Cholesterol trafficking-related serum lipoprotein functions in children with cholesteryl ester storage disease.

OBJECTIVE: Serum lipoproteins influence cell cholesterol content by delivering and removing cholesterol to/from cells, functions mainly exerted by LDL and HDL, respectively. Especially in the case of HDL, structure and composition are crucial for function, beyond serum levels. Cholesteryl ester storage disease (CESD) is caused by LIPA gene mutations and reduced activity of lysosomal acid lipase (LAL), the enzyme responsible for hydrolysis of cholesteryl esters and TG. CESD patients typically present dyslipidaemia, liver damage and premature atherosclerosis. The objective of this work was to evaluate serum HDL cholesterol efflux capacity (CEC) and serum cholesterol loading capacity (CLC) in CESD pediatric patients and to study lipoprotein qualitative modifications. METHODS: HDL CEC was evaluated by radioisotopic techniques, serum CLC was measured by a fluorimetric assay, HDL subclasses were determined by two-dimensional electrophoresis. RESULTS: CESD patients (n = 3) displayed on average increased LDL cholesterol (+163%; p = 0.019), TG (+203; p = 0.012), phospholipids (+40%; p = 0.024) and lower HDL cholesterol (-57%; p = 0.012) compared to controls (n = 9). CESD HDL CEC was impaired both as a whole (average reduction of 26%; p < 0.0001) and with respect to specific membrane cholesterol transporters (-23% for aqueous diffusion; p = 0.005; -32% for ABCA1-efflux; p = 0.0002; -60% for SR-BI-efflux; p < 0.0001; -42% for ABCG1-efflux p = 0.0003). A marked reduction in the pre-ß HDL concentration (-69%; p = 0.012) was detected. Finally, CESD serum CLC was significantly increased (+21%; p = 0.0007). CONCLUSION: These new data demonstrate that the pro-atherogenic modifications of serum include disturbances in lipoprotein functions involved in cell cholesterol homeostasis occurring from very early age in CESD patients.

Clinical-pathological and p53 protein expression study in dysplasia associated with ulcerative colitis / Estudo clínico-patológico e da expressão da proteína p53 nas displasias associadas à retocolite ulcerativa

Background: The association between ulcerative colitis and adenocarcinoma determined strategies for patient follow-up and early detection of dysplastic and neoplastic lesions. Aims: To analyze the incidence of dysplasia in patients with ulcerative colitis, comparing clinical data of patients with and without dysplasia and check immunohistochemical expression of p53 protein in dysplasias. Materials and methods: We analyzed biopsy samples and clinical data of 124 patients with ulcerative colitis at Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil. Results: Dysplasia incidence was low (9.67%) and all cases with low-grade dysplasia. Patients clinical data comparison with and without dysplasia did not show significant statistical differences with regard to the race, age at the start of the disease, age at last biopsy, duration and anatomic extent of ulcerative colitis. Significant difference was found between males and females with predominance of males (58.34%) for dysplasia. Seventeenth biopsy samples of 12 patients with dysplasia, 5 (29.4%) were p53 positive. Conclusions: From these results it is concluded that the incidence of dysplasia was low, higher in males and there was positivity of p53 protein in dysplasia. .

Racional: A associação entre retocolite ulcerativa e adenocarcinoma determinou estratégias para seguimento dos pacientes e detecção precoce das lesões displásicas e neoplásicas. Objetivos: Analisar a incidência de displasia nos pacientes com retocolite ulcerativa, comparar dados clínicos dos pacientes com e sem displasia e verificar a expressão imunoistoquimica da proteína p53 nas displasias. Material e Métodos: Foram estudados os exames anatomopatológicos e dados clínicos de 124 pacientes com e sem displasia, portadores de retocolite ulcerativa no Hospital de Clínicas da Universidade Federal do Paraná. Resultados: A incidência de displasia foi de 9,67% e todos os casos foram de displasia de baixo grau. Na comparação dos dados clínicos dos pacientes com e sem displasia não houve diferença estatisticamente significativa com relação à cor, idade no início da doença, idade na última biópsia, extensão da doença e tempo de evolução da doença. Houve diferença estatística com predomínio de pacientes do sexo masculino (58,34%) em relação ao feminino para displasia. Dos 17 exames avaliados de 12 pacientes com displasia, em 5 exames (29,4%) a expressão da proteína p53 foi positiva. Conclusões: Desses resultados conclui-se que a incidência de displasia foi baixa, maior no sexo masculino e houve positividade da proteína p53 nas displasias. .

