Therapeutic option for children with esophageal caustic stenosis

Caustic ingestion is a leading cause of esophageal stenosis in children. Herein we report four cases using mitomycin C (MMC), a drug that inhibits cell division, protein synthesis and fibroblast proliferation and has been used as an adjuvant therapy for caustic esophageal stenosis that is recalcitrant to conventional dilation techniques. A retrospective chart review was performed on four pediatric patients with severe, recurrent esophageal stricture after caustic ingestion. The patients had required six to 20 esophageal dilations over a 4-16-month period before MMC application. MMC was applied after an endoscopic dilation on saturated pledgets at a dose of 0.1 mg/mL for 2 min in the area where the strictures had been lyzed. From the four children treated with MMC, two have been asymptomatic for 16 and 20 months and two still require esophageal dilation, however, at longer intervals. All patients have shown satisfactory weight gain with food intake exclusively per oral. Although further studies are required, there is strong evidence that MMC is a safe and effective adjuvant therapy in the treatment of esophageal caustic stenosis. © 2008 The Authors.

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

Avaliação dos parâmetros salivares de pacientes portadores da doença do refluxo gastroesofágico antes e após tratamento cirúrgico

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Estudos imuno-histoquímico das proteínas p53, p16, Fhit, caspase 3 e antígeno Ki67 ; e citogenético molecular em lesões benignas e carcinoma de esôfago

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Achados histopatológicos gástricos em crianças e adolescentes brasileiros com dispepsia e infecção por Helicobacter pylori

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Resultados da cirurgia bariátrica e metabólica: gastrectomia vertical versus gastroplastia vertical com derivação em Y-de-Roux. Ensaio clínico prospectivo

Objetivos: Avaliar a equivalência da operação gastrectomia vertical com anel (GVA), em relação à operação gastroplastia vertical com anel e derivação gástrica em Y-de-Roux (DGA), na indução de perda ponderal e modificação da composição corporal em obesas mórbidas. Verificar os impactos laboratoriais e clínicos da GVA sobre as principais doenças associadas à obesidade mórbida, e a ocorrência de complicações, em comparação à DGA. Métodos: Ensaio clínico prospectivo não-randomizado, incluindo 65 mulheres obesas mórbidas, distribuídas em dois grupos, GVA (n = 33) e DGA (n = 32). Operadas consecutivamente, pelo mesmo cirurgião, por via laparotômica. Os parâmetros avaliados foram antropométricos; composição corporal, por meio de bioimpedância elétrica; laboratoriais; efeitos sobre as doenças pré-existentes e complicações. Resultados: Ocorreu perda de peso expressiva (p = 0,0000), redução do índice de massa corporal - IMC (p = 0,0000) e cintura abdominal (p = 0,0000) em ambos grupos. O índice cintura/quadril diminuiu (p = 0,0000) após ambas intervenções. A perda do excesso de IMC foi de 86,05% ± 14,2 no grupo GVA e 85,91 ± 15,71 no grupo DGA. A variação da gordura corporal foi de -35,84% ± 8,66 no grupo GVA e de -37,64% ± 9,62 no grupo DGA. A redução dos níveis de triglicerídios (p = 0,0222) foi mais expressiva no grupo DGA. O grupo DGA atingiu os alvos terapêuticos para o colesterol-LDL com maior freqüência (p = 0,0005), que o grupo GVA. Intolerância à glicose, diabetes mellitus tipo 2, hipertensão arterial sistêmica, esteatose hepática e síndrome metabólica, foram controladas de forma semelhante entre as técnicas. Anemia foi mais prevalente no grupo DGA (p=0,0033) e a esofagite erosiva, no grupo GVA (p = 0,0032). Não houve diferença na formação de cálculos biliares entre os grupos. Conclusões: A GVA é tão efetiva quanto a DGA em induzir perda ponderal e modificação favorável da composição corporal. A GVA é menos efetiva no controle da dislipidemia, em relação à DGA. GVA acarreta anemia em menor freqüência e, esofagite erosiva de maneira mais freqüente, que a DGA. GVA não é mais segura que a DGA, mas deve ser considerada intervenção bariátrica efetiva como segunda opção.

