Hemorragia digestiva média e outras indicações de exame com a capsula endoscópica: resultados em uma série consecutiva de 187 pacientes / Avarage gastrointestinal bleeding and other indications of capsule endoscopy examination with the: results in a consecutive series of 187 patients

Objetivo: verificar as indicações e os resultados do emprego da cápsula endoscópica em uma série consecutiva de pacientes, analisando-se, em especial, os casos de hemorragia de causa obscura e também a relação no momento em que o exame foi efetuado em relação à atividade de sangramento. Análises especiais ainda para os casos de exames inconclusivos, cápsulas retidas e lesões fora do delgado. Material e Métodos: 187 pacientes consecutivos submetidos ao exame do intestino delgado pela cápsula foram analisados. Utilizou-se a cápsula da empresa Given, específica para o delgado (versões M2A e PillCam SB), e as análises de imagens foram efetuadas no software específico deste método, versão 5.1. Resultados: 70,5% (132 casos) dos exames foram indicados por hemorragia de causa obscura (64 casos) ou anemia de causa obscura (68 casos). Diarreia, dor abdominal, suspeita de pólipos e outras menos frequentes foram as demais indicações. Dos 187 casos, em 124 deles observaram-se lesões, sendo 101 lesões em delgado e 23 lesões fora do delgado. Em 29,9% dos casos, a cápsula não observou lesões e, em 3,7% do total de casos, o exame foi inconclusivo. Em 5 casos (2,6%), a cápsula ficou retida. As lesões vasculares do intestino delgado representaram o diagnóstico mais frequente e, quando da análise dos casos de hemorragia em relação ao momento do sangramento, demonstrou-se um percentual de 69,5% de encontro de lesões no paciente com sangramento ativo, 77,7% no paciente com sangramento recente e 64,6% no paciente examinado fora do episódio hemorrágico. Conclusões: a hemorragia digestiva ou a anemia, de causa obscura, foi a indicação mais frequente (70,5%) do exame do delgado com a cápsula endoscópica. Na análise dos resultados em 66,3% dos exames efetuados, a cápsula demonstrou lesões, inclusive fora do delgado. As lesões vasculares foram as mais encontradas e, nos casos de hemorragia/anemia de causa obscura, a capacidade da cápsula em encontrar lesões foi maior nos pacientes que efetuaram o exame durante o episódio hemorrágico, ou logo após do mesmo, do que em pacientes nos quais o exame foi feito distante deste episódio, embora estes resultados não tivessem relevância estatística. Exames inconclusivos tiveram um percentual de 3,7% dos casos e, em 2,6% dos casos, a cápsula ficou retida em estenoses do delgado.

Objectives: to verify the indications and results of the use of endoscopy capsule in a consecutive series of patients, especially the cases of obscure bleeding cause with the moment when the examination was made (related to bleeding activity). Special analysis for the cases not conclusive yet, retained capsules and lesions out of small bowel. Materials and Methods: 187 consecutive patients underwent the small bowel examination by the capsule were analyzed. A capsule from the Given company was used, it is specific for small bowel (M2A e PillCam SB) and the analyses were made in this brand-specific software, version 5,1. Results: in the analysis it was observed that 70,5% of them (132 cases) were indicated by obscure bleeding cause (64 cases) or obscure anemia cause (68 cases). Diarrhea, abdominal pain, suspected polyps and others least often were the other indications. From the 187 cases, in 124 of them were observed lesions, 101 of them in the small bowel and 23 lesions out of it. In 29,9% of the cases the capsule did not observed lesions and in 3,7% of all cases the examination was inconclusive. In 5 cases (2,6%) the capsule was retained. Vascular lesions of the small bowel were the most frequent diagnosis, and the bleeding causes analysis, in relation to the bleeding moment, 69,5% of lesions in the patient with the active bleeding were showed, 77,7% in the patient with recent bleeding and 64,6% in the patient whose examination was out of the bleeding episode. Conclusion: gastrointestinal bleeding and/or obscure anemia cause were the most frequent indication (70,5%) of the small bowel examination with the endoscopy capsule. In the results analysis, in 66,3% of the examinations made, the capsule showed lesion(s), even out of the small bowel. Vascular lesions were the most found and in the obscure bleeding/anemia cause cases the capsules capacity to find lesions was higher in patients that did the examination during the bleeding episode or just after it, than in patients that the examination was done far from the episode. Inconclusive examinations had a percentage of 3,7 of cases and in 2,6% of cases the capsule was retained in small bowel stenosis.

Computerized virtual chromoendoscopy versus indigo carmine chromoendoscopy combined with magnification for diagnosis of small colorectal lesions: a randomized and prospective study.

