Impacto del ultrasonido endoscópico en la evaluación de las lesiones subepiteliales del tracto digestivo: experiencia en el Hospital de Clínicas Caracas / Impact of the endoscopic ultrasound in the digestive tract subepitelial lesions evaluation: experience in the Clinicas Caracas Hospital

EL Ultrasonido Endoscópico (USE) es el método de mayor valor y el que con mas frecuencia se emplea en la evaluación de las lesiones subepiteliales del tracto digestivo, como lo han demostrado grandes estudios multicéntricos. El propósito de este estudio es demostrar el impacto en nuestro centro de la endosonografía para el estudio de las lesiones subepiteliales. Para ello se realizó un estudio retrospectivo donde se incluyeron todos los pacientes que acudieron a la unidad de Exploraciones Digestivas del Hospital de Clínicas Caracas, entre junio de 1999 y mayo de de 2004, con diagnóstico endoscópico de lesiones subepileliales en el tracto gastrointestinal. Los datos se registraron en una tabla de elaborada al efecto, en la que se registraron edad, sexo, motivo del estudio, descripción endoscópica y hallazgos endosonográficos, así como conducta asumida (impacto) de acuerdo a los hallazgos. Se obtuvo un total 152 pacientes, en los que predominó el sexo femenino, con edades comprendidas entre 19 y 85 años. Las patologías mas frecuentes fueron leiomioma 21 por ciento, tumores asociados a tejido linfoide (MALTomas) 15 por ciento y 13 por ciento que comprendía lesiones poco comunes, con un impacto en la conducta terapéutica asumida en el 96 por ciento de todos los pacientes. Concluimos que el USE es un método seguro, de mínima invasión y nos permite decidir la conducta a seguir en la mayoría de los pacientes con lesiones subepiteliales

Usos no hemostaticos de los clips endoscópicos / Non haemostatic uses of the endoscopic clips

Los clips endoscópicos son de gran utilidad en tratamiento de sangramiento digestivo. En el presente reporte se describe el uso de los clips endoscópicos en situaciones y patologías no hemorrágicas. En 30 pacientes los clips endoscópicos fueron utilizados con fines no hemostáticos. En 16 pacientes se realizó fijación endoscópica de sondas de alimentación nasoyeyunal. En 10 pacientes se colocaron clips como marcas radiológicas para asistir la colocación de prótesis metálicas autoexpansibles. Dos pacientes con perforaciones quirúrgicas fueron tratados endoscopicamente con estos dispositivos y en 2 pacientes se colocaron clips para localizar campo de radioterapia externa (un caso de linfoma duodenal y un caso de adenocarcinoma superficial de unión esófago gástrica resecado endoscópicamente). En los dieciséis pacientes a los que se les realizó fijación de sonda nasoyeyunal el procedimiento fue eficiente y sin complicaciones. El marcaje radiológico permitió localizar con precisión los límites de lesiones malignas y diez prótesis metálicas autoexpansibles fueron colocadas adecuadamente. En dos pacientes se logró localizar con facilidad el campo de radioterapia externa. Dos casos de perforaciones quirúrgicas fueron manejados exitosamente. No hubo complicaciones relacionadas con la colocación de los clips. Conclusión: Los clips endoscópicos son útiles y seguros en algunas situaciones y patologías no hemorrágicas. Sin embargo estas situaciones e indicaciones deben ser individualmente evaluadas en ausencia de estudios clínicos controlados

Papel de la recto-sigmoidoscopia en la evaluación médica preventiva: un estudio de 4500 pacientes / Rol of the sigmoidoscopy-rectum in preventive physician evaluation: study of 4500 patients

Se evaluaron 4500 historias de pacientes a los que se les realizó recto-sigmoidoscopia en la unidad de Endoscopia del Hospital de Clínicas Caracas como parte de una evaluación médica preventiva entre Julio de 1995 y Abril de 1997. Se examina la incidencia de algunas patologías colorectales, como la presencia de pólipos, divertículos, entre otras, así como su relación con la edad y el sexo de los pacientes. En este estudio se demuestra que la recto

[Primary immunoproliferative small intestinal disease]. / Enfermedad inmunoproliferativa primaria del intestino delgado (IPSID).

