HELICOBACTER PYLORI CHRONIC GASTRITIS ON PATIENTS WITH PREMALIGNANT CONDITIONS: OLGA AND OLGIM EVALUATION AND SERUM BIOMARKERS PERFORMANCE.

BACKGROUND: H. pylori chronic atrophic gastritis is a premalignant lesion, and its staging, according to OLGA and OLGIM systems aims to identify patients at increased risk of developing gastric cancer and optimize their follow-up. GastroPanel®, serum biomarkers panel including pepsinogen I (PGI), pepsinogen II (PGII), Gastrin 17 (G17) and anti- H. pylori antibodies is a noninvasive test for adenocarcinoma risk assessment in chronic H. pylori gastritis patients. OBJECTIVE: Prospective study to evaluate the concordance between OLGA and OLGIM grading systems, as well as to evaluate GastroPanel´s performance in patients with premalignant lesions secondary to H. pylori chronic gastritis in Brazil. METHODS: Patients with H. pylori chronic gastritis with premalignant lesions confirmed by histology were recruited from the gastrointestinal clinic of a University Hospital. All participants underwent endoscopic examination with biopsies which were reported according to updated Sydney system and premalignant lesions grading systems (OLGA and OLGIM). Blood samples were collected for biomarkers serological analysis (GastroPanel®, Biohit, Helsinki, Finland). The cut off values used to define high risk patients were those recommended by the manufacturer: PGI ≤30 µm/L and PGI/PGII ≤3. RESULTS: 41 patients were recruited: 28 women, 13 men, mean age 67.3 (47-89, SD: 9.6) years. By OLGA system, were obtained: OLGA 0 (n=1), OLGA I (n=7), OLGA II (n=17), OLGA III (n=9), and OLGA IV (n=7). By OLGIM system, were obtained: OLGIM 0 (n=14), OLGIM I (n=5), OLGIM II (n=10), OLGIM III (n=10), and OLGIM IV (n=2). Regarding histological staging among patients staged as low risk (OLGA/OLGIM 0, I and II) and high risk (OLGA/OLGIM III and IV) for gastric cancer development, the concordance rate found between both classifications was 85.4%. Considering high risk patients, those patients thus included in at least one of the systems the final distribution of our sample considered 24 low-risk and 17 high-risk patients for the development of gastric cancer. To determine by GastroPanel® whether the patient would be at low or high risk of developing gastric cancer, PGI showed a sensitivity, specificity and accuracy of 0.47 (95%CI: 0.26-0.69), 0.67 (95%CI: 0.47-0.82), and 0.58 (95%CI: 0.43-0.72), respectively, while PGI/PGII showed sensitivity, specificity and accuracy of 0.06 (95%CI: 0.01-0.27), 0.83 (95%CI: 0.64-0.93) and 0.51 (95%CI: 0.36-0.66), respectively. CONCLUSION: The histological classifications OLGA and OLGIM presented a substantial concordance rate among themselves. Simultaneous use of both histological classification systems increased the identification's rate of high-risk patients. Biomarker analysis was not effective to distinguish low to high risk patients in the studied population. Further studies are needed to validate its use in clinical practice in Brazil.

Clinical Aspects and Prognosis Evaluation of Cirrhotic Patients Hospitalized with Acute Kidney Injury.

Background: Acute kidney injury occurs in approximately 20% of hospitalized cirrhotic patients. Mortality is estimated at 60% within a month and 65% within a year. Aims: To evaluate survival in 30 days and in 3 months of cirrhotic patients hospitalized with acute kidney injury, identifying factors associated with mortality. Methods: 52 patients with cirrhosis admitted to an academic tertiary center who presented acute kidney injury according to the International Club of Ascites criteria were evaluated. Clinical and laboratory data was collected at diagnosis between 2011 and 2015. Results: Average age was 54.6 (±10.7) years and 69.2% were male. The average MELD, MELD-Na, and Child-Pugh scores were 21.9 (±7.0), 24.5 (±6.7), and 10.1 (±2.2), respectively. Thirty patients (57.7%) were in acute kidney injury stage 1, 16 (30.8%) in stage 2, and six (11.6%) in stage 3. Mortality was 28.6% in 30 days and 44.9% in three months. In multivariate analysis, variables that were associated independently to mortality were lack of response to expansion treatment and Child-Pugh score. Mortality was 93.3% in three months among nonresponders compared to 28.6% among those who responded to volume expansion (p<0.0001). Conclusion: Acute kidney injury in cirrhosis has dire prognosis, particularly in patients with advanced cirrhosis and in nonresponders to volume expansion.