Padronização e quantificação de critérios histopatológicos melhoram o diagnóstico da doença intestinal inflamatória? / Do standardization and quantification of histopathological criteria improve the diagnosis of inflammatory bowel disease?

Introduction: Inflammatory bowel disease comprises two major categories: Crohn's disease and ulcerative rectocolitis, both with different clinical and histological aspects, causing sometimes significant morbidity. Objectives: Choose and apply standardized and quantified histopathological diagnosis method, and compare the results and quality index with the original diagnosis. Materials and methods: 43 histological colonoscopic biopsies of 37 patients were re-evaluated by standardized system. Results and discussion: The original diagnoses were more inconclusive (23.3%) than those standardized (2.3%). The agreement with gold standard (clinical, colonoscopical, and radiological diagnosis) was higher on standardized diagnoses (95.3%) than in original (74.4%), especially in relation to Crohn's disease, which percentages were 92.3% and 46.1%, respectively. The quality index was calculated in conclusive diagnosis of each method. For ulcerative rectocolitis, both methods showed sensitivity and negative predictive value of 100%; otherwise the original diagnosis demonstrated specificity of 85.7%, positive predictive value of 96.3% and accuracy of 97.0%, and the standardized diagnosis 92.3%, 96.7% and 97.6%, respectively. For Crohn's disease, there is specificity and positive predictive value of 100% in both methods; the original diagnosis showed sensitivity of 85.7%, negative predictive value of 96.3% and accuracy of 97%, while for the standardized diagnoses 92.3%, 96.7%, and 97.6%, respectively. Conclusion: The standardized diagnosis presented a higher percentage of correct and conclusive diagnoses than those presented in the original diagnosis, especially for Crohn's disease, as well as equal or slightly higher values in some quality index...

Introdução: Duas são as formas de manifestação da doença intestinal inflamatória: doença de Crohn e retocolite ulcerativa, ambas com evolução clínica, tratamento e aspectos histopatológicos diferentes, causando, por vezes, significativa morbidade. Objetivos: Escolher e aplicar método padronizado e quantificado de diagnóstico histopatológico e comparar os resultados e os índices de qualidade, com os dos diagnósticos originais. Materiais e métodos: Foram reavaliadas histologicamente 43 biópsias colonoscópicas seriadas de 37 pacientes por sistema padronizado. Resultado e discussão: Os diagnósticos originais foram mais inconclusivos (23,3%) do que os padronizados (2,3%). A concordância com o padrão-ouro (diagnóstico clínico, colonoscópico e radiológico) foi maior nos diagnósticos padronizados (95,3%) do que nos originais (74,4%), principalmente em relação à doença de Crohn, cujos percentuais foram de 92,3% e 46,1%, respectivamente. Para retocolite ulcerativa, ambos os métodos apresentaram sensibilidade e valor preditivo negativo de 100%; já nos diagnósticos originais, foram verificados especificidade de 85,7%, valor preditivo positivo de 96,3% e acurácia de 97%, e nos diagnósticos padronizados, 92,3%, 96,7% e 97,6%, respectivamente. Para doença de Crohn, verificaram-se especificidade e valor preditivo positivo de 100% nos dois métodos; nos diagnósticos originais, sensibilidade de 85,7%, valor preditivo negativo de 96,3% e acurácia de 97%, e nos diagnósticos padronizados, 92,3%, 96,7% e 97,6%, respectivamente. Conclusão: O diagnóstico padronizado apresentou maior percentual de diagnósticos corretos e conclusivos do que os apresentados no diagnóstico original, principalmente para doença...

