Diagnostic approach to eosinophilic oesophagitis: Pearls and pitfalls.

Eosinophilic oesophagitis (EoE) has first been described a little over 20 years ago. EoE has been defined by a panel of international experts as a "chronic, immune/antigen-mediated, oesophageal disease, characterized clinically by symptoms related to oesophageal dysfunction and histologically by eosinophil-predominant inflammation". A value of ≥ 15 eosinophils has been defined as histologic diagnostic cutoff. Other conditions associated with oesophageal eosinophilia, such as gastro-oesophageal reflux disease (GERD), PPI-responsive oesophageal eosinophilia, or Crohn's disease should be excluded before EoE can be diagnosed. This review highlights the latest insights regarding the diagnosis and differential diagnosis of EoE.

Esôfago de barrett após gastrectomia total com reconstrução em Y de roux

Reflux esophagitis and Barrett's esophagus after total gastrectomy is related to reconstructive procedure of intestinal continuity. The Roux-en-Y operation with length of limb of 40 cm occasionally is not enough to prevent biliary reflux to distal esophagus. Barrett's esophagus is thought to develop as a consequence of biliary reflux and has a malignant potential. Symptoms of retroesternal burning and dysphagia that does not improve with conservative management has to be treated by an operative procedure. To prevent biliary reflux to distal esophagus after total gastrectomy the lenght of limb of Roux-en-Y should be at lest 60 cm.

Effect of the celexoxib in microscopic changes of the esophageal mucosal of rats induced by esofagojejunostomy

OBJECTIVE: To evaluate the protective effect of celecoxib in the esophageal mucosa in rats undergoing esofagojejunostomy.METHODS: Sixty male Wistar rats from the vivarium of the University of Health Sciences of Alagoas were used for the experiment. The animals were divided into four groups: Group I, 15 rats undergoing esofagojejunostomy with the use of celecoxib postoperatively; Group II, 15 rats undergoing esofagojejunostomy without the use of celecoxib; Group III, 15 rats undergoing celiotomy with bowel manipulation; and Group IV, 15 rats without surgery and using celecoxib. The observation period was 90 days. After the death of the animals, the distal segment of the esophagus was resected and sent for microscopic analysis.RESULTS: esofagojejunostomy caused macroscopic and microscopic esophagitis. Esophagitis was equal in both groups I and II. In groups III and IV esophageal lesions were not developed.CONCLUSIONS: celecoxib had neither protective nor inducing effect on esophagitis, but had a protective effect on dysplasia of the animals of group I.

Esophagectomy with gastroplasty in advanced megaesophagus: late results of omeprazole use

Objective: To analyze the late results of advanced Chagasic megaesophagus treatment by esophagectomy associated with the use of proton pump inhibitor (omeprazole) as for the incidence of esophagitis and Barrett's esophagus in the remaining stump. Methods : We studied patients with advanced megaesophagus undergoing esophagectomy and transmediastinal esophagogastroplasty. Patients were divided into three groups: A (20) with esophageal replacement by full stomach, without the use of omeprazole; B (20) with esophageal replacement by full stomach, with omeprazole 40 mg/day introduced after the first postoperative endoscopy and maintained for six years; and C (30) with esophageal replacement by gastric tube with use of omeprazole. Dysphagia, weight loss and BMI were clinical parameters we analyzed. Upper gastrointestinal endoscopy was performed in all patients, and determined the height of the anastomosis, the aspect of the mucosa, with special attention to possible injuries arising from gastroesophageal reflux, and the patency of the esophagogastric anastomosis. Results : We studied 50 patients, 28 males (56%) and 22 (44%) females. All underwent endoscopy every year. In the first endoscopy, erosive esophagitis was present in nine patients (18%) and Barrett's esophagus, in four (8%); in the last endoscopy, erosive esophagitis was present in five patients (8%) and Barrett's esophagus in one (2%). When comparing groups B and C, there was no evidence that the manufacturing of a gastric tube reduced esophagitis and Barrett's esophagus. However, when comparing groups A and C, omeprazole use was correlated with reduction of reflux complications such as esophagitis and Barrett's esophagus (p <0.005). Conclusion : The use of omeprazole (40 mg/day) reduced the onset of erosive esophagitis and Barrett's esophagus during the late postoperative period.