Avaliação do comportamento dos níveis séricos de HMGB1 e IL-6 como preditores de infecção, injúria renal aguda e mortalidade em pacientes cirróticos com varizes sangrantes / Evaluation of the behavior of levels of hmgb1 and il6 as predictors of infection, acute kidney injury and mortality in cirrhotic patients with variceal bleeding

ABSTRACT BACKGROUND: Gastroesophageal varices and associated bleeding are a major cause of morbidity and mortality in cirrhotic patients. OBJECTIVE: To evaluate the potential role of the biomarkers HMGB1 (High Mobility Group Box 1) and IL-6 (Interleukin-6) as predictors of infection, acute kidney injury and mortality in these patients. METHODS: It is a prospective, observational study that included 32 cirrhotic patients with variceal bleeding. RESULTS: The subjects'mean age was 52±5 years and 20 (62.5%) were male. The average MELD was 17.53±5 and the average MELD-Na was 20.63±6.06. Thirty patients (93.3%) patients were Child-Pugh class B or C. Infection was present in 9 subjects (28.1%), acute kidney injury was present in 6 (18.1%) and 4 (12.5%) patients died. The median serum levels of HMGB1 were 1487 pg/mL (0.1 to 8593.1) and the median serum level of IL-6 was 62.1 pg/mL (0.1 to 1102.4). The serum levels of HMGB1 and IL-6 were significantly higher in patients who developed infection, acute kidney injury and death (P<0.05). The Spearman's correlations for HMGB1 and IL-6 were 0.794 and 0.374 for infection, 0.53 and 0.374 for acute kidney injury and 0.467 and 0.404 for death, respectively. CONCLUSION: Serum levels of HMGB1 and IL-6 were higher in patients with the three studied outcomes. HMGB1 serum levels showed a high correlation with infection and a moderate correlation with acute kidney injury and death, while IL-6 showed a moderate correlation with infection and death and a low correlation with acute kidney injury.

RESUMO CONTEXTO: Varizes esofagogástricas são a maior causa de morbimortalidade em pacientes cirróticos. OBJETIVO: Avaliar o papel de biomarcadores, High Mobility Group Box 1 (HMGB 1) e interleucina-6 (IL-6) como preditores de infecção, injúria renal aguda e mortalidade nestes pacientes. MÉTODOS: Estudo prospectivo, observacional que incluiu 32 pacientes com cirrose hepática na fase aguda do sangramento. RESULTADOS: A média de idade dos pacientes foi de 52±5 anos sendo 20 (62,5%) do gênero masculino. A média do MELD foi de 17,53±5 e a média do MELD-Na 20,63±6,06. Trinta (93,3%) pacientes foram classificados como Child B ou C. Complicação infecciosa esteve presente em 9 (28,1%) pacientes, injúria renal aguda em 6 (18,1%) e 4 (12,5%) evoluíram para o óbito. A mediana do nível sérico de HMGB 1 foi de 1487 pg/mL (0,1- 8593,1) e da IL-6 foi de 62,1pg/mL (0,1-1102,4). Os níveis séricos de HMGB 1 e IL-6 foram significativamente maiores nos pacientes que evoluíram com infecção, injúria renal aguda e óbito (P<0,05). Os valores da correlação de Spearman para os níveis séricos de HMGB 1 e IL-6 foram de 0,794 e 0,374 para infecção, 0,53 e 0,374 para injuria renal aguda e 0,467 e 0,404 para óbito, respectivamente. CONCLUSÃO: Níveis séricos de HMGB 1 e IL-6 foram maiores nos três desfechos estudados. Níveis séricos de HMGB 1 apresentaram alta correlação para com o desfecho infecção e moderada correlação para com injúria renal aguda e óbito, enquanto os níveis séricos de IL-6 apresentaram moderada correlação para com infecção e óbito e baixa correlação para com injúria renal aguda.

