Alejandro Piscoya

Validation of String Test for Diagnosis of Helicobacter pylori Infections

ABSTRACT The method of recovering Helicobacter pylori DNA or viable cells absorbed on a string that a person has swallowed and that is retrieved an hour later (string test) should be a useful alternative to traditional analysis of cells or DNA obtained by endoscopy, which is invasive, uncomfortable, relatively costly, and ill-suited for community-based and pediatric studies. Here we assayed the sensitivity and validity of the string test versus conventional endoscopic biopsy for detecting and analyzing H. pylori infection. Forty-four people with gastric complaints were studied using both H. pylori culture and urease gene (ureB) PCR. H. pylori organisms cultured from strings and biopsy specimens from the same patients were fingerprinted by the randomly amplified polymorphic DNA (RAPD) method. Biopsy sections were also hematoxylin and eosin and silver stained for H. pylori detection. H. pylori was cultured from 80% of strings and detected by PCR from 91% of strings from participants whose biopsies had been H. pylori positive by culture, PCR, and/or histology. Strains recovered from strings and biopsy specimens yielded identical or closely related RAPD profiles in each of the 24 cases tested. We conclude that the string test is a useful method for H. pylori recovery and analysis when relatively noninvasive procedures are needed.

Variation in the prevalence of gastric cancer in Perú

Most cases of gastric cancers occur in non‐industrialized countries but there is scarce information about the epidemiology of this illness in these countries. Our study examined whether there was a variation in the prevalence of gastric cancer in Lima, Perú over the last 2 decades. Subjects older than 29 years of age were included. They underwent an esophagogastroduedonoscopy at 3 socioeconomically different health facilities in Lima: a county hospital (7,168 subjects), a Peruvian‐Japanese Clinic (14,794 individuals) and a private hospital (4,893 individuals). Birth cohort prevalence of gastric cancer was used. Regression models were calculated to predict the future prevalence of gastric cancer. It was found that the birth cohort prevalence of gastric cancer decreased in Perú from 22.7 to 2% (p < 0.001), from 12 to 0.5% (p < 0.001), and from 6.5 to 0.1% (p < 0.001) in the low, middle and high socioeconomic group, respectively. The prevalence of intestinal metaplasia decreased from 44.3 to 12.5% (p < 0.001), from 28.4 to 5% (p < 0.001), and from 19.4 to 2.2% (p < 0.001) in the low, middle and high socioeconomic status, respectively. These trends will likely persist over the future decades. Nevertheless, the prevalence of gastric cancer remains high in subjects older than 59 years of age in the low socioeconomic status. It is concluded that the prevalence of gastric cancer is decreasing in Perú, similar to the current trend undergoing in industrialized nations. However, there are still specific groups with high prevalence that might benefit from screening for early detection and treatment.

Aflatoxin contamination of red chili pepper from Bolivia and Peru, countries with high gallbladder cancer incidence rates.

Chilean red chili peppers contaminated with aflatoxins were reported in a previous study. If the development of gallbladder cancer (GBC) in Chile is associated with a high level of consumption of aflatoxin-contaminated red chili peppers, such peppers from other countries having a high GBC incidence rate may also be contaminated with aflatoxins. We aimed to determine whether this might be the case for red chili peppers from Bolivia and Peru. A total of 7 samples (3 from Bolivia, 4 from Peru) and 3 controls (2 from China, 1 from Japan) were evaluated. Aflatoxins were extracted with acetonitrile:water (9:1, v/v) and eluted through an immuno-affinity column. The concentrations of aflatoxins B1, B2, G1, and G2 were measured using high-performance liquid chromatography (HPLC), and then the detected aflatoxins were identified using HPLC-mass spectrometry. In some but not all of the samples from Bolivia and Peru, aflatoxin B1 or aflatoxins B1 and B2 were detected. In particular, aflatoxin B1 or total aflatoxin concentrations in a Bolivian samples were above the maximum levels for aflatoxins in spices proposed by the European Commission. Red chili peppers from Bolivia and Peru consumed by populations having high GBC incidence rates would appear to be contaminated with aflatoxins. These data suggest the possibility that a high level of consumption of aflatoxin-contaminated red chili peppers is related to the development of GBC, and the association between the two should be confirmed by a case-control study.