BACKGROUND AND STUDY AIMS: Magnifying colonoscopy with indigo carmine dye and the analysis of the capillary and the pit patterns by computed virtual chromoendoscopy (Fujinon Intelligent Color Enhancement, FICE) with magnification are effective for the differential diagnosis of neoplastic and non-neoplastic lesions. This study aimed to compare the accuracy of virtual and real chromoendoscopy in differentiating neoplastic and non-neoplastic colorectal lesions. PATIENTS AND METHODS: A prospective randomized trial of magnification colonoscopy with targeted FICE (Group I - 72 patients/111 lesions) versus magnification colonoscopy with targeted indigo carmine dye (Group II - 72 patients/137 lesions) was performed in consecutive patients with lesions 1 cm or less. Histopathology of the specimens was regarded as the gold standard. RESULTS: In group I, 86 (77.5%) lesions showed an intense vascular pattern (positive capillary meshwork), of which 80 (93%) were histologically confirmed as adenomas. From 25 lesions with negative capillary meshwork, 23 (92%) were non-neoplastic. Sensitivity, specificity, accuracy, positive and negative predictive values of the capillary meshwork for the differential diagnosis of these lesions was 97.8, 79.3, 92.8, 93 and 92%, respectively. The same parameters for pit pattern analysis by FICE were 92.7, 82.3, 90.1, 93.8 and 80%, respectively. Indigo carmine magnified chromoscopy showed sensitivity, specificity, accuracy, positive and negative predictive values of 97, 88.9, 94.9, 96.1 and 91.4%, respectively in the discrimination between neoplastic and non-neoplastic lesions. CONCLUSION: Magnified virtual chromoendoscopy is as accurate as indigo carmine magnified chromoendoscopy in distinguishing between neoplastic from non-neoplastic small colorectal lesions.

[Development of colorectal advanced neoplasia/adenomas in the long-term follow-up of patients submitted to colonoscopy with polipectomy]. / Desenvolvimento de neoplasias/adenomas avançados colorretais no seguimento a longo prazo de pacientes submetidos a colonoscopia com polipectomia.

CONTEXT: Colonoscopy with polypectomy reduces the incidence of colorectal cancer and its associated mortality. The ideal interval between surveillance examinations is determined by clinical features and endoscopic findings considered as risk factors to the development of advanced colonic neoplasias. OBJECTIVE: To determine the development rate of advanced neoplasia in patients submitted to surveillance colonoscopy in a tertiary referral center. METHODS: Three hundred and ninety two patients who underwent two or more complete colonoscopies between 1995 and 2005, and who have at least one diagnosed colorectal adenoma entered into the study. The endoscopic findings of the first and subsequent colonoscopies of each patient were analysed, considering advanced neoplasia as the main outcome. The patients enrolled were divided in accordance to the first colonoscopy findings in groups 1 or high risk; 2 or low risk; and 3 or without adenoma at the first colonoscopy. The development of advanced colorectal neoplasia and the period of surveillance until the outcome were analysed and compared among groups. RESULTS: Twenty eight per cent of patients had advanced adenomas at index colonoscopy; 57.8% presented with low grade dysplasia neoplastic lesions and 14.1% had no adenoma at the first examination. The mean age was 59.54 +/- 11.74 years. Twenty six point four per cent of subjects from group 1 presented with advanced neoplasia during the surveillance period, while this outcome occurred in 10.9% and 5.3% of patients from groups 2 and 3, respectively (P<0,05). The mean period of surveillance was 123.35 months, and the mean time between the first examination and the one which presented with the outcome statistically differed among group 1 and the others, being 104.02, 115.31 and 120.61 months, respectively. CONCLUSIONS: Patients with advanced neoplasia at index colonoscopy presented with a higher probability of harbouring this condition during the follow-up when compared with other two groups. These lesions also occur earlier in this patients than in the ones without these lesions at the first examination.

Desenvolvimento de neoplasias/adenomas avançados colorretais no seguimento a longo prazo de pacientes submetidos a colonoscopia com polipectomia / Development of colorectal advanced neoplasia/adenomas in the long-term follow-up of patients submitted to colonoscopy with polipectomy

