UNDERWATER ENDOSCOPIC MUCOSAL RESECTION FOR NON-PEDUNCULATED COLORECTAL LESIONS. A PROSPECTIVE SINGLE-ARM STUDY.

BACKGROUND: Underwater endoscopic mucosal resection (UEMR) has emerged as a revolutionary method allowing resection of colorectal lesions without submucosal injection. Brazilian literature about this technique is sparse. OBJECTIVE: The aim of this study was evaluate the efficacy and safety of UEMR technique for removing non-pedunculated colorectal lesions in two Brazilian tertiary centers. METHODS: This prospective study was conducted between June 2016 and May 2017. Naïve and non-pedunculated lesions without signs of submucosal invasion were resected using UEMR technique. RESULTS: A total of 55 patients with 65 lesions were included. All lesions, except one, were successfully and completely removed by UEMR (success rate 98.5%). During UEMR, two cases of bleeding were observed (3.0%). One patient had abdominal pain on the day after resection without pneumoperitoneum. There was no perforation or delayed bleeding. CONCLUSION: This study supports the existing data indicating acceptable rates of technical success, and low incidence of adverse events with UEMR. The results of this Brazilian study were consistent with previous abroad studies.

Ressecção da mucosa endoscópica sob imersão dágua para lesões colorretais não pediculadas. Um estudo prospectivo de braço único / Underwater endoscopic mucosal resection for non-pedunculated colorectal lesions. a prospective single-arm study

ABSTRACT BACKGROUND: Underwater endoscopic mucosal resection (UEMR) has emerged as a revolutionary method allowing resection of colorectal lesions without submucosal injection. Brazilian literature about this technique is sparse. OBJECTIVE: The aim of this study was evaluate the efficacy and safety of UEMR technique for removing non-pedunculated colorectal lesions in two Brazilian tertiary centers. METHODS: This prospective study was conducted between June 2016 and May 2017. Naïve and non-pedunculated lesions without signs of submucosal invasion were resected using UEMR technique. RESULTS: A total of 55 patients with 65 lesions were included. All lesions, except one, were successfully and completely removed by UEMR (success rate 98.5%). During UEMR, two cases of bleeding were observed (3.0%). One patient had abdominal pain on the day after resection without pneumoperitoneum. There was no perforation or delayed bleeding. CONCLUSION: This study supports the existing data indicating acceptable rates of technical success, and low incidence of adverse events with UEMR. The results of this Brazilian study were consistent with previous abroad studies.

RESUMO CONTEXTO: A ressecção endoscópica da mucosa sob imersão d'água (REMS) surgiu como um método revolucionário que permite a ressecção de lesões colorretais sem injeção submucosa. A literatura brasileira sobre essa técnica é escassa. OBJETIVO: A finalidade deste estudo foi avaliar a eficácia e segurança da técnica REMS na remoção de lesões colorretais não pediculadas em dois centros terciários brasileiros. MÉTODOS: Este estudo prospectivo foi realizado entre junho de 2016 e maio de 2017. As lesões sem tentativa de ressecção prévia, não pediculadas e sem sinais de invasão submucosa foram ressecadas pela técnica REMS. RESULTADOS: Um total de 55 pacientes com 65 lesões foram incluídos. Todas as lesões, exceto uma, foram removidas com sucesso e completamente por REMS (taxa de sucesso de 98,5%). Durante a REMS, foram observados dois casos de sangramento (3,0%). Uma paciente apresentou dor abdominal no dia seguinte à ressecção sem pneumoperitônio. Não houve perfuração ou sangramento tardio. CONCLUSÃO: Este estudo apoia os dados existentes, indicando taxas aceitáveis de sucesso técnico e baixa incidência de eventos adversos com a REMS. Os resultados deste estudo brasileiro foram consistentes com estudos internacionais prévios.

Endoscopic activity, tissue factor and Crohn's disease: findings in clinical remission patients.

