Esofagopatia chagásica complicada com esôfago de Barrett

Gastroesophageal reflux disease (GERD) is an uncommon condition in chagasic esophagopathy not previously treated. In this report, a case of chagasic esophagopathy associated to GERD and complicated with Barrett's esophagus is described. Potential pathophysiologic mechanisms underlying the condition are presented and commented.

Brazilian consensus on gastroesophageal reflux disease: Proposals for assessment, classification, and management

The Brazilian Consensus on Gastroesophageal Reflux Disease considers gastroesophageal reflux disease to be a chronic disorder related to the retrograde flow of gastroduodenal contents into the esophagus and/or adjacent organs, resulting in a variable spectrum of symptoms, with or without tissue damage. Considering the limitations of classifications currently in use, a new classification is proposed that combines three criteria - clinical, endoscopic, and pH-metric - providing a comprehensive and more complete characterization of the disease. The diagnosis begins with the presence of heartburn, acid regurgitation, and alarm manifestations (dysphagia, odynophagia, weight loss, GI bleeding, nausea and/or vomiting, and family history of cancer). Also, atypical esophageal, pulmonary, otorhinolaryngological, and oral symptoms may occur. Endoscopy is the first approach, particularly in patients over 40 yr of age and in those with alarm symptoms. Other exams are considered in particular cases, such as contrast radiological examination, scyntigraphy, manometry, and prolonged pH measurement. The clinical treatment encompasses behavioral modifications in lifestyle and pharmacological measures. Proton pump inhibitors in manufacturers' recommended doses are indicated, with doubling of the dose in more severe cases of esophagitis. The minimum time of administration is 6 wk. Patients who do not respond to medical treatment, including those with atypical manifestations, should be considered for surgical treatment. Of the complications of gastroesophageal reflux disease, Barrett's esophagus presents a potential development of adenocarcinoma; biopsies should be performed, independent of Barrett's esophagus extent or location. In this regard the designation short Barrett's is not important in terms of management and prognosis. © 2002 by Am. Coll. of Gastroenterology.

Esôfago de Barrett e displasia: critérios diagnósticos

A presente revisão focaliza aspectos conceituais e os principais problemas diagnósticos referentes ao esôfago de Barrett e à displasia. O esôfago de Barrett resulta de complicação da doença do refluxo gastroesofágico de longa duração. É identificado endoscopicamente pela presença de mucosa glandular no esôfago tubular acima da junção esofagogástrica. Histologicamente, é caracterizado pela substituição do epitélio estratificado pavimentoso por epitélio colunar especializado com células caliciformes, expresso como metaplasia intestinal. A importância biológica do esôfago de Barrett é o risco de progressão para câncer. A displasia é o principal marcador biológico preditivo de evolução para adenocarcinoma. Identificar e graduar a displasia constitui importante questão na prática diagnóstica. O diagnóstico patológico do esôfago de Barrett deve conter informações sobre a investigação de displasia. O principal diagnóstico diferencial da displasia é feito em relação a reatividade e regeneração epitelial no contexto de inflamação da mucosa. Como a variabilidade de interpretação é um dos principais problemas no diagnóstico da displasia, os casos de esôfago de Barrett devem ser enviados à consulta para segunda opinião diagnóstica. O exame anatomopatológico é fundamental para definir o diagnóstico de esôfago de Barrett e para rastrear a displasia, que é o principal marcador de risco para câncer nesta entidade.

Esophagectomy and substitution of the thoracic esophagus in dogs

OBJETIVO: Avaliar, em cadáveres de cães, uma técnica para remoção do esôfago torácico sem toracotomia e dois métodos de substituição do esôfago torácico. MÉTODOS: Foram utilizados 27 cadáveres de cães. Estes foram aleatoriamente divididos em três grupos de nove animais, em que se estudou: G1 - esofagectomia torácica total pelo método de invaginação retrógrada; G2 - esofagectomia torácica total com substituição esofágica pelo estômago inteiro; G3 - esofagectomia torácica total com substituição esofágica por um gastrotubo confeccionado de acordo com a técnica de Büchler de gastroplastia por rotação do fundo. Após a ressecção esofágica no grupo 1, a integridade da rota intratorácica foi avaliada por endoscopia e solução de azul de metileno a 1%. RESULTADOS: A ruptura da pleura visceral ocorreu em todos os animais, especialmente no terço caudal. Entretanto, a rota transtorácica mediastinal permitiu a elevação de ambos os substitutos esofágicos (G2 e G3) para a realização da anastomose com a extremidade caudal do esôfago cervical. CONCLUSÕES: A substituição por estômago inteiro apresentou menor tensão na anastomose, maior facilidade e rapidez comparada à técnica de gastroplastia por rotação do fundo. Os resultados em cadáveres suportam a realização de estudos clínicos para validação da técnica.

