Migração de clipe metálico para úlcera duodenal após colecistectomia videolaparoscópica: Ligaclip migration into a duodenal ulcer following laparoscopic cholecystectomy

We report a rare cause of pyloric stenosis caused by migration of surgical clips into a duodenal ulcer following laparoscopic cholecystectomy. Even after endoscopic removal of the clips the inflammatory reaction during the healing process caused a stenosis of the pylorus that eventually required a truncal vagotomy and gastroenterostomy.

Tumor estromal do trato gastrintestinal primário da papila duodenal

The majority gastrointestinal wall tumors previously considered leiomyomas or leiomyosarcomas were reclassified into Gastrointestinal Stromal Tumours because of typical imunohistochemic, genetic and biologic behaviors findings. We present a case report of Gastrointestinal Stromal Tumor primary of the duodenal papilla causing digestive haemorrage that was submitted to surgical treatment.

Megacólon chagásico associado a pneumatose cística difusa do delgado e úlcera péptica duodenal

Diffuse intestinal pneumatosis appears as gaseous cysts in the intestinal wall in the submucosal layer or, more frequently, sub-serous layer. It affects more the jejunum than the ileum, can be diffuse and may extend into the colon. It's diagnosis is established during a small bowel transit examination, necropsy examination or during surgical exploration of the peritoneal cavity.

Tratamento de doença bílio-pancreática em pacientes portadores de divertículo duodenal periampolar

OBJETIVO: Analisar o tratamento da doença bílio-pancreática na presença do divertículo periampolar. MÉTODO: De janeiro de 1999 a julho de 2003, 13 doentes com diagnóstico de divertículo periampolar e doença bílio-pancreática associada foram tratados pelo grupo de vias biliares e pâncreas do Departamento de Cirurgia da Santa Casa de São Paulo. Foram analisados retrospectivamente quanto à idade, sexo, quadro clínico e exames laboratoriais e radiológicos, com intuito diagnóstico. O tratamento endoscópico ou cirúrgico e seus resultados foram avaliados. RESULTADOS: Quatro pacientes eram do sexo masculino (30,8%) e nove (69,2%) do sexo feminino, a maioria com idade superior a 70 anos. Os principais sintomas foram de icterícia (61,5%) e dor abdominal (53,8%). Dois doentes apresentaram-se com pancreatite aguda e um com hemorragia digestiva alta. Onze doentes tinham coledocolitíase e dois, diagnóstico de colangiocarcinoma. Dez doentes foram submetidos a colangio-pancreatografia retrógrada endoscópica com 30% de sucesso no tratamento da coledocolitíase. Os outros doentes foram operados: três coledocoduodenostomias, quatro coledocolitotomias com drenagem em T da via biliar. Três doentes foram submetidos à diverticulectomia (23,1%) e um deles (7,7%) à papiloesfincteroplastia. A mortalidade na amostra foi de 7,7%. CONCLUSÃO: A taxa de sucesso do tratamento endoscópico da coledocolitíase foi baixa na presença de divertículo periampolar e a diverticulectomia com ou sem esfincteroplastia pode elevar a morbidade e a mortalidade nestes doentes.

Paraganglioma gangliocítico duodenal

We present a case of a 42-year-old man with abdominal pain, obstructive jaundice and a mass in the second portion of the duodenum, near the papillary region. The patient was operated and the histological study of the specimen returned duodenal gangliocytic paraganglioma (a rare submucosal benign tumor of the duodenum). We also describe, after revision of the literature, the pathology, the diagnosis and its treatment.

Is there a role for pyloric exclusion after severe duodenal trauma?