We report two cases of Primary small Intestinal Lymphoma (IPSID), in adults. The clinical presentation was, watery diarrhea and weight loss. The histology of this cases was non-Hodgkin's Lymphoma, and the treatment was chemotherapy.

[Helicobacter pylori eradication heals the duodenal ulcer. Randomized, simple, and controlled study with omeprazole]. / La erradicación de Helicobacter pylori cicatriza la úlcera duodenal. Estudio aleatorio, sencillo, controlado con omeprazol.

60 patients with Helicobacter pylori (Hp) infection and duodenal ulcer (DU) were randomized to received either: I) Two weeks of bismuth subcitrate, metronidazole and amoxicillin (TG) or II) Omeprazole for four weeks (OG). Endoscopy and antral biopsies were done at entry and four weeks after treatment, control endoscopy was performed 2-4-8 and 12 weeks after inclusion in the trial. Healing was similar in both groups at two four weeks. At twelve weeks DU recurred in OG 65% vs 13.36% in TG and Hp infection was present. Our results showed that Hp eradication healed DU in a similar rate than Omeprazole providing further evidence of a causal link between Hp infection and duodenal ulcer.

[Changes in the natural history of peptic ulcer after Helicobacter pylori eradication. Randomized, double-blind, placebo controlled trial. Follow-up of 44 months]. / Cambio de la historia natural de la ulcera duodenal después de la erradicacíon de Helicobacter pyroli. Estudio aleatório, doble ciego, controlado con placebo. Seguimiento de 44 meses.

We included 63 patients (p) with duodenal ulcer and Helicobacter pylori infection to be treated with Famotidine 40mg/day for six weeks. In the first ten days one group of 33p (TG) received Metronidazole 250mg plus Amoxicillin 500mg T.I.D and 30p (PG) placebo. Helicobacter pylori was eradicated in 62.5% of TG. Infection was always associated with ulcer recurrence. Healing was similar in both groups but recurrence was statistically significant after three month in PG and in the first year all Pg had relapsed. At 44 month only 25% of TG relapsed. The natural history of peptic ulcer disease was changed with Helicobacter pylori eradication.

[Portal hypertensive gastropathy: histologic and endoscopic correlation]. / Gastropatía portal hipertensiva: correlación endoscópico histológica.

Portal Hypertensive Gastropathy (PHG) diagnosed in 42 patients by upper gastrointestinal endoscopy and was correlated with histological findings of gastric biopsies taken from fundus-body and antrum and observed blinded by the pathologist. We found that in the fundus PHG was observed in 97.14% and of these 77.14% were mosaic pattern. Submucosal vessel dilatation was observed in 65.71%, congestion in 60% and chronic gastritis in 62.85%. Histologic and endoscopic correlation was possible in 85.71%. Our results show a histologic and endoscopic correlation.

[Gastric mucosa injuries in portal hypertension]. / Lesiones de la mucosa gástrica en hipertensión portal.

Portal Hypertension (PH) was diagnosed in 114/4145 patients (p) evaluated by upper gastrointestinal endoscopy during 1991-92 (2.75%). Portal hypertensive gastropathy (PHG) was found in 39.47% p. Mild PHG was observed in 82.22% and esophageal varices grade was directly correlated to PHG presence. This is a new entity to be considered because of its bleeding possibility in PH patients.

[The recurrence of duodenal ulcer after treatment for Helicobacter pylori. A randomized, double-blind, placebo-controlled study]. / Recurrencia de la úlcera duodenal después del tratamiento de Helicobacter pylori. Estudio randomizado, doble ciego, controlado con placebo.