Short duration treatment in genotype 1 chronic hepatitis C patients with rapid virologic response to pegylated interferon plus ribavirin.

BACKGROUND: In patients with chronic hepatitis C, rapid HCV-RNA clearance under treatment might allow shorter treatment duration without modifying the sustained virological response (SVR) rate. This study evaluated the impact of rapid virological response (RVR) in HCV genotype 1b infection management. METHODS: In an open-label trial, 180 patients received standard doses of peginterferon alfa-2a plus ribavirin. Those with undetectable serum HCV-RNA at week 6 (RVR) received 24-week short-course treatment; patients with undetectable HCV-RNA at week 12 (early responders [ER]) received 48-week "standard of care" treatment; patients with positive HCV-RNA at week 12 (non-responders [NR]) stopped the treatment. Study end-point was to determine SVR rate at week 24. RESULTS: The following responses were observed: 24% RVR, 44% ER, 32% NR. Among RVR subjects, HCV-RNA baseline levels and age were significantly lower (P=0.038 and 0.035 respectively) than in non-RVR patients. At follow-up, 91% of RVR and 33% of ER patients achieved SVR. Among those with RVR, patients experiencing post-therapy relapse were older than those who achieved a SVR (P=0.028). CONCLUSIONS: Chronic HCV-1b patients, achieving RVR with a 24-week treatment regimen, attained excellent SVR rates. In a cost-effective therapeutic approach, all HCV-1b patients eligible for therapy may have a short duration therapy on the basis of RVR.

Trombocitose como fator prognóstico no câncer colorretal / Trombocitosis as a prognostic factor in colorectal cancer

Objetivos - Investigar o significado prognóstico da trombocitose nos pacientes com câncer colorretal. Método - Trata-se de estudo retrospectivo, com análise de 243 prontuários de pacientes submetidos a operações por câncer colorretal. Foram comparados os dados do estadiamento, recidiva tumoral e óbitos por câncer com a ocorrência de trombocitose no pré-operatório. O grupo controle foi composto de 50 pacientes submetidos à herniorrafia. A média da contagem de plaquetas no pré-operatório destes pacientes foi utilizada para dividir os pacientes em dois grupos: grupo 1, pacientes com contagem de plaquetas abaixo dessa média e grupo 2, pacientes com contagem de plaquetas acima dessa média. Resultados - A média da contagem plaquetária foi 317000/ìl entre os pacientes com câncer e de 267000 entre os pacientes do grupo controle. A prevalência da trombocitose no câncer colorretal foi 32,1 por cento. Dentre os óbitos por câncer, 56,7 por cento ocorreram em pacientes com trombocitose e 32 por cento em pacientes com plaquetas normais (p=0,001). Utilizando a média do grupo controle, a diferença foi ainda mais significativa (p=0,0004). Quanto à recidiva tumoral, 40 por cento dos pacientes do grupo 2 tiveram recidiva e 17,9 por cento do grupo 1 (p=0,003). Com relação ao estadiamento T, no grupo 1, 14,1 por cento eram T1 e 8,4 por cento T4. No grupo 2, 2,2 por cento eram T1 e 19,5 por cento T4 (p=0.0005). Metástases à distância foram encontradas em 9,4 por cento dos pacientes do grupo 1 contra 21,8 por cento do grupo 2 (p=0.02). No que diz respeito ao estadiamento TNM, no grupo 1, 24,6 por cento eram estadio 1 e 11 por cento estadio 4. No grupo 2, 9,6 por cento eram estadio 1 e 22,8 por cento estadio 4 (p=0,02). Conclusão - A contagem de plaquetas no pré-operatório parece ser útil em identificar pacientes com prognóstico desfavorável.