BACKGROUND: As Crohn's disease (CD) is associated with a high risk of thromboembolic events (TE), including patients with subclinical inflammation, we aim to evaluate the correlation between the impact of endoscopic activity (EA) in the coagulation profiling of CD patients while in clinical remission. METHODS: From 164 consecutive CD patients included in clinical remission [Crohn's disease activity index (CDAI) < 150], 75 were in the EA group [Simplified Endoscopic Score for CD (SES-CD) ⩾ 7], 89 were in the endoscopic remission (ER) group (SES-CD ⩽ 2), and 50 were included as healthy controls in the study. Blood samples were analyzed for tissue factor (TF), factor VIII (FVIII), thrombomodulin (TM), ADAMTS-13, von Willebrand factor (VWF), and endogenous thrombin potential (ETP), as well as collecting data regarding risk factors for TE and CD profile. RESULTS: Mean plasma TF activity showed significantly higher levels in the EA group when compared with the ER and control groups (127 pM versus 103 pM versus 84 pM; p = 0.001), although the VWF:Ag (160% versus 168% versus 110%; p = 0.001), VWF/ADAMTS-13 (191 versus 219 versus 138; p = 0.003), FVIII (150% versus 144% versus 90%; p = 0.001) and TM (5.13 ng/ml versus 4.91 ng/mL versus 3.81 ng/ml; p < 0.001) were only increased in CD regardless of EA status when compared with controls. Lastly, ETP with and without TM remained the same in all three groups. CONCLUSIONS: CD patients in clinical remission with EA present endothelial lesion inducing TF exposure and subsequent coagulation cascade activation. Recommended thromboprophylaxis for EA outpatient subgroups will require additional investigation in order to be validated.

FECAL OCCULT BLOOD: A COMPARISON OF CHEMICAL AND IMMUNOCHEMICAL TESTS.

BACKGROUND: Colorectal bleeding is a warning sign that may be identified by fecal occult blood testing. A positive fecal occult blood test result requires a subsequent colonoscopy, a costly and invasive examination. Therefore, the use of diagnostic tests with optimal sensitivity and specificity is warranted. In this study, we evaluated four different fecal occult blood tests in 176 patients undergoing colonoscopy and compared their results. OBJECTIVE: To assess the sensitivity, specificity and predictive values of chemical and immunochemical fecal occult blood tests in patients undergoing colonoscopy and to evaluate the degree of concordance between the tests and colonoscopy. METHODS: Patients with indications for colonoscopy also underwent fecal occult blood testing by chemical (toluidine test) and immunochemical methods, employing three commercially available kits. Based on the endoscopic findings, the colonoscopy was rated as positive or negative for colorectal bleeding. The degree of concordance between the fecal occult blood tests and the colonoscopy was evaluated by the kappa index. RESULTS: Forty-four (25%) colonoscopies were categorized as positive for colorectal bleeding. The toluidine test presented lower concordance than the immunochemical tests, which showed moderate concordance with the colonoscopy. The toluidine test had the least sensitivity, specificity, and positive and negative predictive values. CONCLUSION: The immunochemical fecal occult blood tests showed greater sensitivity, specificity and predictive values in detecting colorectal bleeding. The immunochemical tests had superior indexes of agreement with colonoscopy compared to the toluidine test.

Sangue oculto nas fezes: uma comparação entre os métodos químico e imunoquímico / Fecal occult blood: a comparison of chemical and immunochemical tests