Severe esophageal injuries occurring after general anesthesia in two cats: case report and literature review

Two healthy cats underwent elective surgical procedures under general anesthesia. One developed severe esophagitis leading to esophageal rupture, mediastinitis, and pyothorax. The other cat developed esophageal stricture, diverticulum formation, and suspected iatrogenic perforation. Both cats had signs of dysphagia and regurgitation beginning a few days after anesthesia. The first cat also had severe dyspnea due to septic pleural effusion and pneumomediastinum. In the second cat, endoscopy revealed diffuse esophagitis, an esophageal stricture, and a large esophageal diverticulum. Rupture of the esophageal wall occurred while inflating the esophagus for inspection. Due to the poor prognosis, both cats were euthanized. Necropsy revealed severe esophageal changes. Postanesthetic esophagitis has been previously described in dogs and cats; however, severe life-threatening esophageal injuries rarely occur as a sequel to general anesthesia. To the authors' knowledge, esophageal rupture secondary to perianesthetic reflux has never been reported in cats.

Eosinophils in the gastrointestinal tract: friends or foes?

Eosinophils play an important role in the mucosal immune system of the gastrointestinal tract under resting and under inflammatory conditions. Under steady-state conditions, the mucosa of the digestive tract is the only organ harboring a substantial number of eosinophils, which, if need be, get activated and exert several effector and immunoregulatory functions. The precise function of these late-phase inflammatory cells is not yet completely understood. Nevertheless, it has recently been demonstrated that lipopolysaccharides from gram-negative bacteria activate eosinophils to rapidly release mitochondrial DNA in the extracellular space. Released mitochondrial DNA and eosinophil granule proteins form extracellular structures able to bind and inactivate bacteria. These findings suggest a novel mechanism of eosinophil-mediated innate immune responses that might be important in maintaining the intestinal barrier function. Moreover, eosinophils also play a crucial role in several inflammatory conditions, such as intestinal infections, immune-mediated inflammations and hypersensitivity reactions. Under chronic inflammatory conditions, the ability of the eosinophils to induce repair can lead to pathological sequelae in the tissue, such as esophageal remodeling in eosinophilic esophagitis. It is established that the uncontrolled eosinophilic inflammation induces fibrosis, esophageal wall thickening and strictures leading to damage that results in a loss of esophageal function. One potential mechanism of this remodeling is so-called 'epithelial mesenchymal transition', which is triggered by eosinophils and is potentially reversible under successful anti-eosinophil treatment. Therefore, eosinophils may act either as friends or as foes, depending on the microenvironment.

[Anti-interleukin-5 therapy for eosinophilic diseases]

In a number of diseases with eosinophilia, elevated interleukin (IL)-5 levels are detected in the peripheral blood and/or tissues. IL-5 plays an important role in regulating the production, differentiation, recruitment, activation, and survival of eosinophils. Therefore, neutralizing IL-5 by blocking antibodies seems a promising approach in the treatment of eosinophilic diseases. Clinical trials have demonstrated that anti-IL-5 therapy results in a rapid decrease in peripheral blood eosinophil numbers. Moreover, improvement of symptoms in patients with lymphocytic variants of hypereosinophilic syndromes, in eosinophilic esophagitis and chronic rhinitis with nasal polyposis has been observed. In contrast, in patients with bronchial asthma or atopic eczema, anti-IL-5 therapy showed only moderate or no clinical effects. Future studies will have to identify those eosinophilic diseases in which anti-IL-5 antibodies are effective, perhaps with the help of newly developed biomarkers.

