Aspectos endoscópicos no manejo da úlcera péptica gastroduodenal

Bleeding remains a common and a potential lethal complication for peptic ulcer disease. Multidisciplinary approach by endoscopists, surgeons and intensive care physicians is necessary to improve results for this severe complication. In this article we intend to introduce surgeons and intensive care physicians to endoscopic concepts and maneuvers commonly used in the treatment of bleeding peptic ulcer disease. Early clinical assessment and endoscopic evaluation are helpful to classify the severity of the bleeding episode. Two major achievements have changed the management of this complication: combined endoscopic therapy and proton pump inhibitors. The former consists of combining two different endoscopic methods to stop bleeding or prevent re-bleeding (e.g., injection of a sclerosing substance and thermal coagulation). Surgical treatment for peptic ulcer bleeding is indicated when endoscopic therapy fails or to prevent re-bleeding in high risk patients who presents with a spurting bleeding ulcer and shock. For the remaining situations, there are consistent evidences that a second endoscopic therapy should be attempted when re-bleeding occurs. Keywords: endoscopic hemostasis, recurrent bleeding, peptic ulcer bleeding, proton-pump inhibitor, non-variceal gastrointestinal bleeding.

Síndrome de estenose pilórica por adenocarcinoma de piloro

We present a case of primary malignant pylorus neoplasia, emphasizing its rarity, the difficulty of diagnosis and the importance of an adequate prepare before the endoscopic procedure. Literature shows that tumors compromising the first, third and fourth segments of duodenum are rare, especially those of the pyloric area, representing only 0.35% of all malignant tumors of the gastrointestinal tract. Adenocarcinoma is the most common histological type, representing 50% of all malignant neoplasias at this site. The most common symptoms are weight loss, nausea, vomiting, abdominal pain, abdominal mass, sudden changes in intestinal habits and iron deficiency anemia secondary to chronic intestinal hemorrhage. Survival after five years is only 18%. We report a case of a seventy-one year-old male referring early satiety, epigastric pain, retrosternal burning and dyspepsia, with unspecific results in complementary exams, since complete gastric emptying was not achieved. As symptoms worsened, the patient was submitted to laparotomy, with identification of gastric dilation and severe pyloric stenosis, macroscopically suggesting malignancy. The chosen procedure was a subtotal gastrectomy. Adjuvant radiotherapy and chemotherapy were not used. The patient is been followed-up without tumor recurrence so far.

Effects of sedation during upper gastrointestinal endoscopy on endocrine response and cardiorespiratory function

Upper gastrointestinal endoscopy is often accompanied by tachycardia which is known to be an important pathogenic factor in the development of myocardial ischemia. The pathogenesis of tachycardia is unknown but the condition is thought to be due to the endocrine response to endoscopy. The purpose of the present study was to investigate the effects of sedation on the endocrine response and cardiorespiratory function. Forty patients scheduled for diagnostic upper gastrointestinal endoscopy were randomized into 2 groups. While the patients in the first group did not receive sedation during upper gastrointestinal endoscopy, the patients in the second group were sedated with intravenous midazolam at the dose of 5 mg for those under 65 years or 2.5 mg for those aged 65 years or more. Midazolam was administered by slow infusion. In both groups, blood pressure, ECG tracing, heart rate, and peripheral oxygen saturation (SpO2) were monitored during endoscopy. In addition, blood samples for the determination of cortisol, glucose and C-reactive protein levels were obtained from patients in both groups prior to and following endoscopy. Heart rate and systolic arterial pressure changes were within normal limits in both groups. Comparison of the two groups regarding the values of these two parameters did not reveal a significant difference, while a statistically significant reduction in SpO2 was found in the sedation group. No significant differences in serum cortisol, glucose or C-reactive protein levels were observed between the sedated and non-sedated group. Sedation with midazolam did not reduce the endocrine response and the tachycardia developing during upper gastrointestinal endoscopy, but increased the reduction in SpO2.

Computed tomography angiography in patients with active gastrointestinal bleeding

Abstract Gastrointestinal bleeding represents a common medical emergency, with considerable morbidity and mortality rates, and a prompt diagnosis is essential for a better prognosis. In such a context, endoscopy is the main diagnostic tool; however, in cases where the gastrointestinal hemorrhage is massive, the exact bleeding site might go undetected. In addition, a trained professional is not always present to perform the procedure. In an emergency setting, optical colonoscopy presents limitations connected with the absence of bowel preparation, so most of the small bowel cannot be assessed. Scintigraphy cannot accurately demonstrate the anatomic location of the bleeding and is not available at emergency settings. The use of capsule endoscopy is inappropriate in the acute setting, particularly in the emergency department at night, and is a highly expensive method. Digital angiography, despite its high sensitivity, is invasive, presents catheterization-related risks, in addition to its low availability at emergency settings. On the other hand, computed tomography angiography is fast, widely available and minimally invasive, emerging as a promising method in the diagnostic algorithm of these patients, being capable of determining the location and cause of bleeding with high accuracy. Based on a critical literature review and on their own experience, the authors propose a computed tomography angiography protocol to assess the patient with gastrointestinal bleeding.