ABSTRACT BACKGROUND: Colorectal bleeding is a warning sign that may be identified by fecal occult blood testing. A positive fecal occult blood test result requires a subsequent colonoscopy, a costly and invasive examination. Therefore, the use of diagnostic tests with optimal sensitivity and specificity is warranted. In this study, we evaluated four different fecal occult blood tests in 176 patients undergoing colonoscopy and compared their results. OBJECTIVE: To assess the sensitivity, specificity and predictive values of chemical and immunochemical fecal occult blood tests in patients undergoing colonoscopy and to evaluate the degree of concordance between the tests and colonoscopy. METHODS: Patients with indications for colonoscopy also underwent fecal occult blood testing by chemical (toluidine test) and immunochemical methods, employing three commercially available kits. Based on the endoscopic findings, the colonoscopy was rated as positive or negative for colorectal bleeding. The degree of concordance between the fecal occult blood tests and the colonoscopy was evaluated by the kappa index. RESULTS: Forty-four (25%) colonoscopies were categorized as positive for colorectal bleeding. The toluidine test presented lower concordance than the immunochemical tests, which showed moderate concordance with the colonoscopy. The toluidine test had the least sensitivity, specificity, and positive and negative predictive values. CONCLUSION: The immunochemical fecal occult blood tests showed greater sensitivity, specificity and predictive values in detecting colorectal bleeding. The immunochemical tests had superior indexes of agreement with colonoscopy compared to the toluidine test.

RESUMO CONTEXTO: O sangramento colorretal é considerado um sinal de alarme e não deve ser ignorado. O resultado positivo de um teste de pesquisa de sangue oculto nas fezes (PSOF) requer investigação complementar com colonoscopia, exame invasivo e de alto custo. Justifica-se, portanto, a aplicação de um teste diagnóstico mais sensível e específico. No presente estudo, foram avaliados quatro diferentes testes de PSOF em 176 pacientes submetidos à colonoscopia e seus resultados foram comparados. OBJETIVO: Avaliar a sensibilidade, a especificidade e os valores de predição dos testes químico e imunoquímico de PSOF em pacientes submetidos à colonoscopia e avaliar o grau de concordância entre os testes de PSOF e a colonoscopia. MÉTODOS: Pacientes com indicação de realizar colonoscopia foram submetidos também à PSOF pelo método químico (o-toluidina) e pelo método imunoquímico, empregando três kits comerciais disponíveis no mercado. Fundamentado nos achados endoscópicos, a colonoscopia foi categorizada em positiva ou negativa, de acordo com a possível fonte de sangramento colorretal. O grau de concordância entre os testes de PSOF foi avaliado pelo índice kappa. RESULTADOS: Quarenta e quatro (25%) colonoscopias foram categorizadas como positivas quanto à fonte de sangramento colorretal. O teste da o-toluidina mostrou menor concordância que os testes imunoquímicos, os quais apresentaram moderada concordância com a colonoscopia. O teste da o-toluidina revelou menor sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo. CONCLUSÃO: Os testes imunoquímicos revelaram maior sensibilidade, especificidade e valores de predição na detecção de sangramento colorretal. Os testes imunoquímicos apresentaram melhores índices de concordância com a colonoscopia, quando comparados ao teste da o-toluidina.

High definition endoscopy and "narrow band imaging" in the diagnosis of gastroesophageal reflux disease.

INTRODUCTION: The gastroesophageal reflux disease is a common condition in the western world but less than half of patients present endoscopic abnormalities, making a standard procedure unsuitable for diagnosis. High definition endoscopy coupled with narrow band imaging has shown potential for differentiation of lesions and possible biopsy, allowing early diagnosis and treatment. METHODS: This review describes the principles of biotic and their influence in obtaining images with better definition of the vessels in the mucosa, through the narrow band imaging. Selected papers using it in patients with reflux disease and Barrett's esophagus are analyzed in several ways, highlighting the findings and limitations. CONCLUSION: The meaning of the narrow band imaging in the endoscopic diagnosis of reflux disease will be defined by large scale studies, with different categories of patients, including assessment of symptoms and response to treatment.