Dysphagia due to triple A syndrome: successful treatment of achalasia by balloon dilatation

Triple A syndrome is a rare autosomal recessive inherited disorder which is characterized by alacrima, adrenal insufficiency, and achalasia. We report on a 14-year old girl with dysphagia, regurgitation, and vomiting since 5 years. At the age of five years an Addison crisis was diagnosed and cortisone substitution was initiated. In addition, the patient had episodes of conjunctivitis. Severe esophagitis and candida infection were diagnosed by esophago-gastro-duodenoscopy and treated with omeprazole and fluconazole. The esophageal barium swallow was typical for achalasia. Medical treatment of achalasia with oral nifedipine resulted only in a partial and temporal improvement. But after seven balloon dilatations dysphagia and nocturnal coughing improved clearly and a remarkable gain of weight could be seen. Direct sequencing showed a homozygous nonsense mutation in exon 11 of the AAAS gene leading to truncation at position 342 of the 546 amino acid protein. CONCLUSION: Triple A syndrome has to be considered in patients with dysphagia. In our patient, the absence of tears since birth followed by adrenal insufficiency were early signs of the triple A syndrome. Balloon dilatation of the esophago-gastric junction is an effective treatment, which can avoid surgical interventions.

[Odynophagia of a young mother]

We report the case of a 34-year old mother presenting in the emergency unit because of fever and odynophagia. Herpetic esophagitis with Herpes simplex virus primoinfection in a immunocompetent patient was diagnosed. The virus was transmitted by her own child which came to be hospitalised because of herpetic stomatitis. In the blood chemistry pancreas enzymes were elevated which we interpreted as herpetic pancreatitis because of coincidence with herpetic esophagitis.

Epidemic of Salmonellosis in Passerine Birds in Switzerland With Spillover to Domestic Cats

A die-off of passerine birds, mostly Eurasian siskins (Carduelis spinus), occurred in multiple areas of Switzerland between February and March 2010. Several of the dead birds were submitted for full necropsy. Bacteriological examination was carried out on multiple tissues of each bird. At gross examination, common findings were light-tan nodules, 1 to 4 mm in diameter, scattered through the esophagus/crop. Histologically, a necroulcerative transmural esophagitis/ingluvitis was observed. Bacterial cultures yielded Salmonella enterica subsp. enterica serovar Typhimurium. At the same time, 2 pet clinics reported an unusual increase of domestic cats presented with fever, anorexia, occasionally dolent abdomen, and history of presumed consumption of passerine birds. Analysis of rectal swabs revealed the presence of S. Typhimurium in all tested cats. PFGE (pulsed field electrophoresis) analysis was performed to characterize and compare the bacterial isolates, and it revealed an indistinguishable pattern between all the avian and all but 1 of the feline isolates. Cloacal swabs collected from clinically healthy migrating Eurasian siskins (during autumn 2010) did not yield S. Typhimurium. The histological and bacteriological findings were consistent with a systemic infection caused by S. Typhimurium. Isolation of the same serovar from the dead birds and ill cats, along with the overlapping results of the PFGE analysis for all the animal species, confirmed a spillover from birds to cats through predation. The sudden increase of the number of siskins over the Swiss territory and their persistency during the whole winter of 2009-2010 is considered the most likely predisposing factor for the onset of the epidemic.

Prevalence of gastro esophageal reflux disease following the Montreal Consensus and its association with Helicobacter pylori infection and obesity in a random sample of adults of Ciudad Juarez, Mexico, 2004.