Giant gastroduodenal trichobezoar: Rapunzel syndrome.

To the Editor: Bezoars are non-digestible material collections located inside the gastrointestinal tract. Th e most common are phytobezoars that are of vegetable origin. Trichobezoars are caused due to ingestion of hair associated with trichotillomania. Rapunzel syndrome is characterized by a gastric trichobezoar in which the mass goes through the pylorus extending into the small bowel and sometimes even to the colon (1,2) . A 16-year-old girl came to our outpatient clinic complaining of intermittent colicky abdominal pain located at the epigastrium accompanied by nausea and vomiting. Th ese symptoms were worsening and she had also lost her appetite and had started to lose weight as the nausea and vomiting persisted. She lost 24 kg in a year. She recalled having a craving for dirt (pica) when she was 11 years old. She was married to a much older man (more than twice her age). Her examination showed a thin girl with pallor and swollen red nail beds with no bitten nails. Th ere were no areas of alopecia on her head. In the upper abdomen, we were able to feel a nontender 5 × 10 cm hard mass with regular borders that could be moved a little. On laboratory examination, we found mild anemia (hemoglobin 11 g / dl) and severe hypoalbuminemia (1.7 g / dl). A simple abdominal X-ray showed gastric distension. We performed an upper gastroduodenal endoscopy and were able to identify an extensive mass of hair, wool, and vegetables that covered the entire stomach and duodenum to as far as we could scope ( Figure 1 ). Th e patient was transferred to the surgical ward where a laparotomy was performed, extracting a giant trichobezoar that was 120 cm long ( Figure 2 ). She had an uneventful recovery and was able to start eating again without nausea or vomiting. When evaluated by the psychiatrist, she was diagnosed with major depression and discharged with medication aft er 72 h. Trichobezoars are frequent in young women usually with a psychiatric disorder. Rapunzel syndrome has been named aft er the heroine of a German fairy tale by the Grimm Brothers. Rapunzel let her long golden hair down the tower where she was imprisoned, to allow her prince lover to climb up and rescue her (3) . Th e fi rst Rapunzel syndrome case was described by Vaughan in 1968; it is quite uncommon as there are only 33 cases reported worldwide, one of them previously in Peru (4) . Th ey are formed because of the voluntary ingestion of indigestible material. Most patients present with gastrointestinal symptoms, mainly abdominal pain, distension, nausea, vomiting, or early satiety. Diagnosis is usually carried out by endoscopy and the extraction is by open surgery, although there have been some reports with laparoscopy (5) . An adequate psychiatric assessment is important to avoid its recurrence.

Development of an E-learning System for the Endoscopic Diagnosis of Early Gastric Cancer: An International Multicenter Randomized Controlled Trial

Background In many countries, gastric cancer is not diagnosed until an advanced stage. An Internet-based e-learning system to improve the ability of endoscopists to diagnose gastric cancer at an early stage was developed and was evaluated for its effectiveness. Methods The study was designed as a randomized controlled trial. After receiving a pre-test, participants were randomly allocated to either an e-learning or non-e-learning group. Only those in the e-learning group gained access to the e-learning system. Two months after the pre-test, both groups received a post-test. The primary endpoint was the difference between the two groups regarding the rate of improvement of their test results. Findings 515 endoscopists from 35 countries were assessed for eligibility, and 332 were enrolled in the study, with 166 allocated to each group. Of these, 151 participants in the e-learning group and 144 in the non-e-learning group were included in the analysis. The mean improvement rate (standard deviation) in the e-learning and non-e-learning groups was 1·24 (0·26) and 1·00 (0·16), respectively (P < 0·001). Interpretation This global study clearly demonstrated the efficacy of an e-learning system to expand knowledge and provide invaluable experience regarding the endoscopic detection of early gastric cancer (R000012039).

