7 por ciento). No hubo asociación estadísticamente significativa entre la localización del tumor, el tamaño y el grado histológico. Conclusiones: Predominó el sexo femenino y el grupo de edad de 50-69 años, el síntoma clínico más frecuente fue el dolor abdominal, las lesiones se localizaron con mayor frecuencia en intestino delgado y páncreas, con un predominio de la forma polipoide como patrón endoscópico y menores de 2 cm. No hubo asociación entre la localización anatómica, el tamaño de la lesión y la clasificación histopatológica(AU)

Gastrointestinal cytomegalovirus disease in a patient with pemphigus vulgaris treated with corticosteroid and mycophenolate mofetil

Pemphigus vulgaris is an autoimmune disease characterized by the formation of suprabasal intra-epidermal blisters on the skin and mucosal surfaces. Infectious diseases are the main cause of death in patients with pemphigus due to the disrupture of the physiological skin barrier, immune dysregulation, and the use of immunosuppressive medications leaving the patient prone to acquire opportunistic infections. We report the case of a 67-year-old woman diagnosed with pemphigus vulgaris, who was irregularly taking prednisone and mycophenolate mofetil. She was hospitalized because of a 1-month history of watery diarrhea and oral ulcers. Unfortunately, the patient died suddenly on the ward. The autopsy revealed a bilateral saddle pulmonary embolism, Gram-positive cocci bronchopneumonia, and gastrointestinal cytomegalovirus infection, causing extensive gastrointestinal mucosal ulcers.

ENDOSCOPIC ULTRASOUND IN THE EVALUATION OF UPPER SUBEPITHELIAL LESIONS / Ultrasson endoscópico na avaliação das lesões subepiteliais do trato digestivo alto

BackgroundEndoscopic ultrasound is considered the best imaging test for the diagnosis and evaluation of subepithelial lesions of the gastrointestinal tract.ObjectiveThe present study aims to describe the endosonographic characteristics of upper gastric subepithelial lesions and our experience using endoscopic ultrasound for evaluation of such lesions.MethodsRetrospective data study of 342 patients who underwent endoscopic ultrasound evaluation of subepithelial lesions.ResultsLesions of the fourth layer were more common in the stomach (63.72%) than in the esophagus (44.68%) and duodenum (29.03%). In stomach, 81.1% of the lesions ≥2 cm, and 96.5% ≥3 cm, were from the fourth layer. Endosonographic signs that could be related to malignant behavior, such as irregular borders, echogenic foci, cystic spaces and/or size greater than 3 cm were identified in 34 (15.81%) lesions at the first endoscopic ultrasound evaluation. Endoscopic ultrasound-fine needle aspiration did the diagnosis in 21 (61.76%) patients who were submitted a puncture. Three (12.0%) lesions of 25 who were submitted to regular endoscopic ultrasound surveillance increased the size.ConclusionStomach is the organ most affected with subepithelial lesions of the gastrointestinal tract and the fourth layer was the most common layer of origin. More than 80% of gastric subepithelial lesions from the fourth layer are ≥2 cm. Endoscopic ultrasound evaluation of subepithelial lesions has been very important for stratification into risk groups and to determine the best management.

ContextoA ecoendoscopia é considerada o melhor método de imagem para diagnosticar e avaliar as lesões subepiteliais do trato digestivo.ObjetivoO presente estudo tem como objetivo fazer uma análise dos casos submetidos a ecoendoscopia para avaliação de lesões subepiteliais do trato digestivo alto.MétodosForam analisados de forma retrospectiva 342 pacientes submetidos a ecoendoscopia para avaliação de lesões subepiteliais.ResultadosLesões da quarta camada foram mais comuns no estômago (63,72%) do que no esôfago (44,68%) e no duodeno (29,03%). No estômago, 81,1% das lesões >2 cm, e 96,5% >3 cm, eram da quarta camada. Sinais endossonográficos que poderiam ser relacionados com o comportamento maligno, como bordas irregulares, focos ecogênicos, espaços císticos e/ou tamanho maior que 3 cm foram identificados em 34 lesões (15,81%) na primeira avaliação com ecoendoscopia. Aspiração por agulha fina guiada por ultrassom endoscópico fez o diagnóstico em 21 (61,76%) dos pacientes que foram submetidos a punção ecoguiada. Três (12,0%) lesões das 25, que foram submetidas a vigilância pela ecoendoscopia, aumentaram de tamanho.ConclusãoO estômago é o órgão mais afetado pelas lesões subepitelias do trato gastrointestinal alto, sendo a camada muscular própria a camada de origem mais comum. Mais de 80% das lesões gástricas subepiteliais da quarta camada são >2 cm. A avaliação ecoendoscópica das lesões subepiteliais tem sido muito importante para a estratificação em grupos de risco e para determinar a melhor conduta.