Aims - To investigate the prognostic value of thrombocytosis in patients with colorectal cancer. Method - Charts of 243 patients with colorectal cancer that had undergone surgical treatment were retrospectively reviewed. Data on TNM staging, tumor recurrence and cancer death were compared with the occurrence of thombocytosis before surgery. The control group was formed by fifty patients submitted to herniorrhaphy. Patients were divided into two groups on the basis of mean platelet count of control group: group 1, patients with platelet count below that mean and group 2, patients with platelet count above that level. Results - The mean platelet count was 317000/ìl among cancer patients and 267000/ìl in the control group patients. Prevalence of thrombocytosis in patients with colorectal cancer was 32,1 percent. The cancer death rate was 56,7 percent in patients with thrombocytosis and 32 percent in patients with normal platelet count (p=0,001). When the platelet count mean of control group was used, the difference was significantly greater (p=0004). Tumor recurrence occurred in 40 percent of group 2 patients and in 17,9 percent of group 1 patients (p=0,003). Regarding T staging, on group 1, 14,1 percent of patients were T1 and 8,4 percent were T4. On group 2, 2,2 percent were T1 and 19,5 percent were T4 (p=0,0005). Distant metastasis were found in 9,4 percent patients of group 1 and 21,8 percent of group 2 (p=0,02). Considering TNM staging, group 1 had 24,6 percent of patients in stage 1 and 11 percent in stage 4. On group 2, 9,6 percent belonged to stage 1 and 22,8 percent to stage 4 (p=0,02). Conclusion - Preoperative platelet count seems to be a helpful indicator of patients with poor prognosis.

Comparação entre as soluções orais de manitol a 10 por cento e bifosfato de sódio no preparo mecânico do cólon / Comparison between sodium biphosphate and 10 percent oral mannitol solutions for mechanical bowel preparation

OBJETIVO: Comparar o uso das soluções orais de manitol a 10 por cento e de bifosfato de sódio no preparo mecânico do cólon quanto a qualidade da limpeza, a tolerabilidade e as alterações hidroeletrolíticas e da osmolaridade plasmática. MÉTODO: Foram analisados 60 pacientes de modo randomizado, duplo-cego e prospectivo, com indicação de colonoscopia. A qualidade da limpeza intestinal foi analisada pelo examinador através da classificação de Beck. A tolerabilidade à ingestão baseou-se na pesquisa do gosto, presença ou não de desconforto, aparecimento de efeitos adversos e a quantidade da solução ingerida. Foram dosados o sódio, potássio, cálcio, magnésio, fósforo, uréia, creatinina, glicose, hematócrito, hemoglobina e calculado a osmolaridade plasmática, antes e após a ingestão da solução oral de preparo inestinal. RESULTADOS: Ambas as soluções atingiram qualidade de preparo classificado como bom ou superior em mais de 80 por cento dos pacientes. O uso do bifosfato de sódio determinou menor desconforto e melhor tolerância, apesar de não ter sido superior ao manitol quanto à análise do gosto e presença de efeitos adversos. O bifosfato induziu ao aumento e o manitol a uma redução da osmolaridade, reflexo do que ocorreu com o sódio plasmático nos dois grupos respectivamente. O bifosfato ainda determinou alteração significativa dos níveis séricos de fósforo, cálcio, magnésio e potássio, sem repercussões clínicas. CONCLUSÃO: Ambos os tipos de preparo intestinal determinaram qualidade de limpeza adequada. O bifosfato de sódio, apesar de melhor tolerado, determina maior quantidade de alterações hidroeletrolíticas.

BACKGROUND: To compare the use of sodium biphosphate and 10 percent mannitol solutions for mechanical bowel preparation in terms of cleansing quality, tolerability, disorder in water and electrolyte balance, and plasma osmolality. METHOD: Sixty patients who had been referred for colonoscopy were analyzed in a randomized, double-blind, prospective study. The quality of bowel cleansing was analyzed by the examiner using Beck's classification. Ingestion tolerability was established by investigating taste, whether the patient felt any discomfort or not, the development of adverse effects and the amount of solution ingested. The following measurements were made before and after ingestion of the oral bowel preparation solution: sodium, potassium, calcium, magnesium, phosphorus, urea, creatinine, glucose, hematocrit, hemoglobin and plasma osmolality. RESULTS: Both solutions resulted in bowel preparations that were classified as good or superior in over 80 percent of the patients. The use of sodium biphosphate resulted in less discomfort and better tolerance, although it was not superior to mannitol in terms of taste or the presence of adverse effects. Sodium biphosphate led to an increase, and mannitol to a decrease, in osmolality, reflecting the changes in plasma sodium in both groups. The former also resulted in a significant measurement change in serum phosphorus, calcium, magnesium and potassium levels, without any clinical repercussions. CONCLUSION: Both types of bowel preparation resulted in adequate cleansing. Sodium biphosphate, although better tolerated, leads to more alterations in water and electrolyte balance.