Gastroesophageal reflux disease is a common condition affecting 25 to 40% of the population and causes significant morbidity in the U.S., accounting for at least 9 million office visits to physicians with estimated annual costs of $10 billion. Previous research has not clearly established whether infection with Helicobacter pylori, a known cause of peptic ulcer, atrophic gastritis and non cardia adenocarcinoma of the stomach, is associated with gastroesophageal reflux disease. This study is a secondary analysis of data collected in a cross-sectional study of a random sample of adult residents of Ciudad Juarez, Mexico, that was conducted in 2004 (Prevalence and Determinants of Chronic Atrophic Gastritis Study or CAG study, Dr. Victor M. Cardenas, Principal Investigator). In this study, the presence of gastroesophageal reflux disease was based on responses to the previously validated Spanish Language Dyspepsia Questionnaire. Responses to this questionnaire indicating the presence of gastroesophageal reflux symptoms and disease were compared with the presence of H. pylori infection as measured by culture, histology and rapid urease test, and with findings of upper endoscopy (i.e., hiatus hernia and erosive and atrophic esophagitis). The prevalence ratio was calculated using bivariate, stratified and multivariate negative binomial logistic regression analyses in order to assess the relation between active H. pylori infection and the prevalence of gastroesophageal reflux typical syndrome and disease, while controlling for known risk factors of gastroesophageal reflux disease such as obesity. In a random sample of 174 adults 48 (27.6%) of the study participants had typical reflux syndrome and only 5% (or 9/174) had gastroesophageal reflux disease per se according to the Montreal consensus, which defines reflux syndromes and disease based on whether the symptoms are perceived as troublesome by the subject. There was no association between H. pylori infection and typical reflux syndrome or gastroesophageal reflux disease. However, we found that in this Northern Mexican population, there was a moderate association (Prevalence Ratio=2.5; 95% CI=1.3, 4.7) between obesity (≥30 kg/m2) and typical reflux syndrome. Management and prevention of obesity will significantly curb the growing numbers of persons affected by gastroesophageal reflux symptoms and disease in Northern Mexico. ^

Role of {\it Mycobacterium avium-intracellulare\/} complex infection in AIDS mortality

Disseminated MAC (dMAC) is the third most prevalent opportunistic infection in AIDS patients. In order to understand the role MAC infection plays in affecting survival of AIDS patients, a cohort of 203 suspected dMAC veterans seen at the Houston Veterans Affairs Medical Center between August 14, 1987 and December 31, 1991 were analyzed. The criteria for suspected dMAC infection was HIV+ men having a CD4+ level $\le$200 cells/mm$\sp3,$ on zidovudine treatment $\ge$1 month and who had any of the following: (a) a confirmed respiratory MAC infection, (b) fever $\ge$101$\sp\circ\rm F$ for $\ge$48 hours, (c) unexplained weight loss of 10 lbs or $\ge$10% BW over 3 months or (d) Hgb $\le$7.5 g/dl or decrease in Hgb $\ge$3.0 g/dl, while on 500-600 mg/day AZT. The study was conducted before the commencement of an effective MAC anti-mycobacterial therapy, so the true course of MAC infection was seen without the confounder of a therapeutic regimen. Kaplan-Meier and Cox regression survival analysis was used to compare 45 MAC culture positive and 118 MAC culture negative veterans. The 1 year survival rate of veterans with documented dMAC infection was 0.37 compared to 0.50 for veterans not acquiring dMAC infection. Significant differences between subgroups were also seen with the variables: PCP prophylaxis, the AIDS indicator disease Candida esophagitis, CD4+ lymphocyte level, CD4 percent lymphocyte level, WBC level, Hgb and Hct levels. Using multivariate modeling, it was determined that PCP prophylaxis (RR = 6.12, CI 2.24-16.68) was a predictor of survival and both CD4% lymphocytes $\le$6.0% (RR = 0.33, CI 0.17-0.68) and WBC level $\le$3000 cells/mm$\sp3$ (RR = 0.60, CI 0.39-0.93) were predictors of mortality. CD4+ level $\le$50 cells/mm$\sp3$ was not a significant predictor of mortality. Although MAC culture status was a significant predictor of mortality in the univariate model, a positive dMAC culture was not a significant predictor of AIDS mortality in the multivariate model. A positive dMAC culture, however, did affect mortality in a stratified analysis when baseline laboratory values were: CD8+ lymphocytes $>$600 cells/mm$\sp3,$ Hgb $>$11.0 g/dl, Hct $>$31.0% and WBC level $>$3000 cells/mm$\sp3.$ ^

Pólipos hiperplásicos da junção gastro-esofágica em idade pediátrica

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014