We studied 63 duodenal ulcer (DU) patients (p) diagnosed by upper gastrointestinal endoscopy (UGE) and Helicobacter pylori positive (HP). Patients were randomized, double-blinded to receive placebo (PG) 30p or Amoxicillin plus Metronidazole 33p (TG). All of them took Famotidine for six weeks and at this point UGE was performed. DU healing was similar in both groups. HP eradication was possible in 14/24p of TG and 4/23 of PG (58.33% vs 17.39%) difference was statistically significant. DU recurrence at 3 months was 68.75% in PG vs 11.76% in TG (p = 0.001). At the end point of the study global recurrence of DU was 3/24p in TG vs 19/23 in PG (p = 0.000001). Our findings suggest that DU recurrence is related to the presence of HP. Definitive treatment to permanently eradicate the bacteria is to be evaluated.

[Nonulcerative dyspepsia associated with Helicobacter pylori]. / Dispepsia no ulcerosa asociada a Helicobacter pylori.

30 patients with non ulcer dyspepsia (NUD) were evaluated to find out if there was a relationship with Helicobacter pylori (HP) infection. Gastric biopsies from the antrum were taken and two of them sent to pathology to be stained with H&E and Warthin-Starry. The other three were sent to Microbiology, for urease-test, culture and frotis with Gram stain. To diagnose HP was necessary to get it at least in two of the performed test. This was possible in 20 (66.66%). Chronic active gastritis was observed in 15/20 (75%) and in the 3/10 HP negative patients none had histological alteration shown. Normal aspect of gastric mucosa did not predict Helicobacter pylori infection. The presence of the bacteria could not be correlated to any kind of symptoms and always was associated with chronic gastritis.

[Jejunal leiomyosarcoma. A case report]. / Leiomiosarcoma de yeyuno. Presentación de un caso.

Jejunal leiomyosarcoma, is an uncommon neoplasm. Diagnosis can be difficult because symptoms may be vague and nonspecific. We report the case of a 33-years-old patient, which was diagnosed and operated of this infrequent pathology.

[Non ulcer dyspepsia, endoscopic gastritis and Helicobacter pylori]. / Dispepsia no ulcerosa, gastritis endoscópica y Helicobacter pylori.

We studied 33 patients with non ulcer dyspepsia and endoscopic gastritis. 21 were female (63.4%) and 12 male (36.4%). Helicobacter pylori (HP) was investigated by gastric mucosal biopsy. Urease test, Gram, culture, and histology were performed in all and two or more of these test hat to be positive to consider HP infection. 16/33 resulted HP positive (48.8%). Erosive gastritis was most commonly associated with H.P. infection (62.5%). This was statistically significant. In all the cases HP positive chronic gastritis was present. 15/16 were active chronic gastritis. Our results suggest that erosive gastritis is most frequently associated with HP infection and non ulcer dyspepsia.

[Value of three-dimensional measurement of the caudate lobe in the diagnosis of liver cirrhosis by ultrasound]. / Valor de la medición tridimensional del lóbulo caudado en el diagnóstico de cirrosis por ultrasonido.

To assess the changes of the caudate lobe in the sonographic diagnosis of liver cirrhosis, 96 patients were studied at the Hospital Vargas de Caracas. 27 with histologically proved cirrhosis. 43 with other disease (30 no related with liver and 13 with hepatic disease without cirrhosis, and 26 patients without clinical evidence of liver disease. The longitudinal (CL), transverse (CT), and anteroposterior (CAP) diameters of the caudate lobe and the transverse diameter of the right lobe (RL) were measured and one, two and three dimensional caudate lobe, indexes and ratios were calculated. The analysis of these criteria revealed that the ratio of the three dimensional caudate index (C13) to the right lobe diameter (C13)/RL = iCL x CT x CAP/RL was superior to all other calculated criteria.

Tuberculosis peritoneal más absceso esplénico: reporte de un caso / Peritoneal tuberculosis and splenic abcess: report of a case

Se presenta el caso de TBC peritoneal en base a la clínica de fiebre, pérdida de peso y anemia, VSG elevada, PPD positivo, granulomas tuberculoides en peritoneo y buena respuesta al tratamiento. Es sugestivo que el absceso esplénico sea causado por el mismo BK en base a la poca respuesta a la antibioticoterapia activa contra los gérmenes comunes productores de abscesos esplénicos, presencia de granulomas tuberculoides peritoneales y la respuesta al tratamiento anti TBC tras la segunda punción y drenaje por sonda que permitió conservar el bazo