Antiglycan antibodies as serological markers in the differential diagnosis of inflammatory bowel disease.

BACKGROUND: The objective of the study was to evaluate the diagnostic accuracy of recently developed antiglycan serological tests in clinical practice for the diagnosis of Crohn's disease. METHODS: This study was a cohort analysis of both clinical and biochemical parameters of patients with diagnosed inflammatory bowel disease compared with those in a control population. Antiglycan antibodies were determined using commercially available enzyme immunoassays. The setting was the outpatient unit of the gastroenterology department of a large, tertiary-care referral academic hospital. Participants were 214 consecutive patients, enrolled over a 5-month period, including 116 with Crohn's disease and 53 with ulcerative colitis, as well as 45 with other gastrointestinal diseases and 51 healthy controls. RESULTS: Anti-Saccharomyces cerevisiae antibodies showed the best performance (54% sensitivity and 88%-95% specificity for Crohn's disease). Among patients with negative anti-Saccharomyces antibodies, 19 (34%) had high titers of at least another tested antiglycan antibody. Anti-Saccharomyces and anti-laminaribioside antibodies were associated with disease involving the small bowel and with penetrating or stricturing phenotype. Anti-laminaribioside was significantly higher in patients with a familial history of inflammatory bowel disease. CONCLUSIONS: The new proposed serological markers are significantly associated with Crohn's disease, with low sensitivity but good specificity. About one third of anti-Saccharomyces-negative patients may be positive for at least 1 of those markers. Antiglycan antibodies appear to be associated with characteristic localization and phenotype of the disease.

AT1 receptor antagonist Candesartan in selected cirrhotic patients: effect on portal pressure and liver fibrosis markers.

BACKGROUND/AIMS: The renin-angiotensin system plays an important role in hepatic fibrogenesis and in portal hypertension. To examine the long-term effects of Candesartan cilexetil, an angiotensin type 1 (AT1) receptor blocker, on portal-systemic haemodynamics and on liver fibrosis. METHODS: Forty-seven compensated Child A and Child B (8) cirrhotic patients were randomly assigned to receive Candesartan cilexetil, 8 mg/d (N.24) and no treatment (N.23) for 1 year. Portal-systemic haemodynamic parameters, serological levels of procollagen (PIIINP), hyaluronic acid (HA) and transforming growth factor beta 1 (TGFbeta1) were assessed at baseline and after 12 months. RESULTS: No patients discontinued or decreased the drug. The hepatic venous pressure gradient (HVPG) decreased significantly in treated patients (-8.4%+/-2.4) with a reduction >20% in 25% of cases vs+5.6%+/-2.9 in the untreated group. HA plasma levels decreased significantly in Candesartan treated patients in whom HVPG diminished and rose in untreated patients in whom HVPG increased. CONCLUSIONS: In selected cirrhotic patients, pharmacological inhibition of the AT1 receptor is well tolerated and induced a mild reduction of portal pressure. This haemodynamic effect might be related to liver fibrogenesis activity.

A novel loss of function mutation of PCSK9 gene in white subjects with low-plasma low-density lipoprotein cholesterol.