Fatores de risco para incontinência urinária em mulheres idosas praticantes de exercícios físicos / Risk factors for urinary incontinence in elderly women practicing physical exercises

OBJETIVO: Analisar os fatores de risco para incontinência urinária (IU) em mulheres idosas praticantes de exercícios físicos (EF). MÉTODOS: Participaram deste estudo 152 mulheres idosas, com média de idade de 68,6±5,8 anos, praticantes de EF regularmente. Foram identificadas a presença de IU e fatores de risco ginecológicos, obstétricos, clínicos, comportamentais, hereditários e antropométricos. Também foi aplicado o Domínio 4 do Questionário Internacional de Atividade Física (IPAQ) para identificação do nível de atividade física e mensurados índice de massa corporal (IMC) e circunferência da cintura (CC). Os dados foram tratados por meio de estatística descritiva e inferencial, com nível de significância de 5%. RESULTADOS: A prevalência de IU na amostra foi de 32,2%. Entre os fatores avaliados, apenas o uso de diuréticos (RC=2,7; IC95% 1,0-7,0) e o histórico familiar de perda urinária positivo (RC=2,3; IC95% 1,1-4,8) foram associados aos sintomas de IU. CONCLUSÃO: O uso de diuréticos é considerado um fator de risco modificável da IU, enquanto o histórico familiar é um fator de risco não modificável. .

PURPOSE: To analyze the risk factors for urinary incontinence (UI) in older women practicing physical exercises (PE). METHODS: A total of 152 older women with a mean age of 68.6±5.8 years who regularly practiced PE participated in the study. The presence of UI and gynecological, obstetric, clinical, behavioral, hereditary and anthropometric risk factors was determined identified. It was also applied the Domain 4 of the International Physical Activity Questionnaire (IPAQ) to determine the level of physical activity and body mass index and waist circumference were measured. Data were analyzed using descriptive and inferential statistics, with the level of significance set at 5%. RESULTS: The prevalence of UI in the sample was 32.2%. Among the factors evaluated, only the use of diuretics (OR=2.7; 95%CI 1.0-7.0) and a positive family history of urinary incontinence (OR=2.3; 95%CI 1.1-4.8) were associated with UI symptoms. CONCLUSION: The use of diuretics is considered to be a modifiable risk factor for UI, whereas a family history is not considered to be a modifiable risk factor. .

Parenteral Nutritional Support in Gastrointestinal and Liver Diseases / 대한소화기학회지

Protein-calorie malnutrition and deficiencies of specific nutrients could commonly occur in various types of gastrointestinal diseases. These nutritional problems could delay recovery from diseases, resulting in increased morbidity and mortality, and impairment of quality of life. Parenteral nutrition (PN) is one of the methods of nutritional support through which macronutrients (glucose, amino acids, and triglycerides), micronutrients (vitamins and trace elements), water, and electrolytes are administered via peripheral or central venous route. PN could play an important role for patients for whom enteral/oral feeding is contraindicated or cannot meet the patients' requirement for adequate nutrition due to anatomical and/or functional problems. Since insufficient and excessive PN supplement could both be harmful for patients, it is very important to adhere to correct indication, optimal timing, and dosage/composition of PN. In this article, the current role of PN for various gastrointestinal diseases will be reviewed and discussed.

Enteral Nutritional Support in Gastrointestinal and Liver Diseases / 대한소화기학회지

Nutritional support is important because malnutrition is a major contributor to increased morbidity and mortality, decreased quality of life, increased length of hospital stay, and higher healthcare costs. Patients with gastrointestinal disease are at an increased risk of nutritional deterioration due to therapeutic dietary restriction, fasting for the diagnostic tests, loss of appetite due to anorexia or altered nutritional requirement caused by the disease itself. Therefore, it is important that gastroenterologists are aware of the nutritional status of patients and plan a treatment strategy considering patient's nutritional status. Enteral nutrition is preferred to parenteral nutrition as it is more physiologic, has fewer complications, help to prevent mucosal atrophy and maintain gut barrier function, which decrease intestinal bacterial translocation. Hence, enteral nutrition has been considered to be the most effective route for nutritional support. In this article, we will review enteral nutrition (oral nutritional supplements, enteral tube feeding) as a treatment for the patients with gastrointestinal, liver and pancreatic disease at risk of malnutrition.