Contracaecum pelagicum and C. plagiaticium (Nematoda: Anisakidae) infection in Magellanic penguins (Sphenisciformes: Spheniscidae) on the coast of Rio de Janeiro State

The occurrence of infections and the disease induced by Contracaecum plagiaticium and Contracaecum pelagicum in Magellanic penguins, Spheniscus magellanicus Foster. 1781 (Sphenisciformes: Spheniscidae) were reported on the coast of Rio de Janeiro. Parasites of the genus Contracaecum were present in all of the 11 studied animals. Co-infections by Csontracaecum pelagicum and C. plagiaticium were observed in three hosts (27.27%). Gross lesions included hyperemia of the esophagus and/or stomach in six animals (54.54%). One of these animals (9.09%), parasitized by C. plagiaticium, presented a hemorrhagic area in the gastric mucosa. Histopathological findings demonstrated esophagitis with helminthes segments inserted in the epithelium, showing discrete mixed inflammatory infiltrate of heterophils and mononuclear cells. These parasites may be associated with other diseases, implicating in death of the penguins.

Esophageal striated muscle contractions in patients with Chagas' disease and idiopathic achalasia

Chagas' disease causes degeneration and reduction of the number of intrinsic neurons of the esophageal myenteric plexus, with consequent absent or partial lower esophageal sphincter relaxation and loss of peristalsis in the esophageal body. The impairment of esophageal motility is seen mainly in the distal smooth muscle region. There is no study about esophageal striated muscle contractions in the disease. In 81 patients with heartburn (44 with esophagitis) taken as controls, 51 patients with Chagas' disease (21 with esophageal dilatation) and 18 patients with idiopathic achalasia (11 with esophageal dilatation) we studied the amplitude, duration and area under the curve of esophageal proximal contractions. Using the manometric method and a continuous perfusion system we measured the esophageal striated muscle contractions 2 to 3 cm below the upper esophageal sphincter after swallows of a 5-ml bolus of water. There was no significant difference in striated muscle contractions between patients with heartburn and esophagitis and patients with heartburn without esophagitis. There was also no significant difference between patients with heartburn younger or older than 50 years or between men and women or in esophageal striated muscle contractions between patients with heartburn and Chagas' disease. The esophageal proximal amplitude of contractions was lower in patients with idiopathic achalasia than in patients with heartburn. In patients with Chagas' disease there was no significant difference between patients with esophageal dilatation and patients with normal esophageal diameter. Esophageal striated muscle contractions in patients with Chagas' disease have the same amplitude and duration as seen in patients with heartburn. Patients with idiopathic achalasia have a lower amplitude of contraction than patients with heartburn.

A functional study of caustic strictures of the esophagus in children

The objective of the present study was to assess esophageal motor function in 21 children (7.5 ± 2.9 years) with caustic strictures. Esophageal manometry was performed using a water-infusion system interfaced with a polygraph and displayed on a computer screen. The data were compared with those obtained from 9 healthy children. Radionuclide transit was determined by studying deglutition of a single bolus of 99mTc pertechnetate in 10 ml of water. Non-peristaltic low-amplitude and long-duration waves were the most common findings detected in patients with strictures longer than 20% of esophageal length (N = 11). Compared with the control group, these patients presented lower mean amplitude and longer mean duration of waves (24.4 ± 11.2 vs 97.9 ± 23.7 mmHg, P < 0.05, and 6.7 ± 2.4 vs 1.6 ± 0.1 s, P < 0.05, respectively). Six patients presented low-amplitude waves just below the constricted site. Ten children presented delayed esophageal transit. There was an association between dysphagia and abnormalities on manometry (P = 0.02) and between symptoms and scintigraphy data (P = 0.01). Dysphagia in caustic strictures is due to esophageal motility abnormalities, which are closely related to the scarred segment.