Duodenal trauma is an infrequent injury, but linked to high morbidity and mortality. Surgical management of duodenal injuries is dictated by: patient's hemodynamic status, injury severity, time of diagnosis, and presence of concomitant injuries. Even though most cases can be treated with primary repair, some experts advocate adjuvant procedures. Pyloric exclusion (PE) has emerged as an ancillary method to protect suture repair in more complex injuries. However, the effectiveness of this procedure is debatable. The "Evidence Based Telemedicine - Trauma & Acute Care Surgery" (EBT-TACS) Journal Club performed a critical appraisal of the literature and selected three relevant publications on the indications for PE in duodenal trauma. The first study retrospectively compared 14 cases of duodenal injuries greater than grade II treated by PE, with 15 cases repaired primarily, all of which penetrating. Results showed that PE did not improve outcome. The second study, also retrospective, compared primary repair (34 cases) with PE (16 cases) in blunt and penetrating grade > II duodenal injuries. The authors concluded that PE was not necessary in all cases. The third was a literature review on the management of challenging duodenal traumas. The author of that study concluded that PE is indicated for anastomotic leak management after gastrojejunostomies. In conclusion, the choice of the surgical procedure to treat duodenal injuries should be individualized. Moreover, there is insufficient high quality scientific evidence to support the abandonment of PE in severe duodenal injuries with extensive tissue loss.

Treponema denticola in microflora of bovine periodontitis

Periodontitis in cattle is an infectious purulent progressive disease associated with strict anaerobic subgingival biofilm and is epidemiologically related to soil management at several locations of Brazil. This study aimed to detect Treponema species in periodontal pockets of cattle with lesions deeper than 5mm in the gingival sulcus of 6 to 24-month-old animals considered periodontally healthy. We used paper cones to collect the materials, after removal of supragingival plaques, and kept frozen (at -80°C) up to DNA extraction and polymerase chain reaction (PCR) using T. amylovorum, T. denticola, T. maltophilum, T. medium and T. vincentii primers. In periodontal pocket, it was possible to identify by PCR directly, the presence of Treponema amylovorum in 73% of animals (19/26), T. denticola in 42.3% (11/26) and T. maltophilum in 54% (14/26). Among the 25 healthy sites, it was possible to identify T. amylovorum in 18 (72%), T. denticola in two (8%) and T. maltophilum in eight (32%). Treponema medium and T. vincentii were not detected over all 51 evaluated samples. The presence of Treponema amylovorum, T. maltophilum and, in particular, the widely recognized T. denticola in subgingival microflora brings an original and potencially important contribution in studies of the bovine periodontitis.

Presence of Porphyromonas and Prevotella species in the oral microflora of cattle with periodontitis

Abstratc: Bovine periodontitis is a progressive purulent infectious process associated with the presence of strictly and facultative anaerobic subgingival biofilm and epidemiologically related to soil management in large geographic areas of Brazil. This study aimed to detect species of the genera Porphyromonas and Prevotella, which occurr in periodontal pockets of cattle with lesions deeper than 5mm (n=26) and in gingival sulcus of animals considered periodontally healthy (n=25). Presence of the microorganisms was evaluated by independent-culture medium diagnostic method, using polymerase chain reaction (PCR) with specific primers of Porphyromonas asaccharolytica, P. endodontalis, P. gingivalis, P. gulae, Prevotella buccae, P. intermedia, P. loescheii, P. melaninogenica, P. nigrescens, P. oralis and P. tannerae. The species P. endodontalis (80.7%), P. melaninogenica (73.1%) and P. intermedia (61.5%) were the most predominant in samples of cattle with periodontitis. Regarding non-injured gingival sulcus of cattle, P. endodontalis (40%) and P. loeschei (40%) prevailed. Porphyromonas gingivalis, P. gulae and Prevotella tannerae were not detected in the 51 samples studied. Data evaluation by T test, enabled to verify that ocorrence of Porphyromonas asaccharolytica (p=0.000003), P. endodontalis (p=0.0023), Prevotella buccae (p=0.0017), P. intermedia (p=0.0020), P. melaninogenica (p=0.00006) and P. oralis (p=0.0028) is correlated with bovine periodontitis.