Acurácia da ultrassonografia endoscópica no diagnóstico diferencial dos abaulamentos subepiteliais do trato gastrointestinal / Accuracy of endoscopic ultrasound in the differential diagnosis of subepithelial bulging of the gastrointestinal tract

Introdução: A ultrassonografia endoscópica é importante ferramenta para o diagnóstico diferencial dos abaulamentos subepiteliais do trato gastrointestinal por permitir delinear as diferentes camadas da parede do tubo digestivo. Neste estudo, analisamos o papel do método na avaliação das lesões intramurais subepiteliais e das compressões extrínsecas do trato gastrointestinal. Métodos: Uma análise retrospectiva do papel da ultrassonografia endoscópica para pacientes encaminhados com abaulamentos subepiteliais do esôfago, estômago, duodeno e retossigmoide foi conduzida em um centro de referência pelo mesmo examinador (CVL). Os achados ecográficos analisados foram a natureza da lesão, sua camada de origem, tamanho, bordos, ecogenicidade, homogeneidade e diagnóstico presuntivo. Resultados: De setembro/2009 a março/2013, 126 pacientes (63,5% mulheres; idade média: 51,6 anos) com 128 abaulamentos subepiteliais à endoscopia foram analisados. Das 128 lesões, 104 (81,2%) eram lesões intramurais. Outros 24 (18,8%) abaulamentos eram compressões extrínsecas, na maioria dos casos (n = 21), por órgãos e estruturas normais. Para a detecção de lesões intramurais pela imagem da ultrassonografia endoscópica, a sensibilidade, especificidade, valores preditivos positivo e negativo, e a acurácia do método foram de, respectivamente, 98,1%, 92%, 98,1%, 92% e 96,9%. Por sua vez, para a detecção de compressões extrínsecas pela ultrassonografia endoscópica, os mesmos parâmetros foram de, respectivamente, 92%, 100%, 100%, 98,1% e 98,5%. Quando da punção ecoguiada para lesões intramurais, agulhas calibrosas e lesões maiores de 2cm apresentaram melhores resultados quanto ao diagnóstico diferencial. Conclusões: A ultrassonografia endoscópica é método de grande acurácia para o diagnóstico diferencial entre lesões subepiteliais intramurais e compressões extrínsecas do trato gastrointestinal (AU)

Introduction: Endoscopic ultrasonography is an important tool for the differential diagnosis of gastrointestinal subepithelial bulges because it allows to outline the different layers of the wall of the digestive tract. In this study, we analyzed the role of the method in the evaluation of subepithelial intramural lesions and extrinsic compressions of the gastrointestinal tract. Methods: A retrospective analysis of the role of endoscopic ultrasound for patients with subepithelial bulges of the esophagus, stomach, duodenum and rectosigmoid was conducted in a reference center by the same examiner (CVL). The sonographic findings analyzed were the nature of the injury, its layer of origin, size, borders, echogenicity, homogeneity, and presumptive diagnosis. Results: From September 2009 to March 2013, 126 patients (63.5% women, mean age: 51.6 years) with 128 subepithelial bulges at endoscopy were analyzed. Of the 128 lesions, 104 (81.2%) were intramural lesions. Other 24 (18.8%) bulges were extrinsic compressions, in most cases (n = 21) by normal organs and structures. For the detection of intramural lesions by endoscopic ultrasound image, the sensitivity, specificity, positive and negative predictive values, and accuracy of the method were, respectively, 98.1%, 92%, 98.1%, 92% and 96.9%. In turn, for the detection of extrinsic compression by endoscopic ultrasound, the same parameters were, respectively, 92%, 100%, 100%, 98.1% and 98.5%. For ultrasonographic-guided puncture for intramural lesions, thicker needles and lesions larger than 2 cm showed better outcomes concerning differential diagnosis. Conclusions: Endoscopic ultrasound is a highly accurate method for the differential diagnosis between subepithelial intramural lesions and extrinsic compressions of the gastrointestinal tract (AU)

Beneficio de la ecosonografía abdominal en la evaluación pediátrica de rutina / Routine abdominal ecosonografic scan in children