CONTEXTO: A colonoscopia e a polipectomia diminuem a incidência do câncer colorretal, assim como a mortalidade dele decorrente. O intervalo efetivo entre os exames de seguimento é determinado por características clínicas e achados endoscópicos considerados como preditivos para o desenvolvimento de lesões neoplásicas colônicas avançadas. OBJETIVOS: Avaliar a taxa de surgimento de lesões neoplásicas avançadas em pacientes submetidos a colonoscopias de seguimento em serviço de referência. MÉTODOS: Foram incluídos 392 pacientes submetidos a dois ou mais exames colonoscópicos completos entre 1995 e 2005, constantes no banco de dados e que apresentavam, em pelo menos um dos exames, um adenoma colorretal. Foram analisados os dados da primeira e da última colonoscopias realizadas por cada paciente, ou daquela que mostrava lesão neoplásica avançada - considerado o desfecho principal do estudo. Os pacientes foram divididos de acordo com os achados endoscópicos do primeiro exame em grupos 1 ou de alto risco, 2 ou de baixo risco e 3 ou sem adenoma na colonoscopia inicial. Foram analisados e comparados entre os grupos o aparecimento de neoplasia colônica avançada e o tempo de seguimento até o desfecho. RESULTADOS: Do total de pacientes, 27 por cento apresentavam à colonoscopia inicial, adenomas avançados, 58,4 por cento lesões neoplásicas com displasia de baixo grau e 14,5 por cento não apresentavam adenomas no exame inicial. A média etária foi de 59,54 ± 11,74 anos. Vinte e seis vírgula quatro por cento das pessoas do grupo 1 apresentaram lesão neoplásica avançada ao longo do seguimento, enquanto tal desfecho ocorreu em 10,9 por cento e 5,3 por cento dos pacientes nos grupos 2 e 3, respectivamente (P<0,05). O período médio de acompanhamento foi de 123,35 meses, sendo que o tempo médio entre o primeiro exame e aquele com o desfecho diferiu estatisticamente entre o grupo 1 e os demais, sendo de 104,02, 115,31 e 120,61 meses, respectivamente. CONCLUSÕES: ...

CONTEXT: Colonoscopy with polypectomy reduces the incidence of colorectal cancer and its associated mortality. The ideal interval between surveillance examinations is determined by clinical features and endoscopic findings considered as risk factors to the development of advanced colonic neoplasias. OBJECTIVE: To determine the development rate of advanced neoplasia in patients submitted to surveillance colonoscopy in a tertiary referral center. METHODS: Three hundred and ninety two patients who underwent two or more complete colonoscopies between 1995 and 2005, and who have at least one diagnosed colorectal adenoma entered into the study. The endoscopic findings of the first and subsequent colonoscopies of each patient were analysed, considering advanced neoplasia as the main outcome. The patients enrolled were divided in accordance to the first colonoscopy findings in groups 1 or high risk; 2 or low risk; and 3 or without adenoma at the first colonoscopy. The development of advanced colorectal neoplasia and the period of surveillance until the outcome were analysed and compared among groups. RESULTS: Twenty eight per cent of patients had advanced adenomas at index colonoscopy; 57.8 percent presented with low grade dysplasia neoplastic lesions and 14.1 percent had no adenoma at the first examination. The mean age was 59.54 ± 11.74 years. Twenty six point four per cent of subjects from group 1 presented with advanced neoplasia during the surveillance period, while this outcome occurred in 10.9 percent and 5.3 percent of patients from groups 2 and 3, respectively (P<0,05). The mean period of surveillance was 123.35 months, and the mean time between the first examination and the one which presented with the outcome statistically differed among group 1 and the others, being 104.02, 115.31 and 120.61 months, respectively. CONCLUSIONS: Patients with advanced neoplasia at index colonoscopy presented with a higher probability of harbouring this ...

Redução da prevalência de úlcera duodenal: um estudo brasileiro (análise retrospectiva na última década: 1996-2005) / Prevalence reduction of duodenal ulcer: a Brazilian study. (retrospective analysis in tha last decade: 1996-2005)

RACIONAL: A úlcera duodenal sempre representou uma doença muito prevalente entre as enfermidades digestivas, em qualquer parte do mundo. A prevalência média era de aproximadamente 10 por cento da população mundial. A partir do início dos anos 90, a literatura, tanto européia como norte-americana, passou a demonstrar sua redução gradativa entre seus países. OBJETIVO: Demonstrar, através de análise retrospectiva, a prevalência anual da úlcera duodenal nos últimos 10 anos em um Serviço de Endoscopia Digestiva que é referência para o sistema público de saúde da cidade de Porto Alegre, municípios da Grande Porto Alegre e outras cidades vizinhas da mesma. Os dados analisados são de março de 1996 até dezembro de 2005. MÉTODOS: Estudo retrospectivo transversal, com análise documental de diagnósticos endoscópicos efetuados em endoscopia digestiva alta, no referido Serviço. Foi feita a análise retrospectiva de diagnósticos endoscópicos efetuados em 13.130 pacientes submetidos a endoscopia digestiva alta no período de março de 1996 a dezembro de 2005. A classificação de Sakita foi utilizada para o estádio do grau evolutivo da úlcera duodenal e foi considerado por ela acometido o paciente com a lesão no estágio A1, até o estágio S1, inclusive. Observou-se também a prevalência nos dois sexos, na raça, o percentual médio total nos 10 anos, além da prevalência anual. Para verificar se houve significância estatística dos resultados observados nos diferentes períodos, foi aplicado um teste de regressão linear ("linear regression model"). RESULTADOS: Observou-se decréscimo gradativo dos percentuais de prevalência da úlcera duodenal, ano após ano, iniciando-se em 1996 com 8,6 por cento e se encerrando no final de 2005, com 3,3 por cento. A exceção do período foi observada no ano de 2003 quando houve um acréscimo, comparando-se com o decréscimo gradativo dos 6 anos anteriores. Mas já, a partir do período seguinte (2004), a queda gradativa voltou a ser observada...