Eradication of Helicobacter pylori infection in patients with duodenal ulcer and non-ulcer dyspepsia and analysis of one-year reinfection rates

Helicobacter pylori (HP) infection is endemic worldwide. The proposed treatment is expensive and there are few reports regarding reinfection rates in Brazil. The aim of this study was to compare the eradication rates obtained with two therapeutic options and to evaluate reinfection one year after treatment. This was a prospective randomized trial with 55 patients. Thirty-nine patients had active duodenal ulcer (DU) and 16 non-ulcer dyspepsia (NUD), and all tested positive for HP. Diagnosis was based on at least two positive tests: ultrarapid urease test, histology and/or culture. Patients were randomized to two groups: group OMC treated with 40 mg omeprazole (once a day), 500 mg metronidazole and 250 mg clarithromycin (twice daily) for 7 days, or group NA treated with 300 mg nizatidine (once a day) and 1000 mg amoxicillin (twice daily) for 14 days. Those patients in whom HP was eradicated were followed up for one year to evaluate reinfection. Twenty-five patients were randomized for OMC and 30 for NA. HP eradication occurred in 20/25 patients (80%) treated with OMC and 13/30 (43%) treated with NA (P = 0.01). After reallocation because of initial treatment failure, the overall eradication rate was 44/51 patients (86%). After an average follow-up of one year, we evaluated 34 patients (23 with DU and 11 with NUD). Reinfection occurred in 3/34 patients (7.6%). We conclude that OMC is effective for HP eradication, and that NA should not be used. Reinfection occurs in 7.6% of the patients in the first year after eradication.

Immunopathology of the duodenal mucosa of HIV-positive patients during combined antiretroviral therapy

The objective of the present study was to evaluate the duodenal mucosa of HIV-infected patients during antiretroviral therapy. This was an observational study conducted on HIV-positive patients and a control group. Group 1 comprised 22 HIV-negative individuals while 38 HIV-positive individuals were classified according to the CDC 1993 classification into group 2 (A1 or A2) or group 3 (B2, A3, B3, C2, C3). All subjects were submitted to upper gastrointestinal endoscopy with duodenal biopsies. Qualitative, semi-quantitative and quantitative histological analyses were performed. Results were considered significant when P < 0.05. A higher prevalence of inflammatory infiltrate and eosinophilia was observed in the HIV group, together with a reduction in mucosal CD4+ lymphocyte (L) counts [median (lower-upper quartiles), 12.82 (8.30-20.33), 6.36 (1.75-11.66) and 1.75 (0.87-3.14) in groups 1, 2 and 3, respectively] which was not correlated with disease stage. The extent of CD4+L count reduction was similar in blood and duodenal mucosa. Normal CD8+L and CD45RO+L counts, and normal numbers of macrophages and antigen-presenting cells were also found in the HIV patients. The cytokine pattern did not differ among groups. Tissue HIV, assessed by p24 antigen, correlated with a higher CD45RO+L count (77.0 (61-79.8) and 43.6 (31.7-62.8) in p24+ and p24-, respectively, P = 0.003), and IL-4 positivity (100 and 48.2% in p24+ and p24-, respectively, P = 0.005). The duodenal mucosa of HIV+ patients showed a relatively preserved histological architecture. This finding may be characteristic of a population without opportunistic infections and treated with potent antiretroviral therapy, with a better preservation of the immune status.

Duodenal gastric metaplasia and Helicobacter pylori infection in patients with diffuse nodular duodenitis