Morphological and functional evaluation of distal esophagus of rabbits submitted to esophageal infusion with caustic soda

A ingestão de substâncias cáusticas constitui importante situação de emergência, tendo em vista a gravidade de suas seqüelas. OBJETIVO: Estudar as alterações morfológicas e funcionais do esôfago de coelhos submetidos à infusão esofágica com soda cáustica (NaOH). MÉTODOS: 88 coelhos foram divididos em 4 grupos: G1 (n=22) foi submetido à infusão esofágica com água destilada; G2, G3 e G4 foram submetidos a infusão esofágica com NaOH a 2%, 4% e 6%, respectivamente. Alterações morfológicas foram estudadas em 12 animais de cada grupo e as alterações manométricas, nos 10 animais restantes. Foram feitas análises do esfíncter inferior do esôfago (EIE), número e amplitude das contrações no terço distal do esôfago. Estes estudos foram realizados antes (momento 1 - M1) e aos 30 minutos, 6 horas e 24 horas após a infusão esofágica (momentos M2, M3 e M4, respectivamente). RESULTADOS: Avaliação macroscópica: G1 - sem alterações; G2 - edema, hiperemia e descamação; G3 - aumento do calibre do esôfago, úlceras, descamação da mucosa; G4 - lesões semelhantes as do G3, porém mais intensas, áreas de extensa hemorragia. Avaliação funcional: a pressão no EIE foi mais elevada em M2 no grupo 2; o número das contrações no terço distal do esôfago foi menor em G3 e G4, e a amplitude das contrações foi menor em G4. CONCLUSÕES: 1) a infusão esofágica com NaOH constitui excelente modelo experimental de esofagite cáustica no coelho; 2) a infusão esofágica com NaOH causa lesões na parede do esôfago, com gravidade proporcional a concentração da solução; 3) a infusão causou espasmo do EIE em M2 e redução do número e amplitude das contrações no terço distal do esôfago.

Mate attenuates DNA damage and carcinogenesis induced by diethylnitrosamine and thermal injury in rat esophagus

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Avaliação dos danos do DNA na mucosa esofágica e sangue periférico de portadores da doença do refluxo gastroesofágico

RACIONAL: A doença do refluxo gastroesofágico é a afecção digestiva de maior prevalência. Os portadores podem apresentar na evolução algumas complicações, sendo o esôfago de Barrett a de maior importância, tendo em vista seu potencial de malignidade. Todavia os processos inflamatórios do trato gastrointestinal podem apresentar degeneração maligna. OBJETIVOS: Avaliar os possíveis danos do DNA em portadores de esofagite de refluxo gastroesofágico de vários graus e verificar a aplicação do ensaio Cometa na detecção dos mesmos. MÉTODOS: Foram estudados 25 pacientes distribuídos em quatro grupos: controle (n=5), esofagite leve (n=8), esofagite severa (n=5) e câncer (n=7). O ensaio Cometa foi realizado no sangue periférico (linfócitos) e biópsia do terço distal do esôfago. RESULTADOS: O ensaio Cometa detectou danos no DNA nos pacientes com esofagite leve e severa (sangue periférico e biópsia), sendo que na esofagite severa a intensidade dos danos foi maior (p<0,05). Os danos do DNA dos pacientes com esofagite severa e câncer não mostraram diferença significativa e a intensidade dos mesmos corresponde ao ensaio Cometa classe 4 (maior que 95% de danos). CONCLUSÕES: 1) As frequências de quebras do DNA da mucosa esofágica e linfócitos estão diretamente relacionadas ao grau de inflamação; 2) a esofagite severa apresenta praticamente a mesma frequência de danos no DNA do câncer esofágico; 3) o ensaio Cometa mostrou-se muito sensível para a detecção dos danos do DNA.