Primary and secondary esophageal contractions in patients with gastroesophageal reflux disease

We studied the primary and secondary esophageal peristalsis in 36 patients with heartburn and acid regurgitation and in 14 asymptomatic volunteers. Primary peristalsis was elicited by ten swallows of a 5-mL bolus of water and secondary peristalsis was elicited by intra-esophageal infusion of 5, 10, and 15 mL water, 0.1 N hydrochloric acid and air. Esophageal contractions were measured by an 8-lumen manometric catheter assembly incorporating a 6-cm sleeve device. Contractions were registered at 3, 9, and 15 cm from the upper margin of the sleeve and the infusion was done through a side hole located at 12 cm. Twenty patients had normal endoscopic esophageal examination, 10 with normal (group I) and 10 with abnormal pH-metric examination (group II), and 16 had esophagitis (group III). The amplitude of contractions after swallows was lower (97.8 ± 10.0 mmHg) in the distal esophagus of group III patients than in controls (142.3 ± 14.0 mmHg). Patients of group III had fewer secondary contractions (water: 25% of infusion) than patients of the other groups and controls (67% of infusion). Patients of group III also had a lower amplitude of secondary peristalsis in the distal esophagus (water: 70.1 ± 9.6 mmHg) than controls (129.2 ± 18.2 mmHg). We conclude that patients with esophagitis have an impairment of primary and secondary peristalsis in the distal esophagus.

Facteurs génétiques de prédisposition à la maladie coeliaque et l'oesophagite éosinophilique

Les maladies immunitaires chroniques incluant les maladies auto-immunes et inflammatoires touchent 20 à 25% de la population des pays occidentaux. La comparaison des taux de concordance chez les jumeaux ou l’histoire familiale de sujets atteints de la maladie cœliaque (maladie auto-immune de l’intestin) ou de l’œsophagite éosinophilique (maladie inflammatoire de l’œsophage) indiquent que des facteurs génétiques et environnementaux interviennent dans la susceptibilité à ces maladies. Cependant, ces études ne distinguent pas de manière claire la prédisposition génétique selon l’hétérogénéité clinique (enfants versus adultes) ou ethnique (stratification des populations). Méthodes. Les haplotypes HLA de prédisposition à la maladie cœliaque et les polymorphismes des gènes candidats IL-13 (R130Q), IL-5 (-746 T/G) et IL-5R (-80A/G) impliqués dans la physiopathologie de l’œsophagite éosinophilique, ont été caractérisés par la technique PCR-SSP sur l’ADN génomique. Résultats: Nos études familiales et cas-contrôles réalisées chez une population Québécoises avec un fond génétique très homogène nous a permis : i) d’éviter le problème de stratification des populations, ii) de confirmer que les gènes HLA sont également associés à la maladie cœliaque (enfants et adultes) au Québec comme dans les autres populations Caucasiennes, iii) de mettre en évidence le rôle du gène IL-13 dans la prédisposition à l’œsophagite éosinophilique (garçons et filles) et d’exclure les gènes IL-5 et IL-5R comme facteurs de susceptibilité dans notre population. Conclusion: Ce travail confirme pour la première fois l’impact des gènes HLA dans la prédisposition à la maladie cœliaque et le rôle du facteur génétique dans l’œsophagite éosinophilique chez une population Canadienne Française avec un fond génétique ayant un fort effet fondateur.

Ethanol elicits and potentiates nociceptor responses via the vanilloid receptor-1

The vanilloid receptor-1 (VR1) is a heat-gated ion channel that is responsible for the burning sensation elicited by capsaicin. A similar sensation is reported by patients with esophagitis when they consume alcoholic beverages or are administered alcohol by injection as a medical treatment. We report here that ethanol activates primary sensory neurons, resulting in neuropeptide release or plasma extravasation in the esophagus, spinal cord or skin. Sensory neurons from trigeminal or dorsal root ganglia as well as VR1-expressing HEK293 cells responded to ethanol in a concentration-dependent and capsazepine-sensitive fashion. Ethanol potentiated the response of VR1 to capsaicin, protons and heat and lowered the threshold for heat activation of VR1 from approximately 42 degrees C to approximately 34 degrees C. This provides a likely mechanistic explanation for the ethanol-induced sensory responses that occur at body temperature and for the sensitivity of inflamed tissues to ethanol, such as might be found in esophagitis, neuralgia or wounds.