OBJECTIVES: The PCSK9 gene, encoding a pro-protein convertase involved in posttranslational degradation of low-density lipoprotein receptor, has emerged as a key regulator of plasma low-density lipoprotein cholesterol. In African-Americans two nonsense mutations resulting in loss of function of PCSK9 are associated with a 30% to 40% reduction of plasma low-density lipoprotein cholesterol. The aim of this study was to assess whether loss of function mutations of PCSK9 were a cause of familial hypobetalipoproteinemia and a determinant of low-plasma low-density lipoprotein cholesterol in whites. METHODS AND RESULTS: We sequenced PCSK9 gene in 18 familial hypobetalipoproteinemia subjects and in 102 hypocholesterolemic blood donors who were negative for APOB gene mutations known to cause familial hypobetalipoproteinemia. The PCSK9 gene variants found in these 2 groups were screened in 42 subjects in the lowest (<5th) percentile, 44 in the highest (>95th) percentile, and 100 with the average plasma cholesterol derived from general population. In one familial hypobetalipoproteinemia kindred and in 2 hypocholesterolemic blood donors we found a novel PCSK9 mutation in exon 1 (c.202delG) resulting in a truncated peptide (Ala68fsLeu82X). Two familial hypobetalipoproteinemia subjects and 4 hypocholesterolemic blood donors were carriers of the R46L substitution previously reported to be associated with reduced low-density lipoprotein cholesterol as well as other rare amino acid changes (T77I, V114A, A522T and P616L) not found in the other groups examined. CONCLUSIONS: We discovered a novel inactivating mutation as well as some rare nonconservative amino acid substitutions of PCSK9 in white hypocholesterolemic individuals.

História familial e câncer colorretal em idade precoce: deve-se indicar colectomia estendida? / Family history of colorectal cancer at early age: should extended colectomy be indicated?

OBJETIVO: avaliar a história familial e as características dos tumores em dois grupos distintos por sua faixa etária, bem como questionar quanto à necessidade de colectomia estendida, baseando-se nestas características. MÉTODO: Em estudo retrospectivo analisaram-se 106 pacientes por meio do prontuário e de contato telefônico com o próprio doente e/ou familiares, operados no HC-UFPR. Foram divididos em 2 grupos: Grupo A (n=51) com 55 anos ou menos, e Grupo B (n=55) com mais de 55 anos. Avaliou-se o número de doentes com parentes de 1º. grau com câncer colorretal e em outros sítios; o número de parentes com CCR; o sítio do tumor; o estadiamento TNM; os óbitos no período e a presença de neoplasias associadas. RESULTADOS: No grupo A, 16 (31,4 por cento) pacientes tinham parentes com câncer colorretal. No grupo B, sete (12,7 por cento) (p=0,032). No grupo A houve 16 (31,4 por cento) pacientes de familiares com outro tipo de neoplasia. No grupo B, 19 (34,5 por cento) doentes (p=0,837). Ao incluírem-se apenas as neoplasias associadas à Síndrome do HNPCC, como endométrio e estômago, houve 5 (9,8 por cento) pacientes no grupo A e 3 (5,9 por cento) no grupo B (p=0,477). No grupo A, 3 (5,8 por cento) doentes apresentaram neoplasias associadas ao CCR, sendo elas estômago, rim e bexiga. No grupo B, 3 (5,4 por cento) doentes, mas os tumores eram de mama e próstata (p=0,624). Predominou no grupo A pacientes com estádio III (41,2 por cento) e no grupo B, o estádio II (51,9 por cento) (p=0,480). Houve 19,6 por cento de óbitos no grupo A e 32,7 por cento no Grupo B (p=0,185). CONCLUSÃO: Pacientes com idade = 55 anos possuem história familial mais representativa para o CCR que pacientes mais idosos, podendo fazer parte da síndrome do HNPCC. Possivelmente se beneficiem de colectomia estendida.