Outcome of superficial squamous cell carcinoma of the esophagus: a clinicopathological study

PURPOSE: To analyze the clinicopathological features and outcome of patients with pathologically proven superficial squamous cell carcinoma of the esophagus. METHODS: A total of 234 consecutive cases of esophageal carcinoma in a 15-year period were reviewed. RESULTS: Superficial esophageal cancer was found in five patients (2.1%). They were four men and one woman and the mean age was 52.5 years. Smoking and alcohol were the main risk factors. Achalasia due to Chagas disease occurred in one patient and a second primary tumor developed in the larynx in another patient. Four patients underwent esophagectomy and one patient received chemoradiotherapy. The histopathologic diagnosis was of squamous cell carcinoma in all cases. Intramucosal tumor (Tis) was identified in three cases and superficially invasive carcinoma in two cases. Four patients are free of disease with survival times of two, four, six and nine years. The patient who developed laryngeal cancer died six years after esophagectomy. CONCLUSION: Long-term survival in patients with esophageal cancer is related to early diagnosis. Therefore, a less aggressive surgical approach, such as endoscopic resection, may be a good option for these patients, if depth of tumor invasion can be accurately predicted by the new imaging tools.

Effect of ion reduction of sodium, calcium and potassium on spontaneous contraction of the esophagus of Pomacea lineata SPIX, 1827 (Mollusca-Gastropoda-Prosobranchia)

The invertebrate's musculature still presents many elusive points, especially in molluscs that generally present smooth and cracked fibers with peculiar characteristics. It was found that the molluscs reactions to the ion variation in the bathing are not very clear, mainly in view of the isolated reduction or equivalent of the ions. Suspended in bath, the isolated esophagus of the P. lineata exhibited spontaneous activity. This rhythmic activity was sensitive to the ion variation of the perfusion liquid, evidenced by alterations in the spontaneous contractions. The equivalent reduction of the ion reduced the spontaneous activity, evidenced by the amplitude reduction of the response, besides maintaning an organ contraction, primarily in the reductions below 50%. When the isolated reductions of the Na, Ca or K ion were performed, occurred interference in the spontaneous contractions of the organs, principally in amplitude of the response and maintenance of the contracture in reductions of 50 and 25% of the ion.

Aplicação e contribuição da cromoendoscopia no trato digestório superior de cães, uilizando Lugol, Índigo Carmim e Azul de Metileno

Pós-graduação em Medicina Veterinária - FMVZ

Epidemiological features of esophageal cancer. Squamous cell carcinoma versus adenocarcinoma

PURPOSE: To analyze the epidemiological features of patients with esophageal cancer according to the histopathological types: squamous cell carcinoma or adenocarcinoma. METHODS: A total of 100 patients with esophageal cancer, being 50 squamous cell carcinomas and 50 adenocarcinomas were analyzed for demographics, nutritional factors, lifestyle habits, benign pathological conditions associated, like Barrett's esophagus and megaesophagus, tumor stage and survival rates. The nutritional factors evaluated included body mass index, percent weight loss, hemoglobin and albumin serum levels. RESULTS: Esophageal cancer occurred more often in men over 50 years-old in both histological groups. No significant differences on age and gender were found between the histological groups. Squamous cell carcinoma was significantly more frequent in blacks than adenocarcinoma. Alcohol consumption and smoking were significantly associated with squamous cell carcinoma. Higher values of body mass index were seen in patients with adenocarcinoma. Barrett's esophagus was found in nine patients (18%) with adenocarcinoma, and megaesophagus in two patients (4%) with squamous cell carcinoma. The majority of patients were on stages III and IV in both histological groups. The mean survival rates were 7.7 ± 9.5 months for patients with squamous cell carcinoma and 8.0 ± 10.9 months for patients with adenocarcinoma. No significant differences on tumor stage and survival rates were detected between the histological groups. CONCLUSION: Epidemiological features are distinct for the histopathological types of esophageal cancer. Squamous cell carcinoma is associated with black race, alcohol and smoking, while adenocarcinoma is related to higher body mass index, white race and Barrett's esophagus.