Myiasis gastrointestinal humana por Eristalis tenax

Son caracterizadas las myiasis registradas en Bariloche y establecidas las condiciones probables bajo las cuales se produjeron las infestaciones. Las larvas obtenidas a partir de heces de 2 pacientes fueron identificadas como Eristalis tenax (Diptera: Syrphidae) de acuerdo a las claves de Hartley (1961) y Organización Panamericana de la Salud (1962). Estos 2 casos de myiasis gastrointestinal humana constituyen los primeros registrados en Bariloche (Patagonia, Argentina) y sus características responden a las registradas para esta especie de Díptera en otras partes del mundo. La falta de control específico en el sistema domiciliario de suministro de agua ha sido la causa más probable de la infestación. Este registro extiende la distribución de E. tenax y de las myiasis gastrointestinales humanas en América del Sur hasta los 41º 03' S.

Gastrointestinal translocation as a possible source of candidemia in an AIDS patient

Apart from cryptococcosis and histoplasmosis, which are mycoses contained by T cell-mediated mechanisms of host defense, fungemia is rarely found in AIDS patients. The frequency of fungemia due to Candida spp. has been reported to be as low as 1 %. We report a non-neutropenic AIDS patient who presented a candidemia which probably arose from her gastrointestinal tract.

Importance of immunoglobulin E (IgE) in the protective mechanism against gastrointestinal nematode infection: looking at the intestinal mucosae

This review discusses experimental evidences that indicate the IgE participation on the effector mechanisms that leads to gastrointestinal nematode elimination. Data discussed here showed that, for most experimental models, the immune response involved in nematode elimination is regulated by Th-2 type cytokines (especially IL-4). However, the mechanism(s) that result in worm elimination is not clear and might be distinct in different nematode species. Parasite specific IgE production, especially the IgE produced by the intestinal mucosae or associated lymphoid organs could participate in the intestinal elimination of Trichinella spiralis from infected rats. Intestinal IgE may also be important to the protective mechanism developed against other gastrointestinal nematodes that penetrate the murine duodenum mucosa tissue, such as Strongyloides venezuelensis and Heligmosomoides polygyrus. At least in Trichinella spiralis infected rats, the results indicated that intestinal IgE might work independently from mast cell degranulation for worm elimination.

A preliminary investigation on the gastrointestinal helminths of the Barbados green monkey, Cercopithecus aethiops sabaeus

Faecal samples were collected from fifty three freshly captured monkeys which were kept at the Barbados Primate Research Centre and Wildlife Reserve (BPRCWR). Examination of these samples for gastrointestinal helminths using the zinc sulphate floatation method revealed an overall infection rate of 88.7%.The parasites observed included Strongyloides (62.4%), Physaloptera (58.5%), Trichuris (52.8%), Hookworm (34.0%), Oesophagostomum (30.2%), Trichostrongylus (3.8%) and Ascaris (5.7%). No significant differences in overall prevalence were observed according to sex or age. Polyparasitism appeared to be common as it was observed in 92.5% of all monkeys examined. It is concluded that these monkeys could act as reservoirs of some of the parasites which can infect man.

A preliminary study of the prevalence of intestinal parasites in immunocompromised patients with and without gastrointestinal manifestations

The objective of the present study was to determine the prevalence of the intestinal parasites most commonly found in immunocompromised patients. A group of 111 individuals with acute lymphoid leukaemia (ALL), chronic myeloid leukaemia (CML), human immunodeficiency virus (HIV) and other immunocompromised conditions (principally haematological disorders) was selected. A battery of tests was performed on each individual to identify the presence of parasites (three stool specimens with saline solution and Lugol both directly and by concentration, culture and special staining). No significant differences were found among the frequencies of the different parasites with the several types of immunocompromised conditions. The overall frequencies of potentially pathogenic and opportunistic parasites were 32.4% (36/111) and 9% (10/111) respectively, the most frequently encountered among the latter being Cryptosporidium sp., Microsporidia spp. and Strongyloides stercoralis.

Whipple's disease: rare disorder and late diagnosis

Whipple's disease is a rare systemic infectious disorder caused by the bacterium Tropheryma whipplei. We report the case of a 61-year-old male patient who presented to emergency room complaining of asthenia, arthralgia, anorexia, articular complaints intermittent diarrhea, and a 10-kg weight loss in one year. Laboratory tests showed the following results: Hb = 7.5 g/dL, albumin = 2.5 mg/dL, weight = 50.3 kg (BMI 17.4 kg/m²). Upper gastrointestinal endoscopy revealed areas of focal enanthema in the duodenum. An endoscopic biopsy was suggestive of Whipple's disease. Diagnosis was confirmed based on a positive serum polymerase chain reaction. Treatment was initiated with intravenous ceftriaxone followed by oral trimethoprim-sulfamethoxazole. After one year of treatment, the patient was asymptomatic, with Hb = 13.5 g/dL, serum albumin = 5.3 mg/dL, and weight = 70 kg (BMI 24.2 kg/m²). Whipple's disease should be considered a differential diagnosis in patients with prolonged constitutional and/or gastrointestinal symptoms. Appropriate antibiotic treatment improves the quality of life of patients.