La ecografía abdominal es importante en el diagnóstico y tratamiento de un número elevado de patologías abdominales. El dolor abdominal es la principal indicación de ecografía. Se plan-tea la posibilidad de diagnosticar alteraciones y/o patologías asintomáticas, que pueden requerir intervención temprana. Determinar el beneficio de la ecosonografía abdominal en la evaluación pediátrica de rutina. Trabajo prospectivo y transversal. Se incluyen pacientes escogidos al azar, para realizarles ecografía abdominal. Distribuidos en grupo A, los niños con solicitud de evaluación gastrointestinal y grupo B, niños sin patología gastrointestinal. Se solicita consentimiento informado. Un total de 182 niños, promedio de edad 4,70 años (rango 1m-14 años), 92 varones y 90 hembras. De 131 niños, con enfermedad gastrointestinal, grupo A, 32(24,42%) presentaron alteraciones a la ecografía. De ellos 17/32(53,12%) con hallazgos ecográficos en relación a la enfermedad de base siendo lo más frecuentes hepatopatías (esteatosis, hepatomegalia, fibrosis periportal), litiasis vesicular, cambios en vísceras huecas y reflujo gastroesofágico; 15/32(46,88%) se detectaron alteraciones no relacionados con la enfermedad de base, como: enfermedad renal, tumoración abdominal, esplenomegalia. Grupo B: 16/51 (31,37%) se detectó alteraciones en órganos abdominales: barro biliar, esplenomegalia, hepatopatía, alteraciones renales y otras. Se encontró una diferencia significativa entre los grupos, en relación al hallazgo de alteraciones ecográficas no relacionadas con el motivo de consulta. Los resultados permiten inferir que la ecografía es una herramienta sensible que puede ser utilizada de rutina en la evaluación pediátrica para detectar alteraciones en órganos abdominales para una intervención temprana y tratamiento oportuno.

Abdominal ultrasound is important in the diagnosis and treatment of a large number of abdominal pathology. Abdominal pain is the main indication for ultrasound. It raises the possibility of diagnosing disorders and/or asymptomatic pathologies that may require early intervention. To determine the benefit of abdominal sonography in the routine pediatric evaluation. Prospective and cross. Includes patients are randomly selected for abdominal ultrasound and distributed in two groups: Group A, children with gastrointestinal application indication for assessment and group B, children without gastrointestinal pathology. Informed consent is requested. Results: A total of 182 children, mean age 4.70 years (range 1 m-14 years), 92 males and 90 females. Of 131 children with gastrointestinal disease, group A, 32 (24.42%) had alterations to the ultrasound. Of these 17/32 (53.12%) with ultrasound findings in relation to the underlying disease being the most common liver disease (steatosis, hepatomegaly, periportal fibrosis), gallstones, changes in hollow viscera and gastroesophageal reflux; 15/32 (46.88%) were detected abnormalities not related to underlying disease, such as kidney disease, abdominal tumor, splenomegaly. Group B: 16/51 (31.37%) resulted with detected abnormalities in abdominal organs, biliary sludge, spleen, liver, renal and others. We found a significant difference between groups in relation to the discovery of ultrasound abnormalities unrelated to the complaint. The results allow to conclude that ultrasound is a sensitive tool that can be used in routine pediatric evaluation to detect changes in abdominal organs for early intervention and treatment.

Morphological changes in the digestive system of 93 human immunodeficiency virus positive patients: an autopsy study / Alterações morfológicas no sistema digestivo de 93 pacientes infectados pelo vírus da imunodeficiência humana: um estudo de autopsias

Involvement of the digestive system in patients with acquired immunodeficiency syndrome (AIDS) is frequent and many changes in these patients are diagnosed only at autopsy. There are few studies of autopsy with detailed analysis of this system and only one was conducted in Brazil. We evaluated each segment of the digestive system in 93 consecutive autopsies of patients infected with human immunodeficiency virus (HIV) and the importance of these lesions to death. Of these, 90 (96.8%) patients had AIDS. We reviewed medical records, autopsy reports and histological sections from tongue to rectum stained with hematoxylin-eosin. When necessary, we analyzed special stains and immunohistochemistry to investigate infections. There was damage to the digestive system in 73 (78.5%) cases. The most common infections were candidiasis (42%), cytomegalovirus (29%), histoplasmosis (11.8%), toxoplasmosis (9.7%) and mycobacterial infection (9.7%). Malignancies were rare, present in four (4.3%) cases (two Kaposi's sarcoma, one adenocarcinoma and one metastatic embryonal carcinoma). All segments showed lesions: tongue (48.6%), esophagus (44.8%), stomach (44.7%), colon (43.2%) and small intestine (28.9%). The lesions found were immediate cause of death in five (5.4%) cases. In another 36 (38.7%) cases the basic disease was systemic and also compromised the digestive system.