Total gastrectomy with substitution of stomach by jejunal pouch with and without duodenal passage. Study in rats

A comparison was done between the F. Paulino jejunal pouch (FP) and a jejunal pouch (JP) as esophagusduodenum interpositional graft, for replacing the stomach after total gastrectomy. It was investigated the effect of the two procedures on esophagus histology, nutritional state and serum gastrin in rats. Methods: Male Wistar rats weighing 282±17g were randomly submitted to sham operation (S), FP and JP after total gastrectomy. After eight weeks the rats were killed with overdose of anesthetic and tissue was taken from the distal esophagus for histology. Serum levels of total proteins, albumin, iron, transferring, folate, cobalamine, calcium, as well as serum gastrin were determined. Survival was considered. Results: Fourty six rats were operated and thirty survived for eight weeks. Five (33.3%) died after FP and 11 (52.3%) after JP (p<0.05). Postoperative esophagitis occurred in 6 JP rats. At 8th week, no difference was observed on body weight when compared FP and JP rats (p>0.05). The JP rats had a significant decrease in serum albumin, glucose, transferrin, iron, folate and calcium, compared to sham (p<0.05). Serum gastrin, iron and calcium were significantly higher in JP rats than in FP rats (p<0.05). In FP rats, transferrin and cobalamine showed significant decrease comparing the preoperative with 8th week levels (p<0.05). Conclusion: F. Paulino pouch in rats had lower mortality than JP, and esophagitis was not detected in it. JP rats had serum gastrin, iron and calcium unaffected, possibly because of preservation of duodenal passage

Upper gastrointestinal histopathological findings in children and adolescents with nonulcer dyspepsia with helicobacter pylori infection

Objectives: The aim of the study was to investigate the histopathological lesions in the upper gastrointestinal mucosa associated with Helicobacter pylori infection in children with nonulcer dyspepsia.Methods: A cross-sectional case-control study was performed on 185 Brazilian children and adolescents (4-17 years, mean 9.5 +/- 2.7 years), 63.2% girls, submitted to upper gastrointestinal endoscopy. The histopathological lesions of the esophageal and gastric mucosa were analyzed in biopsy samples.Results: H pylori infection was identified in 96 children (51.8%). Moderate to severe chronic active gastritis was present in antrum (70.5%) and corpus (45.2%), with higher grading in antrum than in corpus (P<0.05). The topographic distribution of inflammation was pangastritis (61.9%), followed by antral (32.1%) and corpus (5.9%). H pylori density was higher in antrum than in corpus. Intestinal metaplasia was not found in the H pylori-infected group, nor was significant gastric atrophy. The scores for esophagitis were significantly higher (P<0.05) in the noninfected group (1.4 +/- 0.8) than in the H pylori-infected group (1.07 +/- 0.9), with significant negative correlation (r = 0.29; P<0.05) with the scores of gastric inflammation.Conclusions: The prevalence of H pylori infection was high among children with dyspepsia and associated with moderate/severe degrees of gastric inflammation. The high scores of esophagitis in the noninfected group point to 2 distinct groups of pathological conditions sharing similar clinical patterns.

Estudo de alterações na cavidade oral em pacientes com doença do refluxo gastroesofágico

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Esophageal and gastric biopsies in symptomatic children and adolescents. Should both be performed?

This study investigated the relationship among the histological diagnosis of esophagitis and gastritis in children and adolescents with gastroesophageal reflux disease (GERD) and/or dyspepsia. Records of 366 patients submitted to endoscopic biopsies were reviewed. Two groups were analyzed: G1 n=258 with esophageal and gastric biopsies, G2 n=108 with gastric biopsies only. For total subjects median age (range) was 8.5y (2mo-19.9y). Helicobacter pylori infection was detected in 30.6 %, median age 12.5y for H pylori-infected and 5.5y for uninfected children. Histological esophagitis was found in 216/258 (83.7 %) and gastritis in 95/258 (36.8 %) of G1. Both biopsies were normal for 13.6 % cases. Normal gastric biopsies were associated with esophagitis in 128/ 163 (78.5 %) of G1, but gastritis was associated with normal esophageal biopsies in only 7/95 (7.4 %) (0<.001). Histological gastritis was found in 80/108 (74.1 %) of G2 patients. Therefore, for symptomatic children both biopsies are indicated.

Expression of Ki-67 Antigen and Caspase-3 Protein in Benign Lesions and Esophageal Carcinoma

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)