High definition endoscopy and "narrow band imaging" in the diagnosis of gastroesophageal reflux disease / Diagnostico da doenca do refluxo gastroesofagico com endoscopia de alta definicao e "narrow band imaging"

Introduction: The gastroesophageal reflux disease is a common condition in the western world but less than half of patients present endoscopic abnormalities, making a standard procedure unsuitable for diagnosis. High definition endoscopy coupled with narrow band imaging has shown potential for differentiation of lesions and possible biopsy, allowing early diagnosis and treatment. Methods: This review describes the principles of biotic and their influence in obtaining images with better definition of the vessels in the mucosa, through the narrow band imaging. Selected papers using it in patients with reflux disease and Barrett's esophagus are analyzed in several ways, highlighting the findings and limitations. Conclusion: The meaning of the narrow band imaging in the endoscopic diagnosis of reflux disease will be defined by large scale studies, with different categories of patients, including assessment of symptoms and response to treatment. .

Introdução: A doença do refluxo gastroesofágico é condição altamente prevalente no mundo ocidental, porém, em menos da metade dos pacientes há alguma alteração endoscópica, indicando que a endoscopia convencional não é o procedimento ideal para o diagnóstico da doença do refluxo gastroesofágico. A endoscopia com aparelhos de alta definição associado ao dispositivo "narrow band imaging" tem demonstrado aplicação na diferenciação de lesões benignas das malignas e a possibilidade de direcionar as biópsias, permitindo diagnóstico e tratamento especialmente nos casos de câncer precoce. Método: Esta revisão descreve os princípios ópticos e sua influência na obtenção de imagens de vasos na mucosa, através da "narrow band imaging". Foram utilizados os descritores para pesquisa no PubMed e as publicações analisadas em diversos aspectos com destaque para o "narrow band imaging", seus fundamentos, aplicações e limitações. Conclusão: O significado do "narrow band imaging" no diagnóstico endoscópico da doença do refluxo gastroesofágico será definido por estudos em larga escala, com categorias diferentes de pacientes, incluindo avaliação de sintomas e resposta ao tratamento. .

Endoscopic findings in uninvestigated dyspepsia.

BACKGROUND: It is important to know the causes of dyspepsia to establish the therapeutic approach. Dyspepsia is a frequent syndrome in our country, where there are restrictions to endoscopy and high prevalence of Helicobacter pylori (H. pylori) infection. This study aimed to assess the endoscopic findings of the syndrome, in an outpatient screening clinic of a tertiary hospital in São Paulo. METHODS: Outpatients with uninvestigated dyspepsia, according to Rome III criteria, answered a dyspepsia questionnaire and underwent esophagogastroduodenoscopy. The Rapid Urease Test was applied to fragments of the antral mucosa and epidemiological data were collected from the studied population. Organic dyspepsia findings were analyzed with different variables to verify statistically significant associations. RESULTS: Three hundred and six patients were included and 282 were analyzed in the study. The mean age was 44 years and women comprised 65% of the sample. Forty-five percent of the patients reported alarm symptoms. Functional dyspepsia was found in 66% of the patients (20% with normal endoscopy results and 46% with gastritis), 18% had GERD and 13% had ulcers (duodenal in 9% and gastric in 4%). Four cases of gastric adenocarcinoma were identified (1.4%), one without alarm characteristics, 1 case of adenocarcinoma of the distal esophagus and 1 case of gastric lymphoma. The prevalence of H. pylori was 54% and infection, age and smoking status were associated with organic dyspepsia. The age of 48 years was indicative of alarm signs. CONCLUSIONS: The endoscopic diagnosis of uninvestigated dyspepsia in our setting showed a predominance of functional disease, whereas cancer was an uncommon finding, despite the high prevalence of H. pylori. Organic dyspepsia was associated with infection, age and smoking status.