Envolvimento do sistema digestório em pacientes com síndrome da imunodeficiência adquirida (AIDS) é frequente e muitas alterações nesses pacientes são diagnosticadas apenas à autopsia. Há escassos estudos de autopsia com análise detalhada desse sistema e apenas um deles foi realizado no Brasil. Neste estudo avaliamos cada segmento do sistema digestório em 93 autopsias consecutivas de indivíduos infectados pelo vírus da imunodeficiência humana (HIV) e a importância dessas lesões para o óbito. Desses, 90 (96,8%) pacientes apresentavam AIDS. Revisamos prontuários médicos, relatórios de autopsias e cortes histológicos da língua ao reto corados pela técnica de hematoxilina-eosina. Quando necessário, analisamos colorações especiais e imuno-histoquímica para pesquisar infecções. Havia lesões no sistema digestório em 73 (78,5%) casos. As alterações mais comuns foram infecciosas: candidíase (42%), citomegalovirose (29%), histoplasmose (11,8%), toxoplasmose (9,7%) e infecção por micobactérias (9,7%). Neoplasias malignas foram raras, presentes em quatro (4,3%) casos (dois sarcomas de Kaposi, um adenocarcinoma gástrico e um carcinoma embrionário metastático). Todos os segmentos apresentaram lesões: língua (48,6%), esôfago (44,8%), estômago (44,7%), intestino grosso (43,2%) e intestino delgado (28,9%). As lesões encontradas foram causa imediata do óbito em cinco (5,4%) casos. Em outros 36 (38,7%) casos a doença básica era sistêmica comprometendo, também, o sistema digestório.

Successful Primary Infliximab Treatment of Orofacial Crohn's Disease without Gastrointestinal Manifestation / 대한소화기학회지

Crohn's disease is a chronic inflammatory bowel disease that can involve the whole gastrointestinal tract. The orofacial manifestation of Crohn's disease, which is rare, can develop irrespective of intestinal involvement. These orofacial lesions are often misdiagnosed as simple oral ulcers. Corticosteroids are the mainstay of therapy for orofacial Crohn's disease. However, infliximab, the chimeric monoclonal antibody to tumor necrosis factor-alpha, is now considered as a primary treatment because of the disease's relatively high rate of steroid resistance. We present a case of deep oral ulcer and periorbital swelling in a 65-year-old woman. She was diagnosed with intestinal Crohn's disease 7 years ago, which was in remission after treatment with an immunosuppressive agent (azathioprine). The patient was given the diagnosed with orofacial Crohn's disease and successfully treated with infliximab.

Tityus zulianus and Tityus discrepans venoms induced massive autonomic stimulation in mice

Venezuelan scorpion envenomation is a public health problem produced by Tityus discrepans (TD) and Tityus zulianus (TZ) species. Patients-envenomend by TD developed gastrointestinal and pacreatic disorders and scorpion accidents involving TZ are associated with high mortality rate, which showed cardiopulmonary clinical disorders may be associated to the high levels of plasma catecholamines levels. This distinctive clinical output seems to be associated to a toxin repertoire diversity, which has been previously demonstrated. Trying to mimic the human-envenomation, some toxinological studies have been performed using TD and TZ venoms in several biomedels such as mice and anesthetized rams. The purpose of this study was to evaluate, in vivo using biomodels (mice), the role of autonomic nervous system (sympathetic) stimulation producing some of the clinical signs, via the catecholamines release, on the patho-physiology of the TZ and TD induced envenomation. Thus, a clinical signs here reported during a period of 1 hr, after a single intra-peritoneal injection of sub-lethal doses of TZ or TD venom, which are related with diarrhea, diaphoresis, intense salivation, dehydratation, dyspnea and spasticity in hind limbs. However, these animals did not exhibit vomiting, which is the most frequent human-envenomed TD patients. All animals inoculated with (TD or TZ) venoms develped diarrhea being more pronounced in TD group. Diaphoresis, sialorrhea and dehydratation were mainly observed in TD group. Dyspnea and the hind limb spasticity were only developed in TZ mice. These clinical manifestations (diarrhea, sialorrhea, dehydratation and intense salivation) are related to an activation of autonomic nervous system, via an intense release of their related neurotransmitters. Thus, autonomic stimulation (sympathetic) was evaluated following the catecholamine (Nor-Epinephrine) (NE) plasma levels in a function of envenomation time. We found a significant increments at 1 hr,...