AIM: To evaluate the family history and the characteristics of the tumors in two different groups of patients, divided by age, questioning the necessity of extensive colectomy for the adequate treatment. METHODS: One hundred and six patients were analyzed retrospectively by hospital chart review or phone contact either with the patient or a next of keen; all were operated at the University Hospital of the "Universidade Federal do Paraná" (Brazil).These patients were divided in Group A (n=51) below 55 years old, and Group B (n=55) with age above 55 years. All patients were analyzed for first degree relatives with history of colon and rectal cancer and cancer history in other organs; number of relatives with colon and rectal cancer; the location of the tumors in the colon; the TNM staging; the occurrence of other malignant neoplasias for each patient; and the death rate for the period of the study. RESULTS: On group A, 16 (31.4 percent) patients had relatives with colorectal cancer; on group B, 7 (12.7 percent) (p=0,032). On group A, 16 (31.4 percent) patients had relatives with other types of malignant neoplasias, and on group B, 19 (34.5 percent) (p=0.837). When it was considered only cancers related to the HNPCC syndrome, as endometrium and stomach, 5 (9.8 percent) patients were found on group A and 3 (5.9 percent) on group B (p=0.477). On group A, 3 (5.8 percent) patients had tumors related to colon and rectal cancers, as stomach, kidney and bladder. On group B, 3 (5.4 percent) patients, but these tumors were in the breast and prostate (p=0.624). On group A, there were more patients with stage III cancers (41.2 percent) and on group B, stage II cancers were more prevalent (51.9 percent) (p=0.480). The death rate was 19.6 percent on group A and 32.7 percent on group B (p=0.185). CONCLUSION: Patients under 55 years of age have an increased family history of colon and rectal cancer when compared to the ones above the age of 55; those could be related to the HNPCC...

Importância da colonoscopia no rastreamento de pólipos e câncer colorretal em pacientes portadores de pólipos retais / Importance of the colonoscopy in the tracking of polyps and colorectal neoplasms in carrying patients of rectal polyps

O câncer colorretal é a terceira causa de morte nas regiões sul e sudeste do Brasil. Os tumores crescem lentamente seguindo a seqüência adenoma-carcinoma. A colonoscopa permite o diagnóstico e a ressecção dos pólipos. Atualmente discute-se a colonoscopia para pacientes portadores de pólipos retais não-neoplásicos e pólipos pequenos, além dos adenomas. Objetivo: verificar a prevalência dos pólipos colônicos nos pacientes portadores de pólipos retais, correlacionar o tipo histológico e o tamanho do pólipo retal com o achado de neoplasia proximal. Pacientes e método: estudo transversal, entre 2000 e 2003, com pacientes portadores de pólipos retais submetidos a colonoscopia. Dividiram-se os pacientes por faixa etária, tipo e tamanho do pólipo retal. Pólipos e câncer foram considerados achados positivos na colonoscopia. Foram excluídas síndromes polipóides genéticas e câncer retal. Resultados: examinaram-se 1.715 pacientes dos quais 74 (4,31por cento) tinham pólipos retais. O estudo histopatológico mostrou que 54,1por cento eram adenomatosos, 23por cento hiperplásicos, 12,2por cento inflamatórios e 10,8por cento, excrescências de mucosa. A maioria dos pólipos foi encontrada em pacientes acima de 40 anos, havendo significância estatística no grupo dos neoplásicos (p<0,0001). Não houve diferença estatística quando comparados os achados positivos na colonoscopia entre os grupos de pólipos retais adenomatosos e hiperplásicos (p=0,052). O tamanho do pólipo retal não foi estatisticamente significante para achados positivos na colonoscopia. Conclusões: prevalência de pólipos proximais em portadores de pólipos retais foi 49,1por cento. Prevalência de neoplasia proximal foi de 42,5por cento e 11,7por cento nos portadores de pólipos retais neoplásicos e não-neoplásicos, respectivamente. O tamanho do pólipo retal não foi preditivo para achado de neoplasia proximal.

Stapled hemorrhoidectomy: initial experience of a Latin American group.