Whether the regression of gastric metaplasia in the duodenum can be achieved after eradication of Helicobacter pylori is not clear. The aim of the present study was to investigate the relationship between H. pylori infection and gastric metaplasia in patients with endoscopic diffuse nodular duodenitis. Eighty-six patients with endoscopically confirmed nodular duodenitis and 40 control patients with normal duodenal appearance were investigated. The H. pylori-positive patients with duodenitis received anti-H. pylori triple therapy (20 mg omeprazole plus 250 mg clarithromycin and 400 mg metronidazole, all twice daily) for one week. A control endoscopy was performed 6 months after H. pylori treatment. The H. pylori-negative patients with duodenitis received 20 mg omeprazole once daily for 6 months and a control endoscopy was performed 2 weeks after treatment. The prevalence of H. pylori infection was 58.1%, and the prevalence of gastric metaplasia was 57.0%. Seventy-six patients underwent endoscopy again. No influence on the endoscopic appearance of nodular duodenitis was found after eradication of H. pylori or acid suppression therapy. However, gastric metaplasia significantly decreased and complete regression was achieved in 15/28 patients (53.6%) 6 months after eradication of H. pylori, accompanied by significant improvement of other histological alterations. Only mild chronic inflammation, but not gastric metaplasia, was found in the control group, none with H. pylori infection in the duodenal bulb. Therefore, H. pylori infection is related to the extent of gastric metaplasia in the duodenum, but not to the presence of diffuse nodular duodenitis.

Efeito do tratamento de sementes e da profundidade de semeadura no desenvolvimento de plantas de aveia-branca (Avena sativa L.) e a microflora da rizosfera e do rizoplano

O estado do Paraná é um dos maiores produtores nacionais de grãos de aveia-branca (Avena sativa L.), com expressivo aumento na área cultivada a cada ano. O presente estudo foi realizado no município de Londrina, PR, onde foram desenvolvidos ensaios de laboratório e campo. O objetivo foi avaliar o efeito do tratamento de sementes e a profundidade de semeadura, na emergência das plântulas, no desenvolvimento das plantas, na população de microrganismos da rizosfera e rizoplano da área de desenvolvimento das plantas e na produção de grãos de aveia. As sementes de aveia-branca, cultivar OR-11, foram semeadas nas profundidades de 3cm, 5cm e 8cm. Foram utilizados os seguintes fungicidas nas doses (g.i.a./100kg de sementes), carboxim+thiram (93,7g+93,7g), thiram (210g) e triadimenol (50g) e o produto biológico kodiak C (Bacillus subtilis) (60g). Os tratamentos com os fungicidas e o produto biológico, controlaram os fungos presentes nas sementes, como: Fusarium avenae, Colletotrichum graminicola e Helminthosporium avenae e melhoram o desenvolvimento das plantas e a microbiota do solo, sendo esse variável com a profundidade de semeadura e o tratamento.

Achado de bactérias selecionadas em crianças de Trinidad com doença amigdaliana crônica

Faringoamigdalite na população pediátrica é largamente tratada com antibióticos. OBJETIVO: Estudar a microflora presente na superfície e no núcleo de amígdalas após adenoamigdalectomia eletiva em crianças. MÉTODO: Amígdalas de 102 crianças de Trinidad foram prospectivamente estudadas por meio de culturas e identificações bacteriológicas feitas a partir de amostras das superfícies e núcleos de suas amígdalas entre 2005-2006. RESULTADOS: A partir de 360 amígdalas, foram isolados Streptococcus spp. (51,3%), Staphylococcus spp. (42,3%) e Gram-Negativos (6,4%). A identificação de estafilococos e estreptococos tanto na superfície quanto no núcleo foi semelhante (p>0,05). Encontramos mais (p<0,001) Streptococcus spp. nas superfícies (82,2%) do que nos núcleos (63,3%); a prevalência de estreptococos alfa-hemolíticos foi maior (p<0,001) do que aquela de estreptococos beta-hemolíticos nas superfícies (74,4% vs. 18,6%) do que nos núcleos (58,9% vs. 13,7%). Não houve concordância entre superfícies e núcleos com relação a estreptococos (p<0,0004) e estreptococos alfa-hemolíticos (p<0,007). Estreptococos beta-hemolíticos foram mais identificados (p<0,05) em crianças dentre 6-16 anos do que naquelas entre 1-5 anos de idade (31% e 23,8% vs 12,5% e 8%). A prevalência de S. pyogenes na superfície e no núcleo foi de (84,6% vs 70%) e (50,0% vs 25,0%) em crianças de maior faixa etária e crianças mais novas, respectivamente. Klebsiella spp. (6,6%, 2,2%), Proteus (4,4%, 4,4%) e Pseudomonas (4,4 %, 1,1%) cresceram nas superfícies e núcleos, respectivamente. CONCLUSÃO: As superfícies amigdalianas tinham mais estreptococos e estreptococos hemolíticos do que seus núcleos. Crianças mais velhas tiveram mais estreptococos beta-hemolíticos, e são altamente colonizadoras de S. pyogenes. Sugerimos estudos que investiguem os mecanismos de aderência estreptocócica em crianças de Trinidad.