BACKGROUND: The duodenal ulcer always represented a very prevalent pathology among the gastrointestinal tract diseases worldwide. The average prevalence is approximately 10 percent of the world population. In the 90s the literature (both European and North American) begin to show a crescent reduction of this prevalence in many countries. AIM: To show through a retrospective analysis the annual prevalence of the duodenal ulcer in the last 10 years in a Digestive Endoscopy Service which is referred to public medical system in Porto Alegre and its suburban area and countryside of the State of Rio Grande do Sul, Brazil. The data analyzed is from March 1996 to December 2005. Specific data: transversal retrospective study with documented analysis of endoscopic diagnosis of upper gastrointestinal endoscopy. METHODS: A retrospective analysis of the diagnosis of the 13.130 procedures of upper gastrointestinal endoscopy between 1996 and 2005. The Sakita classification was used to verify the duodenal ulcer activity taking into consideration the patients who have lesions on A1 to S1 levels. To verify if there was a statistical significant results, a linear regression test was done (linear regression model). RESULTS: A gradate decrease of the prevalence percentuals was observed, year after year, it began with 8.3 percent of prevalence in 1996 and finished with 3.3 percent in the beginning of 2006. The average annual reduction of this prevalence was calculated following the regression test and it was placed in the 1.3 percent a year in the studied period of time. In 2003, in an isolated way, it was an exception in the decrease of the percentage because it presented a prevalence increase of (6.5 percent) comparing to the first 6 years of study. CONCLUSION: In this study it was observed a decrease of duodenal ulcer prevalence, 1.3 percent a year to be more accurate in 10 years of study, showing a statistical significance in the linear regression test.

Magnifying colonoscopy: interobserver agreement in the assessment of colonic pit patterns and its correlation with histopathological findings.

BACKGROUND AND STUDY AIMS: Magnifying colonoscopy (MC) is recognized as an aid to the differential diagnosis between neoplastic and nonneoplastic lesions. This study evaluated interobserver agreement of experienced endoscopists in the assessment of colonic pit patterns through the Kudo's classification and correlated morphological aspects with histopathological findings. MATERIALS AND METHODS: A total of 213 magnification chromoendoscopic pictures of colonic lesions were collected from 161 consecutive patients and presented to three independent observers who expressed opinion about predominant pit pattern. All lesions were excised and sent for histopathological study. RESULTS: Kappa statistics showed that the general agreement index with respect to the aspects of the pits was good among the three observers (0.561). Regarding prediction of histopathology according to the pit pattern diagnosis, overall accuracy was 84%, sensitivity was 91.4%, specificity was 67.2%, positive predictive value was 86.6%, and negative predictive value was 79.3%. CONCLUSION: Although the interobserver reproducibility of the colonic pit pattern is good for experienced endoscopists, MC must not be used to replace the histopathological analysis, since it does not differentiate with the necessary safety neoplastic from nonneoplastic lesions.

[Prevalence reduction of duodenal ulcer: a Brazilian study. (retrospective analysis in the last decade: 1996-2005)]. / Redução da prevalência de úlcera duodenal: um estudo brasileiro (análise retrospectiva na última década: 1996-2005).