COLONOSCOPY COMPLICATIONS IN THE ELDERLY: the impact of age and multimorbidity / Complicações de colonoscopia em idosos: impacto da multimorbidade e idade

ContextAge has been considered an independent risk factor for colonoscopy complications, especially when associated with multimorbidity.ObjectivesThe primary objective was to verify the relationships between age, multimorbidity and colonoscopy complications in the elderly.MethodsA retrospective cohort including patients of 60 years or older who had undergone a colonoscopy. Data relating to age, multimorbidities according to the cumulative illness scale for geriatrics and the Charlson index and complications related to bowel preparation and procedure (sedation and exam) were collected.ResultsOf the 207 patients (mean age 70.47 ± 7.04) with appropriate indication for colonoscopy according to the American Society for Gastrointestinal Endoscopy, 43 (20.77%) patients had some colonoscopy complications: 1 (0.48%) with the sedation (apnea), 4 (1.93%) with the procedure (abdominal pain and bacteremia) and 38 (18.35%) with the bowel preparation (acute renal failure, hypotension). Individuals ≥80 years had an RR = 3.4 (1.2-10.1),P = 0.025, and those with a Charlson index 3 had an RR = 5.2 (1.6-16.8), P = 0.006, for complications. The cumulative illness rating scale for geriatrics was not associated with complications (P = 0.45).ConclusionThere was a significant risk of complications in ≥80 years and in the group with a Charlson index 3. The cumulative illness rating scale for geriatrics was not a good predictor of risk in this sample.

ContextoA idade tem sido considerada um fator de risco independente para complicações colonoscópicas, especialmente na presença de multimorbidade.ObjetivosO objetivo primário foi verificar a correlação entre idade, multimorbidade e complicações colonoscópicas em idosos.MétodosCoorte retrospectiva de pacientes com 60 anos ou mais submetidos a colonoscopia. Foram coletados idade, multimorbidade (de acordo com os índices cumulative illness scale for geriatrics e Charlson) e complicações relacionadas ao preparo e procedimento (sedação e exame).ResultadoDos 207 pacientes (idade média 70.47 ± 7.04) com indicação apropriada para colonoscopia segundo a Sociedade Americana de Endoscopia Gastrointestinal, 43 (20.77%) tiveram alguma complicação: 1 (0.48%) com complicação pela sedação (apneia), 4 (1.93%) relacionada ao procedimento (dor abdominal e bacteremia) e 38 (18.35%) pelo preparo (insuficiência renal aguda, hipotensão). Pacientes ≥80 anos tiveram RR = 3.4 (1.2-10.1), P= 0.025, para complicações e aqueles com índice de Charlson 3, um RR = 5.2 (1.6-16.8), P= 0.006. Cumulative illness rating scale for geriatrics, não mostrou associação com complicações (P = 0.45).ConclusãoHouve risco significativo de complicação em muito idosos (≥80 years) e no grupo com índice de Charlson 3. Cumulative illness rating scale for geriatrics não se mostrou um bom preditor de risco nesta amostra.

What are the most important factors regarding acceptance to the colonoscopy?: study of related tolerance parameters.

CONTEXT: Colonoscopy plays an indubitable role in the setting of clinical practice, however, it is an invasive exam; complex, lengthy, embarrassing, not devoid of risks and discomfort that yields fear and anxiety in the majority of patients. In a new era of rising competition between health institutions, where the quality of health care and client satisfaction are praised, studies regarding tolerance-related colonoscopy issues yield great potential to be explored. In the present study, tolerance is defined as willingness to repeat the exam. OBJECTIVES: Evaluate information associated to bowel preparation, the exam itself and post-examination period that might interfere with the tolerance to the colonoscopy. METHODS: Analysis of the tolerance to the colonoscopy at three stages (pre, post, and during) through a checklist: patient's questionnaire and a medical assessment form were used. RESULTS: In this present study, 91.2% of 373 patients exhibited positive tolerance to the colonoscopy. Aspects related to a negative level of tolerance were patient gender (12.9% of women versus 3.2% of men would not repeat the exam), age extremes (less than 20 years and greater than 80 years of age), and abdominal pain, both during the bowel preparation and after the procedure. CONCLUSIONS: Gender, age, patient cooperation and abdominal pain were the decisive components regarding tolerance to the colonoscopy. Notably, in two phases of the exam, the abdominal pain was the most important feature associated to a lessened tolerance.