PATHOGENICITY OF Blastocystis sp. TO THE GASTROINTESTINAL TRACT OF MICE: RELATIONSHIP BETWEEN INOCULUM SIZE AND PERIOD OF INFECTION

The pathogenic potential of Blastocystis sp. in experimental models requires further investigation. In this work, the pathogenicity of this parasite in the gastrointestinal tract of male Swiss mice was evaluated according to the inoculum size and period of infection. Animals were infected intragastrically, with 100, 500, 1,000, 5,000 and 10,000 Blastocystis sp. vacuolar forms obtained from a mixture of eight human isolates cultured axenically in Jones' medium. After seven, 14, 21, 28 and 60 days of infection, the animals were sacrificed and fragments of the small intestine (duodenum), large intestine, and cecum were subjected to histopathological analysis. Blastocystis sp. triggered an inflammatory response in the different tissues analyzed, with a predominance of mononuclear cells. The parasite was found in the muscular layer of the cecum, showing its invasive character. Larger inocula triggered inflammatory processes earlier (seven days) than smaller ones (from 21 days). We conclude that, in the proposed model, the pathogenicity of Blastocystis sp. isolates that were studied is related to inoculum size and period of infection.

PREVALENCE, RISK FACTORS AND SYMPTOMS ASSOCIATED TO INTESTINAL PARASITE INFECTIONS AMONG PATIENTS WITH GASTROINTESTINAL DISORDERS IN NAHAVAND, WESTERN IRAN

We studied the prevalence of intestinal parasites (IPs), their risk factors and associated symptoms among patients with gastrointestinal disorders. A total of 1,301 participants aged 22 days-90 years were enrolled in this study. We used a structured questionnaire to obtain socio-demographic and stool examination to investigate intestinal parasite infections. Data analysis was performed using SPSS16. The overall prevalence of intestinal parasites (IPs) was 32.2% (419/1,301). Three hundred and fifty nine cases/1,301 (27.6%) were infected with a single parasite and 60/1,301 cases (4.6%) presented polyparasitism. The most common IP was Blastocystis sp. 350/1,301 (26.9%), followed by Entamoeba coli 38/1,301 (2.92%), Giardia lamblia 30/1,301 (2.3%) and Cryptosporidium spp. 17/1,301 (1.3%). Regarding the socio-demographic variables, educational status (p = 0.001), contact with domestic animals and soil (p = 0.02), age above 15 years (p = 0.001) and seasons (p = 0.001) were significantly associated to intestinal parasitic infections. Concerning clinical characteristics, the presence of IPs was significantly associated to diarrhea (OR = 1.57; CI 95% = 1.24-1.98; p < 0.001) and dysentery (OR = 1.94; CI 95% = 1.03-3.66; p < 0.04). Our findings suggest that IPs are one of the main causal agents of gastrointestinal disorders. Improving the knowledge on local risk factors such as poverty, low level of education, poor sanitation, contact with soil and contact with domestic animal is warranted.

Lesões do trato gastrointestinal na síndrome da imunodeficiência adquirida: [title]estudo de 45 necrópsias consecutivas

Com objetivo de estudar afrequência e etiologia das lesões do tubo digestivo na Síndrome da Imunodeficiência Adquirida (AIDS), foram analisadas retrospectivamente 45 necrópsias consecutivas de pacientes adultos portadores do vírus da AIDS. Lesões macroscópicas e cortes histológicos de amostras da boca à região anal foram estudados, sendo as lâminas coradas por HE, métodos histoquímicos ou imunohistoquímicos. Trinta e sete (82,3 %)pacientes apresentaram lesões no tubo digestivo. O local mais freqüente de lesões foi a boca (73,3%), seguido do cólon (55,5%). Lesões múltiplas foram identificadas em 17 (37,7%) casos. O diagnóstico mais prevalente foi infecção pelo citomegalovírus (35,7%) identificado predominantemente no cólon. Candidíasefoi mais freqüente na boca (26,6%) e infecção herpética no esôfago (8,8%). Verificou-se leucoplasiapilosa oral em 16 (35,5%) eneoplasias emsete (15,5%). Asneoplasias incluíram quatro sarcomas de Kaposi, dois Carcinomas intramucosos anais e um linfoma gástrico. Os dados do presente estudo confirmam a importância do trato gastrointestinal como sede de alterações patológicas relacionadas à AIDS.