BACKGROUND: The duodenal ulcer always represented a very prevalent pathology among the gastrointestinal tract diseases worldwide. The average prevalence is approximately 10% of the world population. In the 90s the literature (both European and North American) begin to show a crescent reduction of this prevalence in many countries. AIM: To show through a retrospective analysis the annual prevalence of the duodenal ulcer in the last 10 years in a Digestive Endoscopy Service which is referred to public medical system in Porto Alegre and its suburban area and countryside of the State of Rio Grande do Sul, Brazil. The data analyzed is from March 1996 to December 2005. Specific data: transversal retrospective study with documented analysis of endoscopic diagnosis of upper gastrointestinal endoscopy. METHODS: A retrospective analysis of the diagnosis of the 13.130 procedures of upper gastrointestinal endoscopy between 1996 and 2005. The Sakita classification was used to verify the duodenal ulcer activity taking into consideration the patients who have lesions on A1 to S1 levels. To verify if there was a statistical significant results, a linear regression test was done (linear regression model). RESULTS: A graduate decrease of the prevalence percentuals was observed, year after year, it began with 8.3% of prevalence in 1996 and finished with 3.3% in the beginning of 2006. The average annual reduction of this prevalence was calculated following the regression test and it was placed in the 1.3% a year in the studied period of time. In 2003, in an isolated way, it was an exception in the decrease of the percentage because it presented a prevalence increase of (6.5%) comparing to the first 6 years of study. CONCLUSION: In this study it was observed a decrease of duodenal ulcer prevalence, 1.3% a year to be more accurate in 10 years of study, showing a statistical significance in the linear regression test.

Colonoscopia com magnificação de imagem: análise da variação interobservadores para os padrões de criptas e comparação das imagens endoscópicas com os achados histopatológicos / Magnification colonoscopy images: analysis of variation interobservers for pit patern and comparison of endoscopy and histopatologic findings

A colonoscopia com magnificação de imagem (CMI) é considerada uma técnica que possibilita o diagnóstico diferencial entre lesões colorretais neoplásicas e não-neoplásicas. Este estudo avaliou a variação da concordância interobservadores para os padrões de criptas através de três endoscopistas experientes com a classificação de Kudo, e correlacionou esses aspectos morfológicos com os achados histopatológicos. Um total de 213 imagens de lesões magnificadas (polipóides e planas) forma coletadas de 161 pacientes consecutivos e apresentadas a três observadores independentes que expressaram opinião sobre o padrão de criptas predominante. Todas as lesões foram completamente excisadas e enviadas para estudo histopatológico. A estatística estimada de Kappa mostrou que o índice de concordância geral para padrões de criptas entre os três observadores foi bom (0,561). Com relação aos resultados histapatológicos, quando comparados aos padrões de criptas, observou-se: acuária de 84 por cento; sensibilidade de 91,4 por cento; especifidade de 67,2 por cento; valor preditivo positivo de 86,6 por cento valor preditivo negativo de 79,3 por cento e índice de Kappa de 0,61. Embora a reprodutilidade interobservadores dos padrões de criptas seja boa, a CMI não deve substituir o estudo histopatológico, pois não diferencia com a necessária segurança lesões neoplásicas de lesões não-neoplásicas.

Colonoscopy with magnified view is the most reliable nonbiopsy method for distinguishing non-neoplastic from neoplastic colorectal lesions. This study analysed lhe interobserver concordance in diagnosis of pit patem, with 3 experients endoscopists using Kudo Classification and correlating the this aspects with histological ones. A total of 213 magnificated images injuries (polipoides and plain) had been collected of 161 independent observing patients consecutive and presented tres that had expressed opinion on the predominant standard of criptas. All the injuries had been completely ressected and send for histopatológico study. The analysis esteem statistics of Kappa showed that the indice of general agreement for standards of criptas between the 3 observers was 84 percent; sensitivity 91.4 percent; specificity 67.2 percent positive preditivo value 86.6 percent; negative preditivo value 79.3 percent; e index of Kappa of 0,61 percent. Although the interobserver reproduction of pit patern are good, the image for colonoscopia with magnificação, does not have to substitute the histopatologic study, therefore it does not differentiate with the necessary security neoplastic injuries of non neoplastic.

Digital image analysis and stereology of angiogenesis in polypoid and nonpolypoid colorectal adenomas.

OBJECTIVE: To evaluate 3-dimensional parameters and bidimensional microvascular quantification in the different morphologic presentations of colorectal adenomas. STUDY DESIGN: A study was carried out, including 102 neoplastic colorectal lesions obtained by endoscopy or surgical resection. For the analysis of angiogenesis, immunohistochemistry, digital image analysis, microvascular quantification and stereology were used. RESULTS: Microvascular quantification, volume and microvascular length estimate rose gradually with high grade dysplasia as compared to the low grade ones (P < .001). There was no significant difference in angiogenesis between polypoid and nonpolypoid colorectal adenomas in terms of quantification and microvascular length estimate. CONCLUSION: The use of digital image analysis and stereology added greater objectivity and effectiveness to angiogenic evaluation because they allowed accurate segmentation of hypervascular areas, representation of the characteristic 3-dimensional morphology of the vascular supply and identification of differences in microvascularization in the developmental stages of colorectal cancer. However, no significant relation could be found between macroscopic type and angiogenesis, suggesting that angiogenesis may contribute little to morphogenesis of colorectal adenomas.