The purpose of the present study was to determine the value of circular hemorrhoidectomy (procedure for prolapse and hemorrhoids [PPH]) on the basis of data collected prospectively during the initial experience of a group of Latin American surgeons. Between 2000 and 2001, PPH was performed using a circular stapler in 177 patients who had third- and fourth-degree hemorrhoidal disease. The average age of the patients was 47.7 years (range 26 to 85 years). Anal bleeding was the most common preoperative complaint (93.2%) followed by anal pain (60.2%), anal itching (43%), and constipation (41%). Hemorrhoids were classified as third degree in 132 patients (74%) and fourth degree in 45 patients (25.4%). Skin tags were detected in 86 patients (48.8%) and rectocele in 14 patients (7.9%). Data collected included patient demographics, type of anesthesia, and specific details of the surgery such as duration of the operation, distance from the staple line to the dentate line, need for complementary hemostasis, and any unexpected occurrences. Postoperative data collected included the degree of pain, which was evaluated on the basis of the type and dosage of analgesics required, laxative consumption, and the presence of bleeding, fever, urinary retention, or hematomas. Each patient completed a written questionnaire addressing these events. Patients returned for follow-up visits on days 7, 15, 30, and 90. Responses to pain, bleeding, fever, anal continence, recurrence of hemorrhoids, and level of satisfaction were compiled. The duration of the procedure ranged from 6 minutes to 2 hours (average 23 minutes), and most operations lasted no more than 20 minutes, with the exception of one that lasted 2 hours because of intraoperative bleeding. Intraoperative problems were minor. An additional one or a few sutures were required in 58.7% of patients to achieve perfect hemostasis. In 128 patients (72.3%) the hospital stay was less than 24 hours. Same-day surgery was chosen for 37 patients (20.9%). Pain was controlled with analgesia only using one to six doses of oral dipirona in 126 patients. Five patients were readmitted to the hospital: four for control of bleeding and one for conventional hemorrhoidectomy due to an acute episode of external hemorrhoidal thrombosis. At day 30, patients rated the efficacy of the procedure in alleviating preoperative symptoms as follows: 77.5% excellent; 16% good; 5.3% average, and 1.2% poor. At 3 months postoperatively no patient had had a recurrence of hemorrhoidal prolapse, and there were no instances of stenosis or anal incontinence. Surgeons also rated the efficacy of the procedure as excellent in 75%, good in 19.8%, average in 4.7%, and poor in 0.6%. With proper selection of patients and adequate stapling technique, stapled hemorrhoidectomy may be considered safe; it is easily learned, has a satisfactory degree of pain, and is well accepted by both patients and surgeons.

Abscesso hepático como complicaçäo na doença de Crohn: relato de caso / Liver abscess with complication at the CrohnÝs disease

Abscesso intra-abdominal é complicaçäo comum em pacientes portadores de doença de Crohn. Todavia, a associaçäo entre abscesso hepático e doença inflamatória intestinal é rara.O objetivo do presente estudo é relatar o caso de uma paciente de 40 anos, portador de doença de Crohn perianal e colônica em tratamento há 7 anos, que desenvolveu em um surto de agudizaçäo da doença inflamatória intestinal um abscesso hepático. O paciente encontrava-se em tratamento com imunossupressor (azatioprina) antes do diagnóstico do abscesso, porém näo vinha fazendo uso correto da medicaçäo apesar das orientações médicas. A tomografia demonstrou lesäo heterogênea, expansiva de 18,5x 13,5x 16,5 cm no lobo direito do fígado, sugestiva de abscesso hepático. Procedeu-se entäo à drenagem percutânea da lesäo, guiada por ultrassonografia com colocaçäo de cateter de demora, associada a antibioticoterapia prolongada. O paciente apresentou melhora importante do seu quadro clínico, com reduçäo significativa do tamanho da lesäo nos exames de imagem de controle após 4 semanas.Salienta-se que os pacientes portadores de doença de Crohn com queixas álgicas no hipocôndrio direito e febre de origem indeterminada devem ser submetidos a exames de imagem. Deve-se ainda incluir o abscesso hepático no diagnóstico diferencial das causas da complicaçäo.O diagnóstico diferencial com reagudizaçäo da doença inflamatória intestinal é difícil, e a suspeita do desenvolvimento de abscesso hepático deve ser aventada. O tratamento de escolha, nos pacientes com abscesso único, deve ser a drenagem percutânea associada ao uso de antibióticos. A laparotomia, indicada por princípio, näo traz maiores vantagens, aumentando a morbidade conferida pela doença e pelo procedimento