Chronic Diarrhea and Pancolitis Caused by Paracoccidioidomycosis: A Case Report

South American blastomycosis is a systemic micosis caused by infection with Paracoccidioides brasiliensis. The most frequently affected sites are the lower lip buccal mucous membrane, palate, tongue, sublingual region, lymph glands, and lungs. However, colonic involvement is not a common expression of Paracoccidioidomycosis. We report a case of chronic diarrhea and pancolitis caused by Paracoccidioidomycosis with fatal outcome.

Dimorphic fungal coinfection as a cause of chronic diarrhea and pancolitis.

Histoplasma capsulatum and Paracoccidioides brasiliensis are dimorphic fungi that cause systemic mycosis mostly in tropical South America and some areas of North America. Gastrointestinal involvement is not uncommon among these fungal diseases, but coinfection has not previously been reported. We report a patient with chronic diarrhea and pancolitis caused by paracoccidioidomycosis and histoplasmosis.

In response to fluid resuscitation with lactated Ringer’s solution vs. normal saline in acute pancreatitis: A triple-blind, randomized, controlled trial

We have read the article by de-Madaria et al. titled ‘‘Fluid resuscitation with lactated Ringer’s solution vs. normal saline in acute pancreatitis: A triple-blind, randomized, controlled trial,’’ and after discussing all the topics about it we have some contributions to the discussion. We agree with the investigators that a larger sample size is needed to give real results about the controversy of normal saline (NS) solution vs. lactated Ringer’s (LR) solution used in the fluid resuscitation of patients with acute pancreatitis (AP); however, we are not sure whether it would be feasible because of resource constrains. On the other hand, de-Madaria et al. mention that C-reactive protein (CRP) is a ‘‘good surrogate’’ pancreatic inflammatory marker and gave some references that have multiple issues that need to be pointed out. First of all, the references are more than a decade old and give only weak conclusions about the use of CRP. In one reference, the authors said CRP seems to be a good severity predictor only if it is in high serum concentrations and helps to differentiate mild from severe disease only at the end of the first week after the beginning of symptoms. Also, Puolakkainen et al. mentioned that the high increase in CRP was significant enough (p< 0.001) to classify the severity of the acute pancreatitis; however, as we said before, this reference is 30 years old and is probably too old to be used to sustain the application of CRP in the current study. And Mäkelä et al. support the use of CRP as an inflammatory marker for predicting intensive care unit (ICU) length of stay and hospital mortality. In this article, the investigators measured CRP before ICU admission; so, in fact, they did not use it for the clinical evolution of the disease. The last guideline from the Japanese Society of Hepato-Biliary-Pancreatic Surgery, published in 2015, did not support the use of CRP as an inflammatory marker as it did in 2006. The guideline says that CRP could be used for the prognosis of a patient’s condition only together with other severity prognostic markers such as PaO2 60mmHg, creatinine depuration 2.0mg/dl, and platelet count 100,000/mm. Some recent studies prove that the use of CRP as an inflammatory marker doesn’t have a significant positive likelihood ratio (LR) of 1.58 (using the values of sensitivity and specificity of the study cited, 100% and 36.8% each, respectively). Moreover, in the last diagnostic review by the Cochrane Collaboration, the authors explained that all the studies that were undertaken about the diagnostic development and accuracy of CRP in acute pancreatitis weren’t strong enough and more research has to be conducted in the future on the implementation of these serum inflammatory markers (most of the LRs in this review weren’t very strong or did not suggest good development). In conclusion, we do think this clinical trial is an interesting study that compares two different options for the hydration treatment of acute pancreatitis; however, the employment of CRP might be not so accurate as a good surrogate maker for AP during the study.