Tratamento endoscópico de lesões sangrantes do trato gastrointestinal por meio de eletrocoagulação com argônio / Endoscopic treatment of bleeding lesions of the gastrointestinal tract by argon plasma coagulation

Introdução e objetivos: A eletrocoagulação com argônio (APC) é um método térmico de não-contato que pode ser utilizado como alternativa ao laser em endoscopia. Um amplo espectro de indicações têm sido propostas para tratamento através de APC, desde a introdução do uso em endoscopia, em 1991. O objetivo deste estudo é avaliar a eficácia do uso do APC na hemostasia endoscópica de lesões sangrantes do esôfago, estômago, duodeno, cólon e reto. Metodologia: Um total de 22 pacientes consecutivos (14M/8F, média de idade 66,7 anos) foram submetidos ao tratamento com APC entre 1998 e fevereiro de 2002. As causas de sangramento incluíam retite actínica (12 pacientes), ectasia vascular do antro gástrico (GAVE) ­ watermelon stomach (6 pacientes), angiodisplasias de esôfago, estômago e cólon (2 pacientes), gastrite actínica (1 paciente) e síndrome de Osler-Weber-Rendu (1 paciente). Resultados: Um total de 49 sessões foram realizadas (média de 2,2 sessões por paciente). Sucesso no tratamento endoscópico foi obtido em 18 pacientes (85,8%). Complicações foram observadas em 3 pacientes: 2 apresentaram dor local após as sessões de APC e um paciente desenvolveu estenose retal tratada com sucesso em uma sessão de dilatação endoscópica. Não houve mortalidade relacionada ao método. Conclusões: APC é um método seguro, efetivo, de relativo baixo custo e boa aceitação pelos pacientes para o tratamento de lesões sangrantes do trato gastrointestinal. Deve, portanto, ser considerado método de primeira escolha no tratamento dessas afecções (AU)

Background and aims: Argon plasma coagulation (APC) is an innovative non-touch electrocoagulation technique. A broad spectrum of indications has been proposed for APC since its introduction into endoscopy in 1991. The aim of this study is to evaluate the efficacy of utilizing APC in the endoscopic hemostasis of bleeding lesions of the esophagus, stomach, duodenun, colon and rectum. Methodology: A total of 22 consecutive patients (14M/ 8 F, mean age 66.7 years) underwent APC treatment between 1998 and february 2002. Causes of bleeding included radiation colitis (12 patients), gastric antral vascular ectasia ­ watermelon stomach (6 patients), esophagus,stomach and colon angiodysplasia (2 patients), radiation gastritis (1 patient) and Osler-Weber-Rendu Syndrome (1 patient). Results: A total of 49 sessions were performed (mean 2.2 sessions / patient). Succesful endoscopic APC treatment was achieved in 18 patients (85,8%). Complications were observed in 2 patients that referred local pain after therapy and 1 patient that developed a rectal stenosis succesfully reversed in one session of endoscopic dilation. No mortality related to APC was observed. Conclusions: APC is a safe, effective, and relative low-cost hemostatic modality for bleeding vascular lesions of the gastrointestinal tract. Therefore, APC should be considered as a first-line therapy for these conditions (AU)

Tratamento da ectasia vascular do antro gástrico por eletrocoagulação com argônio / Treatment of gastric antrum vascular ectasia with argon plasma coagulation

Introdução e objetivos: a ectasia vascular do antro gástrico (watermelon stomach) é uma causa rara de hemorragia digestiva aguda e crônica de difícil resposta a tratamento. a eletrocoagulação com argônio é um método de não contato que pode ser usado como alternativa ao laser em endoscopia. Neste estudo são apresentados resultados com o uso dessa técnica no tratamento da ectasia vascular do antro gástrico. Pacientes e métodos: foram analisados, retrospectivamente, seis pacientes (3M/3F; média de idade = 58,3 anos), com diagnóstico de ectasia vascular do antro gátrico tratados por eletrocoagulação com argônio em sessões mensais a uma potencia de 90w e fluxo de gás de 2l/min. Dois desses pacientes com ectasia vascular do antro gástrico não-cirrótico, houve resolução das lesões em dois casos e importante melhora endoscópica e sintomatica em outro dois. Nenhum desses pacientes, os quais se apresentavam clinicamente com hemorragia digestiva, necessitou de transfusões sanguineas após o termino da sessões com argônio, ou mesmo voltou a apresentar melena e /ou hematêmese. Conclusão: A eletrocoagulação com argônio é um tratamento seguro, efetivo e bem tolerado para a resolução do sangramento por ectasia vascular do antro gástrico. Essa técnica deve ser considerada terapêutica de primeira escolha no tratamento dessa afecção quando na ausênciade cirrose

Angiogenesis in advanced colorectal adenocarcinoma with special reference to tumoral invasion.