Laparoscopic Heller Myotomy and Fundoplication in Patients with Chagas' Disease Achalasia and Massively Dilated Esophagus

Laparoscopic Heller myotomy and fundoplication is considered today the treatment of choice for achalasia. The optimal treatment for end-stage achalasia with esophageal dilation is still controversial. This multicenter and retrospective study aims to evaluate the outcome of laparoscopic Heller myotomy in patients with a massively dilated esophagus. Eleven patients (mean age, 56 years; 6 men) with massively dilated esophagus (esophageal diameter greater than 10 cm) underwent a laparoscopic Heller myotomy and anterior fundoplication between 2000 and 2009 at three different institutions. Preoperative workup included upper endoscopy, esophagram, and esophageal manometry in all patients. Average follow-up was 31.5 months (range, 3 to 60 months). Two patients (18%) had severe dysphagia, four patients (36%) had mild and occasional dysphagia to solid food, and five patients (45%) were asymptomatic. All patients gained or kept body weight, except for the two patients with severe dysphagia. Of the two patients with severe dysphagia, one underwent esophageal dilatation and the other a laparoscopic esophagectomy. They are both doing well. Heller myotomy relieves dysphagia in the majority of patients even when the esophagus is massively dilated.

Effect of metoclopramide, ranitidine, and droperidol on the lower sphincter of the esophagus. Experimental study on the opossum (Didelphis albiventris)

Electromanometric measures of the gastroesophageal junction were performed in 20 adult, male and female, anesthetised opossums. The electromanometric examinations were performed according the intermitent pull through technique. The research was divided in four groups, according to the drug to be analysed: group 1 (20 animals) IM injection of physiological solution (control group); group 2 (20 animals) IM injection of metoclopramide; group 3 (20 animals) IM injection of ranitidine; group 4 (20 animals) IM injection of droperidol. Electromanometry was done 15 minutes before the drug injection, just after the injection and 15, 30, 45 and 60 minutes after the injection. In each one of the moments the pressure of the lower esophageal sphincter (LES-mmHg) was analysed. Considering LES pressure the results observed were: in group 1 it was not observed any significative alteration after IM injection of physiologic solution; in group 2 it was observed significative pressure increase, 15 minutes after metoclopramide IM injection; in group 3 it was observed pressure increase, being significative at 15 and 30 minutes after IM injection; in group 4 it was observed significative increase in LES pressure in every moment, 15 minutes after droperidol IM injection.

Diagnosis and management of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is probably one of the most prevalent diseases in the world that also compromises the quality of life of the affected significantly. Its incidence in Brazil is 12%, corresponding to 20 million individuals. OBJECTIVE: To update the GERD management and the new trends on diagnosis and treatment, reviewing the international and Brazilian experience on it. METHOD: The literature review was based on papers published on Medline/Pubmed, SciELO, Lilacs, Embase and Cochrane crossing the following headings: gastroesophageal reflux disease, diagnosis, clinical treatment, surgery, fundoplication. RESULTS: Various factors are involved on GERD physiopathology, the most important being the transient lower esophageal sphincter relaxation. Clinical manifestations are heartburn, regurgitation (typical symptoms), cough, chest pain, asthma, hoarseness and throat clearing (atypical symptoms), which may be followed or not by typical symptoms. GERD patients may present complications such as peptic stenosis, hemorrhage, and Barrett's esophagus, which is the most important predisposing factor to adenocarcinoma. The GERD diagnosis must be based on the anamnesis and the symptoms must be evaluated in terms of duration, intensity, frequency, triggering and relief factors, pattern of evolution and impact on the patient's quality of life. The diagnosis requires confirmation with different exams. The goal of the clinical treatment is to relieve the symptoms and surgical treatment is indicated for patients who require continued drug use, with intolerance to prolonged clinical treatment and with GERD complications. CONCLUSION: GERD is a major digestive health problem and affect 12% of Brazilian people. The anamnesis is fundamental for the diagnosis of GERD, with special analysis of the typical and atypical symptoms (duration, intensity, frequency, triggering and relief factors, evolution and impact on the life quality). High digestive endoscopy and esophageal pHmetry are the most sensitive diagnosctic methods. The clinical treatment is useful in controlling the symptoms; however, the great problem is keeping the patients asymptomatic over time. Surgical treatment is indicated for patients who required continued drug use, intolerant to the drugs and with complicated forms of GERD.