Echoendoscopy with elastography in mediastinal lymph nodes.

Elastography is a widely used procedure in conventional ultrasonography that has recently been incorporated in echoendoscopy. This is an innovative and promising technology that aims to increase the negative predictive value of endoscopic ultrasonography and fine-needle aspiration punctures. It is useful for directing punctures in suspect areas and, consequently, improves diagnostic performance. This is a non-invasive technique, easy to perform, without additional costs or complications. The main indications are the analysis of solid pancreatic masses, lymph nodes, subepithelial lesions, lesions in the left hepatic lobe and in the left adrenal. Negative or inconclusive cases of fine-needle aspiration can be submitted to elastography when there is a strong suspicion of malignancy. Elastography has a high precision for the differential diagnosis of solid masses and in difficult-to-access anatomic sites, as well as in mediastinal lymph nodes and pancreatic tumors. The procedure is based on the degree of tissue elasticity measurement, with a good correlation between the elasticity index and histopathological features. We report the case of four patients evaluated by echoendoscopy and qualitative elastography who had differential diagnoses in mediastinal lymph nodes: sarcoidosis, lymphoma, histoplasmosis and esophageal neoplasia.

Improvement of Body Composition and Quality of Life Following Intragastric Balloon.

BACKGROUND: The aim is to evaluate the effects of IGB in overweight or class I obese patients, by analyzing body composition and quality of life (QOL). METHODS: Prospective study including patients with BMI 27-34.9 kg/m2.body composition analysis (BCA) was performed before IGB implantation and its removal, after 6 months of treatment. QOL was assessed by the Short Form 36 (SF-36) Health Survey at baseline and after treatment. RESULTS: Forty patients were included in this study, but four were excluded. The total weight decreased by 12.29 kg after 6 months of use of IGB, which corresponds to loss of 13.69% of the total weight. There was a significant reduction in body fat mass and fat area. QOL improved in all eight sections analyzed (p < 0.001 to 0.041): functional capacity, physical aspects, pain, general health status, vitality, social aspects, emotional aspects, and mental health. CONCLUSIONS: IGB induces not only weight loss but changes in body composition through the reduction of body fat mass and fat area. Furthermore, it improves QOL.

Fecal microbiota transplant by push enteroscopy to treat diarrhea caused by Clostridium difficile.

Clostridium difficile is the major etiological agent of pseudomembranous colitis and is found in up to 20% of adult inpatients. The recommended treatment is antibiotic therapy with metronidazole and/or vancomycin. However, the recurrence rate may reach up to 25% and it increases in each episode. The newest alternative to treat diarrhea due to recurrent Clostridium difficile is fecal microbiota transplantation. The procedure was performed in 12 patients, with a 6-month follow-up on 10 of them. Of the ten cases, bacterial recurrence was diagnosed in only one patient, after a course of antibiotic to treat urinary tract infection, without presenting with diarrhea. The particularity of our study, besides being an unprecedented event in South America, is the way to perform the infusion of fecal microbiota by enteroscopy.

Systematic review and meta-analysis of endoscopic ablative treatment of Barrett's esophagus.

BACKGROUND: Barrett's esophagus (BE) is the main risk factor for esophageal adenocarcinoma. Its therapeutic approach is controversial and surgical treatment in the presence of high-grade intraepithelial neoplasia may be indicated. Endoscopic approach is an alternative with lower mortality and morbidity rates and favorable results. OBJECTIVE: To define the best option, according to literature, to treat Barrett's Esophagus. DESIGN: Systematic review of PUBMED, EMBASE, LILACS, and Cochrane Library databases was conducted and articles of randomized, controlled studies on BE endoscopic ablative treatment were selected. The systematic review through PUBMED retrieved results with higher evidence level and available recommendation grade regarding BE ablative therapy. Nine articles on randomized, controlled studies classified as A or B according to the Oxford table were selected. Cryotherapy, laser, photodynamic therapy (PDT), multipolar electrocoagulation (MPEC), and ablation through argon plasma coagulation (APC) and radiofrequency were considered ablation therapies. PATIENTS: 649 patients from 10 different studies were analysed. RESULTS: PDT was found to present an increase in treatment failure compared with APC, NNH = -7. BE ablation through MPEC or APC was found to have similar risk for treatment failure in meta-analysis. PDT associated with proton pump inhibitor (PPI) is beneficial for BE ablation regarding PPI use alone, NNT = 2.Radiofrequency with PPI is an efficient method to reduce risk of treatment failure, NNT = 1. CONCLUSIONS: There are no studies demonstrating the benefit of indicating cryotherapy or laser therapy for BE endoscopic approach. APC ablation was found to have superior efficacy compared with PDT and ablation through APC and MPEC was found to present effective, similar results. Radiofrequency is the most recent approach requiring comparative studies for indication.

Pediatric nephrology patients are overweight: 20 years' experience in a single Canadian tertiary pediatric nephrology clinic.

BACKGROUND: Obesity is an independent risk factor for chronic kidney disease (CKD). We compared the body composition of pediatric nephrology patients with that of the general child population over 2 decades. METHODS: About 4,959 patients above 2 years of age (mean: 9.6 +/- 4.5) were referred to a tertiary pediatric nephrology clinic from 1985 to 2006. In 3,422 patients (69.0% with the same mean age) there were sufficient data to analyze body composition, expressed as body mass index (BMI) Z-score and calculated on the basis of normal data taken from the National (USA) Center for Health Statistics (2000). RESULTS: Hematuria (21.68%), recurrent urinary tract infections (16.09%), proteinuria (13.95%) and hypertension (8.27%) were the most common referral diagnoses. Mean BMI Z-score of the pediatric nephrology patients increased significantly from 0.29 +/- 1.07 during the years 1985-1991 to 0.44 +/- 1.27 in 1992-1999 and 0.87 +/- 1.70 in 2000-2006 (P < 0.0001, ANOVA). Whereas the rate of the increase in BMI Z-score was not statistically different from that seen in the normal population, the young nephrology patients had over the entire time consistently significantly higher BMI Z-scores (average +0.72) than the comparable normal USA data. Several disease groups with potential for development of CKD had higher BMI Z-scores than found in the age- and sex-adjusted control data. CONCLUSIONS: The increased rate of obesity in our studied population suggests that pediatric nephrology patients are at even greater risk for developing CKD later in life than could be predicted from their renal disease only. We recommend therapeutic intervention to address this potentially modifiable risk factor.