WHAT ARE THE MOST IMPORTANT FACTORS REGARDING ACCEPTANCE TO THE COLONOSCOPY?: Study of related tolerance parameters

Context Colonoscopy plays an indubitable role in the setting of clinical practice, however, it is an invasive exam; complex, lengthy, embarrassing, not devoid of risks and discomfort that yields fear and anxiety in the majority of patients. In a new era of rising competition between health institutions, where the quality of health care and client satisfaction are praised, studies regarding tolerance-related colonoscopy issues yield great potential to be explored. In the present study, tolerance is defined as willingness to repeat the exam. Objectives Evaluate information associated to bowel preparation, the exam itself and post-examination period that might interfere with the tolerance to the colonoscopy. Methods Analysis of the tolerance to the colonoscopy at three stages (pre, post, and during) through a checklist: patient's questionnaire and a medical assessment form were used. Results In this present study, 91.2% of 373 patients exhibited positive tolerance to the colonoscopy. Aspects related to a negative level of tolerance were patient gender (12.9% of women versus 3.2% of men would not repeat the exam), age extremes (less than 20 years and greater than 80 years of age), and abdominal pain, both during the bowel preparation and after the procedure. Conclusions Gender, age, patient cooperation and abdominal pain were the decisive components regarding tolerance to the colonoscopy. Notably, in two phases of the exam, the abdominal pain was the most important feature associated to a lessened tolerance. .

Contexto É inquestionável o papel da colonoscopia na prática clínica, entretanto, trata-se de exame invasivo, complexo, demorado, impudico, não isento de riscos e desconforto, que gera receio e ansiedade à maioria dos pacientes. Em uma nova época de elevada competição entre instituições de saúde, na qual se valoriza a qualidade dos serviços prestados e satisfação dos clientes, estudos sobre fatores relacionados a tolerância à colonoscopia oferecem grande potencial a ser explorado. No presente estudo considerou-se tolerância a disposição de repetir o exame. Objetivo Analisar informações relacionados ao preparo, exame e pós exame que interferem na tolerância à colonoscopia. Métodos Análise da tolerância à colonoscopia em três momentos da colonoscopia (pré, pós e durante) através de check list: “formulário do paciente” e “ficha de avaliação médica”. Resultados No presente estudo 91.2% de 373 pacientes apresentaram tolerância positiva à colonoscopia. Os fatores relacionados à tolerância negativa foram o sexo feminino (12.9% mulheres and 3.2% dos homens não repetiriam o exame), extremos de idade (<20 anos e >80 anos) e dor abdominal durante o preparo intestinal e após o procedimento. Conclusões Gênero, idade, cooperação do paciente e dor abdominal foram fatores determinantes da tolerância à colonoscopia. Significativa em duas fases do exame, a dor abdominal foi o fator mais importante relacionado à redução da tolerância. .

Bowel preparation for performing a colonoscopy: prospective randomized comparison study between a low-volume solution of polyethylene glycol and bisacodyl versus bisacodyl and a mannitol solution.

CONTEXT: Colonoscopy is currently the gold standard method to examine the colon, the rectum and the terminal ileum. In order to perform the colonoscopy, it is necessary to clean the bowel and use medications that are generally poorly tolerated by the patients. OBJECTIVE: Compare the tolerability, acceptability, safety and efficacy of two solutions used for intestinal preparation for a colonoscopy. METHODS: One hundred patients matched for sex and age were prospective randomized into two groups. Polyethylene glycol group received bisacodyl 10 mg plus 1 L of polyethylene glycol the night before and 1 L on the day of the exam. Mannitol group received bisacodyl 20 mg the day before and 1 L of a 10% mannitol solution on the day of the exam. The diet was the same for both groups. Tolerability and acceptability were measured using previously validated questionnaires. In terms of safety, variations in vital signs before and after the preparation were recorded, in addition to any complications. The quality of the preparation was graded based on the Boston and Ottawa scales. RESULTS: Ninety-six percent (96%) completed the study. As for tolerability, the mannitol preparation group exhibited a significantly higher frequency of nausea, vomiting, abdominal pain, and abdominal distension than polyethylene glycol group (P < 0.05). Acceptability was significantly better in polyethylene glycol group. The polyethylene glycol solution has also previously been shown to be safer than mannitol. No difference was observed in the quality of the preparation between the two preparation methods. CONCLUSIONS: The following conclusions can be made: polyethylene glycol solution had higher tolerability, acceptability, and safety than the mannitol and should be used instead of mannitol. Both preparation solutions have similar efficacy.