EVALUATION OF THE BEHAVIOR OF LEVELS OF HMGB1 AND IL6 AS PREDICTORS OF INFECTION, ACUTE KIDNEY INJURY AND MORTALITY IN CIRRHOTIC PATIENTS WITH VARICEAL BLEEDING.

BACKGROUND: Gastroesophageal varices and associated bleeding are a major cause of morbidity and mortality in cirrhotic patients. OBJECTIVE: To evaluate the potential role of the biomarkers HMGB1 (High Mobility Group Box 1) and IL-6 (Interleukin-6) as predictors of infection, acute kidney injury and mortality in these patients. METHODS: It is a prospective, observational study that included 32 cirrhotic patients with variceal bleeding. RESULTS: The subjects'mean age was 52±5 years and 20 (62.5%) were male. The average MELD was 17.53±5 and the average MELD-Na was 20.63±6.06. Thirty patients (93.3%) patients were Child-Pugh class B or C. Infection was present in 9 subjects (28.1%), acute kidney injury was present in 6 (18.1%) and 4 (12.5%) patients died. The median serum levels of HMGB1 were 1487 pg/mL (0.1 to 8593.1) and the median serum level of IL-6 was 62.1 pg/mL (0.1 to 1102.4). The serum levels of HMGB1 and IL-6 were significantly higher in patients who developed infection, acute kidney injury and death (P<0.05). The Spearman's correlations for HMGB1 and IL-6 were 0.794 and 0.374 for infection, 0.53 and 0.374 for acute kidney injury and 0.467 and 0.404 for death, respectively. CONCLUSION: Serum levels of HMGB1 and IL-6 were higher in patients with the three studied outcomes. HMGB1 serum levels showed a high correlation with infection and a moderate correlation with acute kidney injury and death, while IL-6 showed a moderate correlation with infection and death and a low correlation with acute kidney injury.

ASSESSMENT OF THE GASTRO-JEJUNO-DUODENAL TRANSIT AFTER JEJUNAL POUCH INTERPOSITION / AVALIAÇÃO DO TRÂNSITO GASTROJEJUNODUODENAL APÓS INTERPOSIÇÃO DE ALÇA JEJUNAL

Background : The jejunal pouch interposition between the gastric body and the duodenum after the gastrectomy, although not frequent in the surgical practice today, has been successfully employed for the prevention and treatment of the postgastrectomy syndromes. In the latter, it is included the dumping syndrome, which affects 13-58% of the patients who undergo gastrectomy. Aim : Retrospective assessment of the results of this procedure for the prevention of the dumping syndrome. Methods : Fourty patients were selected and treatetd surgically for peptic ulcer, between 1965 and 1970. Of these, 29 underwent vagotomy, antrectomy, gastrojejunalduodenostomy at the lesser curvature level, and the 11 remaining were submitted to vagotomy, antrectomy, gastrojejunal-duodenostomy at the greater curvature level. The gastro-jejuno-duodenal transit was assessed in the immediate or late postoperative with the contrasted study of the esophagus, stomach and duodenum. The clinical evolution was assessed according to the Visick grade. Results : Of the 40 patients, 28 were followed with the contrast evaluation in the late postoperative. Among those who were followed until the first month (n=22), 20 (90%) had slow gastro-jejuno-duodenal transit and in two (10%) the transit was normal. Among those who were followed after the first month (n=16), three (19%) and 13 (81%) had slow and normal gastric emptying, respectively. None had the contrasted exam compatible with the dumping syndrome. Among the 40 patients, 22 underwent postoperative clinical evaluation. Of these, 19 (86,5%) had excellent and good results (Visick 1 and 2, respectively). Conclusions : The jejunal pouch interposition showed to be a very effective surgical procedure for the prevention of the dumping syndrome in gastrectomized patients.