BACKGROUND: Angiogenesis is a crucial step in tumor growth and progression. Its quantification by microvessel counting has a prognostic value in several types of malignancies and recently has been appraised in gastrointestinal tumors. AIM: To assess the prognostic significance of microvessel quantification in colorectal carcinomas, studying its association with hematogenous metastases, survival and clinicopathological variables such as size, histologic differentiation and depth of tumoral invasion. PATIENTS/METHODS: Forty eight patients with colorectal adenocarcinoma were included in this study. Histologic sections of invasion tumoral margin (4 microns) were analyzed and endothelined microvessels were immunostained with monoclonal mouse Von Willebrand Factor (anti-FVIII). The microvessel count was performed from the identification of the area with increased microvessel density--hot spots--and results of the mean in five of these fields. RESULTS: The cut-off microvessel count was 14 microvessels/0.785 mm2, which divided the sample into hypovascular and hypervascular groups. While 2/8 (25%) tumors with muscularis propria invasion were classified as hypervascular, 11/15 (73%) tumors with serosa or perivisceral fat were classified as hypervascular. However, a non-significant statistical association was found between the angiogenesis quantification, hematogenous metastases, survival and clinicopathological variables such as size and histologic differentiation of the tumor. CONCLUSIONS: The findings of significantly increase of microvessel count in conformity with tumoral invasion depth supports the hypothesis that tumor progression might be related to angiogenesis. Although angiogenesis is an important step in the tumoral growth and during the metastatization process, other factors can be implicated.

Angiogenesis in advanced colorectal adenocarcinoma with special reference to tumoral invasion

Angiogenesis is a crucial step in tumor growth and progression. Its quantification by microvessel counting has a prognostic value in several types of malignancies and recently has been appraised in gastrointestinal tumors. AIM: To assess the prognostic significance of microvessel quantification in colorectal carcinomas, studying its association with hematogenous metastases, survival and clinicopathological variables such as size, histologic differentiation and depth of tumoral invasion. PATIENTS/METHODS: Forty eight patients with colorectal adenocarcinoma were included in this study. Histologic sections of invasion tumoral margin (4 microns) were analyzed and endothelined microvessels were immunostained with monoclonal mouse Von Willebrand Factor (anti-FVIII). The microvessel count was performed from the identification of the area with increased microvessel density--hot spots--and results of the mean in five of these fields. RESULTS: The cut-off microvessel count was 14 microvessels/0.785 mm2, which divided the sample into hypovascular and hypervascular groups. While 2/8 (25%) tumors with muscularis propria invasion were classified as hypervascular, 11/15 (73%) tumors with serosa or perivisceral fat were classified as hypervascular. However, a non-significant statistical association was found between the angiogenesis quantification, hematogenous metastases, survival and clinicopathological variables such as size and histologic differentiation of the tumor. CONCLUSIONS: The findings of significantly increase of microvessel count in conformity with tumoral invasion depth supports the hypothesis that tumor progression might be related to angiogenesis. Although angiogenesis is an important step in the tumoral growth and during the metastatization process, other factors can be implicated

Angiogênese no carcinoma colorretal - revisäo e perspectivas / Colorectal carcinoma angiogenisis - review and perspectives

Em adiçäo aos sistemas de estadiamento clinicopatológicos comumente utilizados, fatores de risco para a recorrência no carcinoma colorretal têm sido investigados. Entre estes a quantificaçäo da angiogênese e de peptídeos angiogênicos têm demonstrado aplicaçäo clínica na avaliaçäo da sobrevida e recorrência. A angiogênese é o crescimento de novos capilares, estando associada tanto ao desenvolvimento tecidual pré e pós-natal, cicatrizaçäo e reproduçäo como em doenças inflamatórias e neoplasias. Além de permitir o crescimento tumoral, evidências experimentais demonstram que a angiogênese associa-se com o processo metastático, pois maior é a superfície vascular para o escape de células neoplásicas, o que também pode ser facilitado pela imaturidade dos novos vasos. Neste artigo de revisäo discute-se o processo de formaçäo de vasos capilares, associado ao crescimento tumoral e ao surgimento de metástases hematogênicas, bem como uma revisäo de literatura abordando angiogênese e carcinoma colorretal e o seu papel como um possível alvo terapêutico