Bowel preparation for performing a colonoscopy: prospective randomized comparison study between a low-volume solution of polyethylene glycol and bisacodyl versus bisacodyl and a mannitol solution / Preparo de cólon para realização de colonoscopia: estudo prospectivo randomizado comparativo entre solução de polietilenoglicol baixo volume mais bisacodil versus solução de manitol mais bisacodil

CONTEXT: Colonoscopy is currently the gold standard method to examine the colon, the rectum and the terminal ileum. In order to perform the colonoscopy, it is necessary to clean the bowel and use medications that are generally poorly tolerated by the patients. OBJECTIVE: Compare the tolerability, acceptability, safety and efficacy of two solutions used for intestinal preparation for a colonoscopy. METHODS: One hundred patients matched for sex and age were prospective randomized into two groups. Polyethylene glycol group received bisacodyl 10 mg plus 1 L of polyethylene glycol the night before and 1 L on the day of the exam. Mannitol group received bisacodyl 20 mg the day before and 1 L of a 10% mannitol solution on the day of the exam. The diet was the same for both groups. Tolerability and acceptability were measured using previously validated questionnaires. In terms of safety, variations in vital signs before and after the preparation were recorded, in addition to any complications. The quality of the preparation was graded based on the Boston and Ottawa scales. RESULTS: Ninety-six percent (96%) completed the study. As for tolerability, the mannitol preparation group exhibited a significantly higher frequency of nausea, vomiting, abdominal pain, and abdominal distension than polyethylene glycol group (P < 0.05). Acceptability was significantly better in polyethylene glycol group. The polyethylene glycol solution has also previously been shown to be safer than mannitol. No difference was observed in the quality of the preparation between the two preparation methods. CONCLUSIONS: The following conclusions can be made: polyethylene glycol solution had higher tolerability, acceptability, and safety than the mannitol and should be used instead of mannitol. Both preparation solutions have similar efficacy.

CONTEXTO: O exame de colonoscopia é atualmente o padrão-ouro para investigação do cólon e íleo terminal. Para sua realização há necessidade de limpeza do cólon com soluções que, em geral, são mal toleradas pelos pacientes. OBJETIVO: Comparar duas soluções de preparo intestinal para colonoscopia quanto à tolerabilidade, aceitabilidade, segurança e efetividade. MÉTODOS: Cem pacientes pareados por sexo e idade foram randomizados prospectivamente em dois grupos. O grupo polietilenoglicol recebeu bisacodil 10 mg + 1 litro de polietilenoglicol na véspera e 1 litro no dia do exame. O grupo manitol recebeu bisacodil 20 mg na véspera e 1 litro de manitol 10% no dia do exame. A dieta foi a mesma nos dois grupos. A tolerabilidade e aceitabilidade foram aferidas por questionários previamente validados. Quanto à segurança foram avaliados: variação de sinais vitais antes e após o preparo e complicações, além de quaisquer sinais de complicação. A qualidade do preparo foi graduada através das escalas de Boston e Ottawa. RESULTADOS: Noventa e seis pacientes (96%) completaram o estudo. Quanto à tolerabilidade o grupo manitol apresentou manifestação significativamente maior de náusea, vômito, dor abdominal e distensão abdominal do que o grupo polietilenoglicol (P<0,05). Aceitabilidade foi significativamente melhor com o grupo polietilenoglicol. O grupo polietilenoglicol também se mostrou mais seguro. Não se observou diferença na qualidade do preparo entre os métodos. CONCLUSÕES: A solução de polietilenoglicol apresentou melhor tolerabilidade, aceitabilidade e segurança e deve ser usada ao invés da solução de manitol. Ambas as soluções são semelhantes em eficácia.