Detecção do vírus Epstein-Barr em tonsilites recorrentes

As tonsilites recorrentes têm sido objeto de muitos estudos. Eventos considerados na predisposição e causa incluem a utilização errônea de antibióticos em crises agudas, alterações da microflora, mudanças estruturais nas criptas epiteliais tonsilares e infecções virais. A infecção pelo vírus Epstein-Barr (EBV) ocorre freqüentemente na infância persistindo em linfócitos de tonsilas, podendo causar tonsilites recorrentes. Pouco se conhece sobre a persistência e reativação do EBV em pacientes imunocompetentes. Alguns métodos como a hibridização in situ, a reação em cadeia da polimerase (PCR) e a imuno-histoquímica têm sido utilizados no estudo da patogenia do vírus. OBJETIVO: Para caracterizar a associação do vírus Epstein-Barr com tonsilites recorrentes examinamos a presença do EBV pela PCR e por imuno-histoquímica usando como alvo a proteína viral LMP-1. FORMA DE ESTUDO: Estudo transversal com análise de prevalência amostral. MATERIAL E MÉTODOS: Foram selecionados 24 blocos parafinados de tonsilas, provenientes do Serviço de Anatomia Patológica, removidas de crianças de 2 a 12 anos com diagnóstico de tonsilite recorrente. Resultados: O genoma do EBV foi detectado em 13 (54,1%) e a LMP-1 em 9 (37,5%) dos casos. CONCLUSÃO: As tonsilas das crianças podem ser colonizadas pelo EBV e este pode estar associado à patogenia das tonsilites recorrentes.

Anemia ancilostomótica: estudo da fisiopatologia

Foram estudados 17 casos de ancilostomose e determinados alguns parâmetros hematológicos como: dosagem de hemoglobina, do ferro sérico e da transferrina, contagem de hemácias, hematócrito, volume corpuscular médio (VCM) e hemoglobina corpuscular média (HCM). O estudo incluiu também a obtenção de alguns dados eritrocinéticos, como a determinação da velocidade de decaimento do ferro plasmático (T1V2 do 59Fe) e da incorporação do ferro à hemoglobina. O estudo radioisotópico permitiu ainda determinar o volume de sangue e a quantidade de hemoglobina perdida nas fezes, bem como o teor de ferro reabsorvido dessa hemoglobina. Estabeleceram também o grau de infecção através da contagem de ovos e de vermes nas fezes. Os doentes não apresentaram evidente alteração nutricional. A carência de ferro foi o fator comum a todos os casos que exibiram anemia, constituindo a base fisiopatológica da anemia ancilostomótica. O verme fixado à mucosa duodenal suga o sangue do hospedeiro e esta espoliação de sangue a longo prazo provoca a anemia. O volume de sangue perdido é geralmente proporcional ao grau de infecção, mas a quantidade de hemoglobina perdida mostrou ser independente do volume de sangue espoliado. A reabsorção de grande parte do ferro da hemoglobina perdida na luz intestinal concorre para que a anemia se estabeleça mais tardiamente que em outras hemorragias como a vaginal. Os indivíduos anêmicos foram submetidos a transfusões de sangue e com isso apresentaram melhora clínica e laboratorial, imediata mas temporária. A cura clínica foi estabelecida somente após tratamento adequado com vermífugos.