El escorpionismo en Venezuela es un problema actual de salud pública producido por las especies de Tityus discrepans (TD) y Tityus zulianus (TZ). Los pacientes que presentan escorpionismo producido por TD desarrollan trastornos gastrointestinales y pancreáticos mientras que los afectados por TZ presentan una alta mortalidad y muestran una sintomatología relacionada a desordenes cardiopulmonares, los cuales parecen estar asociados a niveles elevados de las catecolaminas plasmáticas. Esta clínica diferente parece estar asociada a una composición distinta de toxinas de dichos venenos, lo cual ha sido previamente demostrado. En un intento de mimetizar o reproducir el escorpionismo en humanos se han realizado estudios toxinológicos con los venenos de TZ y TD utilizando varios biomodelos como son ratones y carneros anestesiados. El propósito de este trabajo fue evaluar, “in vivo” usando un Biomodelo (ratones), el papel de la estimulación del sistema nervioso autónomo (simpático) para producir algunos signos clínicos, vía la liberación de catecolaminas, en la fisiopatología del escorpionismo producido por TZ y TD. Así, los signos clínicos aquí descritos y observados durante 1 hr., después de la inyección de una dosis sub-letal de los venenos de TZ y TD, fueron la presencia de diarrea, diaforesis, salivación intensa, deshidratación, disnea y parálisis en las extremidades posteriores. Sin embargo, estos animales no presentaron vómitos, el cual es uno de los signos más frecuentemente observado en los pacientes con accidentes escorpiónicos por TD. Todos los animales inyectados con los venenos de TD y TZ presentaron diarrea especialmente en grupo TD. La disnea y la parálisis en los miembros posteriores fueron sólo observadas en el grupo de ratones inyectados con TZ. Las manifestaciones clínicas como son diarrea, diaforesis y la salivación intensa están asociadas a una activación del sistema nervioso autónomo...

Upper endoscopy versus endosonography in differential diagnosis of gastrointestinal bulging / Endoscopia digestiva alta versus ecoendoscopia no diagnóstico diferencial dos abaulamentos gastrointestinais

CONTEXT: The identification of a bulging covered by normal epithelium is a common finding during an upper gastrointestinal endoscopy. OBJECTIVE: To compare the endoscopic and endosonography findings in the differential diagnosis of the gastrointestinal bulging (subepithelial tumor or extrinsic compression). METHOD: Patients referred by endosonography with bulging of upper gastrointestinal tract were studied retrospectively. The size, location, consistency and presumptive diagnosis were recorded at time of endoscopy and endosonography. Endosonography-guided fine-needle aspiration was proposed in case of uncertain diagnose to increase diagnostic sensitivity. RESULTS: One hundred seventy-six patients (93 women) and mean age 62.5 years (10-87). One hundred fifty-three had subepithelial tumor and 23 had extrinsic compression as a final diagnosis. Endosonography had sensitivity, specificity and accuracy higher than those found by endoscopy for both diagnosis subepithelial tumor and extrinsic compression. Endoscopy and endosonography showed poor concordance (K = 0.13) for subepithelial tumor diagnosis and unsuitable agreement for diagnosis in extrinsic compression (K = 0.01). The endosonography-guided fine-needle aspiration had sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 75 percent, 72.4 percent, 80.5 percent, 65.6 percent and 74 percent, respectively. CONCLUSION: Endoscopy has high sensitivity and low specificity for subepithelial tumor and both are low for the extrinsic compression. Endoscopy is a good tool for diagnosis of the subepithelial tumors, but not to determine the cause of an extrinsic compression. The endosonography identifies the layer from which subepithelial tumor comes, obtain histological samples, and increasing the diagnostic accuracy.

CONTEXTO: Abaulamentos da parede do trato gastrointestinal cobertos por epitélio normal são achados comuns durante endoscopia digestiva alta. OBJETIVOS: Comparar os achados da endoscopia com os da ecoendoscopia no diagnóstico diferencial entre tumor subepitelial e compressão extrínseca. MÉTODO: Estudaram-se, retrospectivamente, pacientes com abaulamento do trato gastrointestinal alto encaminhado à ecoendoscopia. O tamanho, localização, consistência e o diagnóstico presuntivo foram registrados no momento da endoscopia e da ecoendoscopia. Esta associada à punção aspirativa com agulha fina foi proposta nos casos de dúvida para aumentar a sensibilidade diagnóstica. RESULTADOS: Cento e setenta e seis pacientes (93 mulheres), com média de idade de 62,5 anos (10-87 anos). O diagnóstico final foi de tumor subepitelial em 153 (87 por cento) e compressão extrínseca em 23 (13 por cento). A sensibilidade, especificidade e precisão obtida pela ecoendoscopia foram superiores as da endoscopia, tanto para o diagnóstico do tumor subepitelial como de uma compressão extrínseca. A endoscopia e a ecoendoscopia mostraram concordância ruim (k = 0,13) para o diagnóstico de tumor subepitelial e concordância inadequada para o diagnóstico de compressão extrínseca (k = 0,01). A punção aspirativa com agulha fina apresentou sensibilidade, especificidade, valor preditivo positivo, valor preditivo negativo e precisão de 75 por cento, 72,4 por cento, 80,5 por cento, 65,6 por cento e 74 por cento, respectivamente. CONCLUSÃO: A endoscopia tem alta sensibilidade e baixa especificidade para o diagnóstico de tumor subepitelial. No caso de compressão extrínseca a sensibilidade e especificidade são baixas. A ecoendoscopia identifica a camada de origem do tumor subepitelial, obtém amostras histológicas e aumenta a precisão diagnóstica.