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

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

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

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

Association of LEC and tnpA Helicobacter pylori genes with gastric cancer in a Brazilian population.

BACKGROUND: H. pylori seroprevalence in Brazilians varies and is dependent on socioeconomic status, sanitation conditions and ethnicity; furthermore, H. pylori is not always associated with the incidence of gastric cancer, suggesting the role of more virulent strains. The purpose of this study was to analyze the association of more virulent H. pylori strains with gastric cancer. METHODS: DNA was extracted from gastric biopsies of thirty-four cases of gastric cancer (11 intestinal-type, 23 diffuse-type), and thirty-four of patients with endoscopic gastritis. The presence of cagPAI genes (cagA, cagA promoter, cagE, cagM, tnpB, tnpA, cagT and the left end of the cagII (LEC)) and babA were analyzed by PCR. RESULTS: Comparison of H. pylori isolates from gastric cancer and gastritis patients showed significant associations of tnpA and LEC with gastric cancer (73.5% [OR, 6.66; 95% CI, 2.30-19.25] and 58.8% [OR, 10.71; 95% CI, 3.07-37.28] of cases, respectively). Other cagPAI genes were detected in both groups at similar frequencies. CONCLUSIONS: tnpA and LEC of H. pylori cagPAI were associated with gastric cancer; nonetheless, these results were restricted within this group of patients and further studies are needed to confirm these results in a larger sample and determine their role in gastric carcinogenesis.

Helicobacter pylori reinfection in Brazilian patients with peptic ulcer disease: a 5-year follow-up.

BACKGROUND: The Helicobacter pylori reinfection seems to be higher in developing countries, than in developed ones. The aim of the study was to determine the annual recurrence rate of H. pylori, in Brazilian patients with peptic ulcer disease, in a 5-year follow-up. METHODS: Patients, with peptic ulcer disease diagnosed by upper digestive endoscopy (UDE) and H. pylori infection verified by histological analysis, rapid urease test, polymerase chain reaction, and urea breath test (UBT), were treated for bacterial eradication. The cure of the infection was verified using the same tests, 3 months after. Clinical evaluation and UBT were performed after sixth and ninth month. After 1 year of follow-up, UBT and UDE were repeated. Up to the fifth year, patients were assessed twice a year and an UBT was performed annually. The patients included and all the reinfected were tested for 15 different genes of the H. pylori. RESULTS: One hundred and forty-seven patients were followed: 19 for 1 year, eight for 2 years, four for 3 years, five for 4 years, and 98 for 5 years, totaling 557 patients/years. Recurrence did not occur in the first year. In the second year, two patients were reinfected; in the third, four patients; in the fourth, three patients; and in the fifth, one patient. The total of reinfected patients was 10. The annual reinfection rate was 1.8%. CONCLUSION: Brazil presents a low prevalence of H. pylori reinfection, similar to the developed countries.

Diverticulose, doença diverticular e diverticulite / Diverticulosis, diverticulitis and diverticular disease

Os autores revisaram um dos assuntos mais relevantes dentro da Gastroenterologia: diverticulose cólica, doença diverticular, diverticulite e outras complicações relacionadas com os divertículos cólicos, como o sangramento diverticular. São apresentados, extensivamente, dados epidemiológicos, fatores de risco, quadro clínico e os métodos diagnósticos mais atuais relativos à doença diverticular, diverticulite e outras complicações. Nos últimos anos, a abordagem terapêutica, particularmente nos casos não complicados de doença diverticular, evoluiu consideravelmente com o uso de mesalazina e probióticos, assuntos que mereceram uma análise crítica por parte dos autores, no contexto dos novos itens fisiopatológicos.

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

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