Colonoscopia com magnificaçäo de imagem no diagnóstico de carcinoma colorretal invasivo da submucosa na polipose adenomatosa familiar / Magnifying colonoscopy diagnosis of submucosal invasive colorectal carcinoma in familial adenomatous polyposis

The development of colonoscopy with image magnification has enable to study the colonic mucosa in detail and to do differential diagnosis between neoplastic and non-neoplastic lesions from the observation of pit patterns. The results are comparable to stereomicroscopy being possible to predict the histologic diagnosis. In a patient with familial adenomatous polyposis magnifying colonoscopy was performed and this method demonstrated a wide variation of benign polypoid lesions and the morphological features of early colorectal cancer. In this patient, the evaluation by image magnification, together with indigo carmin 0.4 per cent chromoscopy, showed a wide variety of lesions in the colon and rectum: laterally spreading tumor in the cecum, with IIIL + IV pits, subpediculate polyp in the transverse colon with approximately 2.0 cm diameter and IV + V pits, flat elevated lesions IIIL type, and in the sigmoid colon IIa + Iic lesion with V type of Kudo's classification were observed. The evaluation of pit patterns of the lesions in the transverse and sigmoid colon has enable to do the endoscopic diagnosis of the lesion with submucosal invasion

Estudo comparativo entre imagens de videocoloscopia convencional e imagens digitais para aplicaçäo em telemedicina / Comparative study betwen conventional videocolonoscopic imagens and digitized for tele-medicine application

O objetivo do presente estudo foi investigar a possibilidade de emitir uma opiniäo diagnóstica sobre lesöes do colon baseada em imagens endoscópicas digitalizadas. Para tal, 100 pacientes foram submetidos a colonoscopia na Fundaçäo Rio-Grandense Universitária de Gastroenterologia-Fugast, em Porto Alegre, no ano de 1997, e tiveram seus diagnósticos firmados por um mesmo autor (CRT). Após isso, essas imagens foram digitalizadas por um segundo autor (CS), e entäo submetidas a um observador (GAB). Os objetivos foram: a) verificar o grau de concordância entre os dois observadores sobre o diagnóstico de cada caso, b) registrar a impressäo do segundo observador sobre essas imagens digitalizadas com propósitos diagnósticos, c) verificar a factibilidade de empregar equipamento padräo simplificado com propósitos de telendoscopia. Sensibilidade, especificidade, valores preditivo-positivo e preditivo-negativo, e intervalos de confiança de 95 por cento foram calculados. O coeficiente Kappa foi usado para verificar o grau de concordância entre os dois tipos de imagens. Houve concordância total entre os dois observadores em 90 dos casos. Em seis casos houve concordância parcial e, em quatro, discordância. As imagenbs digitalizadas foram consideradas suficientes, tanto em quantidade como em qualidade, para propósitos diagnmósticos. Näo houve complicaçöes técnicas com o equipamento e o custo do sistema empregado näo foi excessivo (U$3.690,00) O coeficiente Kappa foi de 0,897, o valor preditivo positivo de 95,5 por cento e o valor preditivo negativo de 83,3 por cento. Os valores de sensibilidade e especificidade foram de 94,4 por cento e 86,6 por cento respectivamente. Baseado nesses resultados é possível concluir que as imagens digitalizadas säo adequadas para propósitos diagnósticos. A eficácia do diagnóstico colonoscópico digital é comparável ao diagnóstico videocolonoscópico convencional, quando realizado por endoscopistas experientes

Ressecçäo de "laterally spreading tumor" por "strip biopsy" / Resection of a laterally spreading tumor by strip biopsy

Paciente masculino, branco, 58 anos é submetido a videocolonoscopia indicada para "follow-up" de ressecçäo de adenocarcinomma colorretal avançado há 33 meses. Identificam-se pequenos pólipos colônicos que foram ressecados, (adenomas tubulares com displasia moderada ao exame anatomopatológico). No ângulo hepático do cólon havia lesäo plano-elevada de espalhamento lateral ("laterally spreading tumor") que, após adequada demarcaçäo com azul-de-metileno a 0,1 por cento, foi ressecada pela técnica de "strip biopsy". Näo houve complicaçöes relacionadas ao método empregado e, através desta técnica, conforme exame anatomopatológico, obteve-se a ressecçäo completa da lesäo. É apresentada a seqüência amplamente aceita adenoma-carcinoma colorretal e as lesöes do câncer de novo - surgimento de malignidade sem lesäo precursora adenomatosa/polipóide - além das indicaçöes para ressecçäo endoscópica ("strip biopsy") do câncer colorretal precoce.