Trastornos funcionales gastrointestinales: metoclopramida, domperidona y trimebutina / Functional gastrointestinal disorders: metoclopramide, domperidone and trimebutine

Muchos de los síntomas digestivos en niños, no están asociados a cambios patológicos, osea, en los trastornos funcionales no hay alteración en la mucosa, como tampoco en la endoscopia. Estas alteraciones son muy amplias, no solamente incluye el reflujo gastroesofágico. Los procinéticos aumentan la actividad colinérgica. La metoclopramida, es un antagonista dopaminérgico que aumenta el tono del esfínter esofágico inferior y mejora el vaciamiento gástrico. La domperidona, es un antagonista periférico de la dopamina con propiedades procinéticas y antieméticas. La trimetutina, es un regulador de la motilidad del tracto digestivo inferior.

Many of the gastrointestinal symptoms in children are not associated with pathological changes, that is, in functional disorders there is no alteration in the mucosa, nor in endoscopy. These changes are extensive, not only includes gastroesophageal reflux. Prokinetics increase cholinergic activity. Metoclopramide is a dopaminergic antagonist that increases lower esophageal sphincter tone and enhances gastric emptying. Domperidone is a peripheral dopamine antagonist with prokinetic and antiemetic properties. Trimetubine, is a regulator of the lower digestive tract motility.

Gastrointestinal sarcoidosis: a case report

Gastrointestinal sarcoidosis commonly occurs subclinically, with clinical manifestations present in only 0.1 to 0.9% of patients with the disease. Gastric sarcoidosis particularly involves the antrum. Small bowel, liver and spleen involvement is seen in approximately 10% of patients with systemic sarcoidosis. We report a rare case of gastrointestinal sarcoidosis of the stomach and terminal ileum, affecting the liver and spleen without pulmonary involvement, who responded favorably to corticosteroid treatment

Parasitosis intestinales en preescolares y escolares inmunodeficientes secundarios, con síntomas gastrointestinales Barquisimeto, Venezuela / Intestinal parasitic infection in immunocompromised pre school and school children with gastro intestinal symptoms

En niños inmunodeficientes secundarios con síntomas gastrointestinales, es indispensable estudiar causas parasitarias. Caracterizar las parasitosis intestinales en preescolares y escolares inmunodeficientes secundarios, con síntomas gastrointestinales, que acuden al Hospital Universitario de Pediatría ¨Dr. Agustín Zubillaga¨, Barquisimeto-Lara. Se evaluaron 50 niños, examinando de cada uno, entre una y tres muestras de heces (directo, concentrado, Hematoxilina Férrica, Ziehl-Neelsen modificado, Quenzel, Graham y Baerman). Se calcularon porcentajes y proporciones y se utilizó Chi cuadrado y test de Fisher con intervalo de confianza estadística de 95%. Se encontró parasitada 68,00% de la muestra, predominando en preescolares (64,70%) y en pacientes masculinos (64,70%). Dolor abdominal e hiporexia fueron los síntomas más frecuentes (34,00% cada uno). La especie predominante fue B. hominis (50,00%), seguida de G. Lamblia y Cryptosporidium sp. (41,18% cada uno), E. histolytica (20,59%), A. lumbricoides (5,88%) y Estrongiloideos (2,94%). E. vermicularis se encontró en 6,90% de 29 pruebas de Graham. La frecuencia de parasitados fue proporcional al número de muestras evaluadas. Los más afectados fueron los pacientes oncológicos (88,24%). La tinción de Ziehl-Neelsen modificado fue la única técnica que permitió demostrar Cryptosporidium sp. E. vermicularis se demostró sólo por el método de Graham. La frecuencia de parasitosis intestinales en niños inmunodeficientes secundarios fue mayor a la reportada para la población infantil, con elevada proporción de Cryptosporidium sp