Estudio doble ciego, placebo-controlado de efecto del misoprostol, sobre la gastropatia por antiinflamatorios no esteroideos en pacientes con artritis reumatoidea, estudio multicéntrico / Double blind study, placebo-controlled of the misoprostol effects over the gastropaty by non-steroideal antiinflamatory in patients with rheumatoid arthritis. Multicentric study

Ochenta y tres pacientes con artirtis reumatoidea y que recibían diclofenac sódico para el control de su enfermedad fueron seleccionados para ingresar a un estudio doble-ciego placebo controlado de 4 semanas de duración, recibiendo la mitad de ellos 50 ml de diclofenac sódico tres veces al día, y la otra mitad 50 mg de Diclofenac sódico tres veces al día más placebo. El propósito del estudio fue evaluar el efecto del misoprostol sobre las lesiones erosivas o sangrantes, dándoseles un puntaje de acuerdo a nuestro protocolo de investigación. Los pacientes que recibieron misoprostol mostraron un descenso significativo en las lesiones erosivas (112 a 31, p menor de 0.05) que al compararlas con los que recibieron placebo (123 a 60) también fué estadísticamente significativa (p menor de 0.05). No se observaron diferencias significativas en relación con las lesiones sangrantes al comparar los dos grupos. Cinco pacientes desarrollaron úlceras para el final de estudio (4 antrales y una duodenal), 4 de ellos recibieron placebo. Hubo un discreto efecto atenuante de la acción antiinflamatoria del diclonac sódico en nuestros pacientes. Se concluye que el misoprostol disminuyó significativamente las lesiones erosivas en los pacientes reumatoideos y protegió contra el efecto ulcerogénico del diclofenac sódico

[Budd-Chiari syndrome, pulmonary thromboembolism, and deep venous thrombosis associated with "lupus anticoagulant" and recent use of oral contraceptives]. / Síndrome de Budd-Chiari, tromboembolismo pulmonar y trombosis venosa profunda, asociado con "anticoagulante lúpico" y uso reciente de anticonceptivos orales.

The Budd-Chiari syndrome is the clinical manifestation of the total or partial obstruction of the hepatic veins and/or inferior vena cava. It is an infrequent cause of portal hypertension. The chronic presentation is the most frequent and is characterized by right upper quadrant pain, hepatomegaly, and ascites of slow onset. We report a case of a 26 year old woman affected by this disorder associated to a recent use of oral contraceptive and a "Lupus Anticoagulant". She subsequently developed deep venous thrombosis and pulmonary embolism. She died almost 6 years after the onset of symptoms.

PIP: A 26-year-old woman sought medical care in April 1983 because she had been experiencing pain in the right upper quadrant for 2 months, as well as an enlarged abdomen and postprandial fullness accompanied by nausea and vomiting. She had used oral contraceptives (OCs) for a period of 11 months up to 4 months before the inception of the symptoms. Examination showed normal vital functions but painful hepatomegaly. Hepatic biopsy showed dilatation of the central vein of the lobe; ultrasound of the liver showed hepatomegaly, the dilatation of hepatic veins, and suprahepatic veins; and echos of the inside were suggestive of thrombosis. The Doppler instrument revealed inversion of the hepatic flow towards the spleen and the presence of multiple collateral veins. Venocavography confirmed almost total obstruction of the inferior vena cava in its retrohepatic trajectory. Percutaneous transhepatic splenoportography demonstrated evidence of slow suprahepatic drainage with obstruction of the contrast medium in the area of the cava. The pressure in the suprahepatic vein was 43 cm of H2O. As the illness progressed, profound venous thrombosis of the left lower extremity developed, which was treated with heparin and managed with fenindione for 4 years. 5 years later, multiple pulmonary thromboembolism was confirmed by pulmonary gammagram of perfusion and digital arteriography. She received medical treatment based on low sodium and diuretic diet. Her hepatic function progressively deteriorated with increased ascites and collateral venous network. She died in December 1988.