Racional : A interposição de alça jejunal entre o corpo gástrico e o duodeno após a antrectomia, apesar de pouco frequente na prática cirúrgica atual, tem sido empregada com sucesso na prevenção e tratamento das síndromes pós-gastrectomias. Entre estas se inclui a síndrome de dumping, que acomete 13-58% dos pacientes gastrectomizados. Objetivo : Avaliação retrospectiva dos resultados desse procedimento na prevenção da síndrome de dumping. Métodos : Foram selecionados 40 pacientes todos encaminhados para tratamento cirúrgico de úlcera cloridropéptica entre 1965 e 1970. Destes, 29 foram submetidos à vagotomia, antrectomia, gastrojejunoduodenostomia no nível da pequena curvatura, e os 11 restantes à vagotomia, antrectomia, gastrojejunoduodenostomia no nível da grande curvatura. O trânsito gastrojejunoduodenal foi avaliado no pós-operatório imediato ou tardio por meio do estudo contrastado de esôfago, estômago e duodeno. A evolução clínica no pós-operatório foi avaliada segundo a classificação de Visick. Resultados : Dos 40 pacientes, 28 foram acompanhados com o estudo contrastado no pós-operatório tardio. Entre aqueles de até o 1º mês de pós-operatório (n=22), 20 (90%) apresentaram o trânsito gastrojejunoduodenal lento e dois (10%) tiveram o trânsito normal. Entre os que puderam ser acompanhados após o 1º mês (n=16), três (19%) e 13 (81%) mostraram o esvaziamento gástrico lento e normal, respectivamente. Nenhum apresentou o estudo contrastado compatível com a síndrome de dumping. Entre os 40 doentes, 22 foram submetidos à avaliação clínica pós-operatória. Destes, 19 (86,5%) apresentaram excelentes e bons resultados (Visick 1 e 2, respectivamente). Conclusões : A interposição de alça jejunal mostrou-se procedimento cirúrgico bastante eficaz na prevenção da síndrome de dumping em pacientes gastrectomizados.

ASSESSMENT OF THE GASTRO-JEJUNO-DUODENAL TRANSIT AFTER JEJUNAL POUCH INTERPOSITION.

BACKGROUND: The jejunal pouch interposition between the gastric body and the duodenum after the gastrectomy, although not frequent in the surgical practice today, has been successfully employed for the prevention and treatment of the postgastrectomy syndromes. In the latter, it is included the dumping syndrome, which affects 13-58% of the patients who undergo gastrectomy. AIM: Retrospective assessment of the results of this procedure for the prevention of the dumping syndrome. METHODS: Fourty patients were selected and treatetd surgically for peptic ulcer, between 1965 and 1970. Of these, 29 underwent vagotomy, antrectomy, gastrojejunalduodenostomy at the lesser curvature level, and the 11 remaining were submitted to vagotomy, antrectomy, gastrojejunal-duodenostomy at the greater curvature level. The gastro-jejuno-duodenal transit was assessed in the immediate or late postoperative with the contrasted study of the esophagus, stomach and duodenum. The clinical evolution was assessed according to the Visick grade. RESULTS: Of the 40 patients, 28 were followed with the contrast evaluation in the late postoperative. Among those who were followed until the first month (n=22), 20 (90%) had slow gastro-jejuno-duodenal transit and in two (10%) the transit was normal. Among those who were followed after the first month (n=16), three (19%) and 13 (81%) had slow and normal gastric emptying, respectively. None had the contrasted exam compatible with the dumping syndrome. Among the 40 patients, 22 underwent postoperative clinical evaluation. Of these, 19 (86,5%) had excellent and good results (Visick 1 and 2, respectively). CONCLUSIONS: The jejunal pouch interposition showed to be a very effective surgical procedure for the prevention of the dumping syndrome in gastrectomized patients.