In secondary immunodeficient children suffering gastrointestinal symptoms it is essential to study parasitic causes To characterize the intestinal parasitoids in secondary immunedeficient school children and preschool children with gastrointestinal symptoms attending the Pediatric University Hospital ¨Dr. Agustín Zubillaga¨ Barquisimeto-Lara. 50 children were evaluated. One to three feces samples were obtained from each children (direct, concentrate, ferric hematoxiline, modified Ziehl-Neelsen, Quenzel, Graham and Baerman). Percentage and proportions were calculated and square Chi and Fisher test used, with an interval of statistical confidence of 95%. 68.00% of the samples were parasited, mainly in preschool children (64.70%) and males (64.70%). Abdominal pain and hyporexia were the most frequent symptons (34.00% each). The predominant specie was B. hominis (50.00%), followed by G. Lamblia and Cryptosporidium sp. (41.18% each), E. histolytica (20.59%), A. lumbricoides (5.88%) and strongiloides (2.94%). E. vermicularis was present in 6.90% of 29 tests of Graham. The frequency of parasited children was proportional to the number of samples evaluated. The more affected were oncological patients (88.24%). Modified Ziehl-Neelsen stain was the unique technique that allowed to demonstrate Cryptosporidium sp. E. vermicularis was demonstrated for Graham method only. A higher frequency of intestinal parasitoses was demonstrated in secondary immunodeficient children when compared with the general children population, with a high proportion of Cryptosporidium sp

Laringitis por reflujo: mito o realidad? / Reflux laryngitis: mith or reality?

La enfermedad por reflujo gastroesofágico (ERGE) es un trastorno gastrointestinal frecuente que representa una de las causas de consulta más común en medicina general y gastroenterología. Recientemente, se ha descrito que la ERGE puede asociarse a manifestaciones otorrinolaringológicas como laringitis, tos crónica, odinofagia, escurrimiento nasal posterior y asma. En su fisiopatología se involucran mecanismos directos e indirectos, considerándose al ácido como el agente más nocivo, aunque otras sustancias pueden lesionar las estructuras laríngeas como pepsina, moco y contenidos duodenales. El diagnóstico de ERGE laríngeo se basa en la realización cuestionarios específicos, laringoscopia y la pHmetría ambulatoria de 2 canales. Independientemente del método diagnóstico empleado, cuando se asume que la ERGE es causa de síntomas laríngeos, en la actualidad el uso de medicamentos que suprimen el acido (especialmente IBPs) constituye la piedra angular del tratamiento, aunque los resultados clínicos sobre su efectividad son muy controversiales. En la presente revisión se analizan los aspectos más controversiales respecto a la fisiopatología, diagnóstico y tratamiento de las manifestaciones laríngeas de la ERGE...

Gastro-esophageal reflux disease (GERD) is a frequent gastrointestinal disorder that has became one of the most common conditions presenting in general and gastroenterology practice. Recently, it has been described that GERD may have otolaryngological manifestations such as laryngitis, chronic cough, odynophagia, posterior nasal drip and asthma. Several patophysiological mechanisms have been described, but abnormal acid exposure is the most important. However, there is evidence that other substances can damage laryngeal structures, such as pepsin, mucus and duodenal content). Laryngeal GERD is diagnosed by using specific questionnaires, or by the presence of laryngeal signs in the laryngoscopy or by the detection of abnormal acid exposure using a dual ambulatory pH monitoring. Suppressive acid secretion drugs (specifi cally PPI´s) represent the gold standard therapy when laryngeal symptoms are related to GERD. However, the evidence regarding the effectiveness of PPI´s in laryngeal GERD are controversial. In this review, we analyze the most relevant issues regarding the pathophysiology, diagnosis and treatment of laryngeal GERD...

Gastrointestinal opportunistic infections in human immunodeficiency virus disease

Gastrointestinal [GI] opportunistic infections [OIs] are commonly encountered at various stages of human immunodeficiency virus [HIV] disease. In view of the suppressive nature of the virus and the direct contact with the environment, the GI tract is readily accessible and is a common site for clinical expression of HIV. The subject is presented based on information obtained by electronic searches of peer-reviewed articles in medical journals, Cochrane reviews and PubMed sources. The spectrum of GI OIs ranges from oral lesions of Candidiasis, various lesions of viral infections, hepatobiliary lesions, pancreatitis and anorectal lesions. The manifestations of the disease depend on the level of immunosuppression, as determined by the CD4 counts. The advent of highly active antiretroviral therapy has altered the pattern of presentation, resorting mainly to features of antimicrobial-associated colitis and side effects of antiretroviral drugs. The diagnosis of GI OIs in HIV/ acquired immunodeficiency syndrome patients is usually straightforward. However, subtle presentations require that the physicians should have a high index of suspicion when given the setting of HIV infection