Pseudotumor inflamatorio por Fasciola hepática: a propósito de un caso

Resumen Fasciola hepatica es un parasito de la clase Trema-toda comun en paises en desarrollo. La infeccion en el ser humano se caracteriza por la triada de fiebre, dolor abdominal en el cuadrante superior derecho y eosinofilia. Se presenta el caso de una mujer de 67 anos procedente de una zona rural al norte de Lima, con historia de dolor abdominal de seis meses de evolucion, con una imagen hipodensa hepatica en el TAC abdominal y eosinofilia. La biopsia hepatica mostro un infiltrado inflamatorio con eosinofilia. En el diagnostico diferencial en pacientes con un tumor hepatico y eosinofilia, se deben incluir infecciones parasitarias como F. hepatica ; sobre todo en pacientes que proceden de areas endemicas. Referencias bibliograficas 1.- Marcos L A, Terashima A, Gotuzzo E. Update on hepatobiliary flukes: fascioliasis, opisthorchiasis and clonorchiasis. Curr Opin Infect Dis 2008; 21: 523-30.2.- Yilmaz B, Koklu S, Gedikoglu G. Hepatic mass caused by Fasciola hepatica : a tricky differential diagnosis. Am J Trop Med Hyg 2013; 89: 1212-3.3.- Muro A, Perez del Villar L, Velasco V, Perez-Arellano J L. Infecciones por trematodos. Medicine 2010; 10: 3717-28.4.- Loja Oropeza D, Alvizuri Escobedo J, Vilca Vasquez M, Aviles Gonzaga R, Sanchez Mercado M. Hematoma hepatico subcapsular por fascioliasis. Rev Gastroenterol Peru 2003; 23: 142-8.5.- Marcos L A, Tagle M, Terashima A, Bussalleu A, Ramirez C, Carrasco C, et al. Natural history, clinicoradiologic correlates, and response to triclabendazole in acute massive fascioliasis. Am J Trop Med Hyg 2008; 78: 222-7.6.- Fica A, Dabanch J, Farias C, Castro M, Jercic M I, Weitzel T. Acute fascioliasis- clinical and epidemiological features of four patients in Chile. Clin Microbiol Infect 2012; 18: 91-6.7.- Espinoza J R, Terashima A, Herrera-Velit P, Marcos L A. Fasciolosis humana y animal en el Peru: impacto en la economia de las zonas endemicas. Rev Peru Med Exp Salud Publica. 2010; 27: 604-12.8.- Venkatesh S K, Chandan V, Roberts L R. Liver masses: a clinical, radiologic, and pathologic perspective. Clin Gastroenterol Hepatol 2014; 12: 1414-29.9.- Castillo Contreras O B, Frisancho Velarde O. Pseudotumor hepatico en fasciolosis aguda. Acta Gastroenterol Latinoam 2013; 43: 53-8.10.- Sapunar J, Braghetto I, Diaz J C, Brahm J, Apt W, Carreno L, et al. Fascioliasis hepatica que simularon tumores hepaticos. Bol Chil Parasitol 2001; 57 (3-4): 59-65.11.- Aksoy D Y, Kerimoglu U, Oto A, Erguven S, Arslan S, Unal S, et al.

Early Prevention and Screening of Cervical Cancer in a Developing Country

We have read with much interest an article recently published by Ekwueme et al. about the impact of the National Breast and Cervical Cancer Early Detection Program on cervical cancer mortality among uninsured low-income women in the U.S. Cervical cancer is a relevant issue in Peru, owing to its high incidence and mortality rate when compared with other countries. Despite being a fully preventable cancer with a clearly known pathogen, its early prevention and detection remains a problem in Peru, which is worsened by poverty conditions and inadequate access to health care, as well as unequal distribution of health workers among the country’s different regions. Cervical cancer has the second highest incidence and mortality rates of all cancers among women of all ages in Latin America. Peru has a population of 10.87 million women aged Z15 years who are at risk of developing cervical cancer. An epidemiologic cancer surveillance program reported 109,914 cases in the 2006–2011 period, during which cervical cancer was the most common cancer among women (24.1%). Of all the reported cases of cervical cancer, only 5.6% were diagnosed through an early detection program, a troubling finding that showcases the need for better screening coverage. Although the percentage of cervical cancer cases diagnosed through early detection has shown an incremental increase in recent years, from 3.7% in 2006 to 6.8% in 2011, the number remains unsatisfactory, and it is clear that there is a long road ahead until satisfactory cervical cancer prevention results such as those reported by Ekwueme et al. are achieved in Peru. Differences in the healthcare systems could be one explanation as to why screening methods have not yet shown results as promising as those in other countries. The authors recommend that more studies be conducted regarding prevention of cervical cancer in developing countries so that strategies may be undertaken to improve screening coverage and reduce its incidence and mortality.