Estudio doble ciego, placebo-controlado del efecto del misoprostol sobre la gastropatía por antiinflamatorias no esteroideos en pacientes con osteoartritis estudio multicentrico / Double-blind placebo-controlled study of the effect of misoprostal on upper gastropathies for non esteroidal anti-inflammatory in patients with osteoarthritis; multicentric study

Ochenta y cuatro pacientes con osteoartritis y gastropatía por naproxen fueron ubicados en un estudio doble-ciego, placebo controlado de 4 semanas de duración, para recibir tratamiento con naproxen (250 mg dos veces día) más misoprotol (200 mg dos veces al día), o naproxen (250 mg dos veces al día) más placebo. El Propósito del estudio fue investigar el efecto del misoprostol sobre las lasiones erosivas y/o sangrantes del tracto digestivo superior ocasionadas por el naproxen. Se practicó una endoscopia inicial y otra final a cada paciente con la finalida de detectar lesiones erosivas o sangrantes, dándoseles un puntaje de acuerdo a nuestro protocolo. Cuarenta y dos pacientes recibieron misoprostol, mostraron un descenso en las lesiones erosivas final del estudio (110 a 42, t: 3,99 p < 0,001); lo mismo ocurrió con las lesiones sangrantes (t: 3,24, p < 0.01). El grupo que recibió placebo no mostró diferencias estadísticamentes significativas al comparar las lesiones erosivas y sangrantes basales y finales. Cuando se aplicó la correccion de Yates (X2) a los dos grupos experimentales sólo hubo mejoría estadísticamente significativa en el grupo que recibió misoprostol en lo concerniente a las lesiones erosivas (p < 0.001). Once pacientes desarrollaron úlceras para el final del estudio (1 en el fondo gástrico, una en el cuerpo, 8 antrales y una duodenal), todos estaban recibiendo placebo. Conclusiones: 1) El misoprostol disminuyó significativamente las lesiones erosivas. 2) El misoprostol protegió contra el efecto ulcerogénico del naproxen

[Retrograde endoscopic cholangiopancreatography. Incidence of bacteremia]. / Colangiopancreatografía retrógrada. Incidencia de bacteriemia.

ERCP like all the endoscopic procedures, implies some risks of complications, between them, infections. Bacteremia may occur in any endoscopic and gastrointestinal procedure. The rate on ERCP is about 0 to 5.6%. In the present investigation we intended to determine the rate of bacteremia produced by ERCP, the organism that cause bacteremia and to correlate ductal pathology, stasis and bacteremia. From May to October 1988, at the Hospital Vargas of Caracas, 22 ERCP were performed in patients that were included for analysis. Haemocultives were taken for aerobics and anaerobics, gems before ERCP, immediately after the cannulation of biliary and/or pancreatic ducts and 5 minutes later after concluding the study. A high incidence of bacteremia was reported, 13.6%, all the previous haemocultives were negative. The positive haemocultives were during the cannulation procedure and no haemocultive after the study was positive. The organism isolate were Peptococcus sacharoliticcus and Staphylococcus epidermidis both of the normal flora of small intestine and the last one on the skin too. There were not relation between the ductal pathology, stasis and bacteremia. Some organisms were related to nosocomial agents, we considered though the disinfection and polishment of the accessories and equipment adequate. It is recommendable to use prophylactic antibiotic in immunosuppressed patients with valvular prosthesis.

[Percutaneous liver biopsy in outpatients]. / Biopsia hepática percutánea en pacientes ambulatorios.

We studied prospectively 44 patients with diffuse liver disease. We performed percutaneous liver biopsy in these outpatients. They were required to be in absolute response during the following 4-6 hours after the biopsy was completed. After that period, they could go home and have a relative rest for the remnant day. These patients were followed by clinical evaluation and by real time abdominal ultrasound. We found some complications: Transitory arterial hypotension, pain in the site of puncture, hepatic hematomas. Only one of the patients with hematomas required hospitalization during 24 hours. The mortality was 0%. According to our experience, the hepatic biopsy is a procedure that can be performed in outpatients with a wide margin of security. An important point of view to consider is the economic advantage since it means a decrease in costs by each hepatic biopsy accomplished considering the cost/day of hospitalization.