Carlos Robles-Medranda

Endoscopic treatment of gastroesophageal varices in young infants with cyanoacrylate glue: a pilot study

BACKGROUNDnIn children, endoscopic sclerotherapy and variceal ligation (EVL) are the most used techniques for the treatment of gastroesophageal variceal bleeding (VB). However, these techniques achieve poor results in cases of gastric variceal bleeding, and EVL is not applicable in young infants.nnnOBJECTIVEnOur purpose was to evaluate the feasibility, efficacy, and safety of cyanoacrylate glue injection for the treatment of gastroesophageal varices in young infants.nnnDESIGNnSingle-center prospective study.nnnPATIENTSnFrom 2001 to 2005, 8 young infants (<or=2 years old, <or=10 kg) with portal hypertension and gastroesophageal varices underwent treatment with N-butyl-2-cyanoacrylate.nnnMAIN OUTCOME MEASUREMENTSnDemographic data and the results were registered and analyzed at 1, 6, and 12 months after treatment.nnnRESULTSnThe mean age and weight were 1.3 +/- 0.42 years (range 0.8 to 1.9 years) and 8.5 +/- 1.6 kg (range 5.5 to 10 kg). Glue injection was successfully performed in all infants. The mean volume injected was 1.15 +/- 0.62 mL (range 0.5 to 2 mL). Immediate control of bleeding was achieved in all cases. Ulcer bleeding as a complication was observed in 1 case. Varices relapse with bleeding was observed in 3 of 8 (37.5%) patients after a mean of 12.5 +/- 10.6 weeks (range 5 to 20 weeks). Patients with variceal rebleeding were retreated. Varices eradication was achieved in all cases after a mean of 1.4 +/- 0.52 sessions (range 1 to 2 sessions).nnnLIMITATIONSnOpen prospective series with a relatively small number of patients.nnnCONCLUSIONnIn young infants, the use of cyanoacrylate glue is safe and effective for the treatment of gastroesophageal VB.

Severe dysphagia in children with eosinophilic esophagitis and esophageal stricture: an indication for balloon dilation?

Background: Esophageal stricture is one of the most severe complications in eosinophilic esophagitis (EoE). Clinical practice is based on limited data and some treatments are still considered controversial. We report on our experience in the treatment of severe dysphagia and esophageal strictures in EoE, especially using balloon dilation, showing the clinical practice in our pediatric population. Patients and Methods: This was a single-center retrospective study between December 2002 to November 2007, identifying all of the pediatric patients with severe dysphagia in the context of EoE. Demographic data and the results of various treatment regimens were reviewed. Results: Severe dysphagia was identified in 13 cases (77% male, mean age 12.8 ± 4.4 years). Endoscopic findings were mucosal edema (62%), long segment strictures, esophagitis, and off-white appearance in 31%. Histologically, >20 eosinophils per high-power field were present in all of the patients. Medical treatment consisted of proton pump inhibitor PPI (77%), montelukast (31%), local corticosteroids (54%), systemic corticosteroids (8%), elemental diet (15%), and food elimination diet (61%). A combined therapeutic approach was performed in all of the cases, due to clinical relapse or no response to monotherapy. Good response was obtained clinically in 70%, endoscopically in 62%, and histologically in 75%. Relapses were observed in 46% of the cases. Balloon dilation was necessary in 31% of the cases (mean dilation sessions 3.3 ± 0.95), being effective in 100% of patients, without complications. Conclusions: In our pediatric series, combined medical (corticosteroids, elemental diet, and food elimination diet) and endoscopic approach (repeated balloon dilation) were effective and safe in patients with severe EoE and esophageal stricture.

Spontaneous esophageal perforation in eosinophilic esophagitis in children

intermittent solid food dysphagia and blockage was admitted because of chest pain, pyrosis, and fever (38.3 8C). The only medication she was on at the time of our evaluation was the inhaler Salbuta− mol−sulfate, which she used as needed. Symptoms started a few hours after a food blockage episode. Physical examina− tion was normal, except for tachycardia (135 bpm). Laboratory results showed: leukocytosis (17300/mm3), 11.59 x94 109 neutrophils, a high C−reactive protein (180 mg/l), and erythrocyte sedimenta− tion rate of 74 mm/h. Chest radiograph was normal. Chest com− puted tomography scan (l Fig. 1 a) showed a retroesophageal perforation, with periesophageal fluid collection. Ini− tial treatment consisted of fasting, intra− venous antibiotics (ceftriaxone 1.5 g/d, metronidazole 300 mg t. i.d, gentamicin 90 mg/d), and proton pump inhibitor (30 mg/d), with good evolution. Upper endoscopy (l Fig. 1 b) 2 months later showed an upper esophageal resistance to the tube passage without stenosis, and normal mucosa. Biopsies demonstrated very many intraepithelial eosinophil ag− gregates > 20 eos/HPF (l Fig. 1 c). Eosinophilic esophagitis is characterized by esophageal and/or upper gastrointesti− nal tract symptoms in association with an esophageal mucosal biopsy containing 3 15 intraepithelial eos/HPF in one or more biopsy specimen, without patho− logic gastroesophageal reflux disease (GERD) [1]. Eosinophilic esophagitis is a rare chronic inflammatory disease, with a varied clinical and endoscopic spec− trum. Some age−related differences were noted between symptoms in children and adults. In children, feeding refusal or intolerance, GERD−like symptoms, eme− sis, abdominal pain, dysphagia, food im− paction, chest pain, and diarrhea have been described [1]. In adults, intermittent dysphagia and food impaction are more common [1]. Transmural inflammation has been reported in eosinophilic esopha− gitis. It significantly increases the risk of perforation. Mucosal laceration and transmural perforation have been report− ed after endoscopy or dilation in eosino− philic esophagitis [2, 3]. Spontaneous esophageal perforation was recently reported in three adults, asso− ciated with eosinophilic esophagitis [2± 4]. Until now, no reports of this unusual association and presentation have been reported in children, extending the clini− cal spectrum of eosinophilic esophagitis in this population.

A first report of collagenous gastritis, sprue, and colitis in a 9-month-old infant: 14 years of clinical, endoscopic, and histologic follow-up.

pital with acute severe dehydration because of watery diarrhea. He had a history of low weight for height, due to chronic intermittent vomiting and diarrhea since 15 days from birth. Hypoproteinemia (3.5 g/100 ml), hypoalbuminemia (1.4 g/100 ml), hypogammaglobulinemia (4.6 g/l) and lymphocytosis (8.4 G/l) were found. Endoscopy showed an atrophic gastric mucosa with erosions, without other alterations. Histology showed a diffuse irregular thickening of the subepithelial collagen tissue (SCT) (stomach 50 m, duodenum 12 m, colon 12– 17 m), erosive epithelium, and jejunal villous atrophy (grade III). In spite of 13 years of aggressive treatment (prednisolone 0.5– 1 mg/kg/d, alternating with budesonide 3 –4 mg/d, night enteral nutrition, and a gluten-free diet), clinicopathological disease progression was observed (l Figs. 1, 2). Endoscopy at age 3 showed pseudopolyps with inflammatory areas in the gastric body, and erythematous mucosal areas in the colon. At age 10, a thick small tubular stomach, disappearance of gastric folds, and diffuse atrophic areas (as far as the duodenum), with erythema and multiple small submucosal nodules were observed. The colonic mucosa had become diffusely pale, thickened, and nodular, with disappearance of the normal vascular pattern. Histological examination showed a diffuse atrophic mucosa and an increase in the SCT (12 –100 m) was observed in the gastrointestinal tract. At age 14, because there was no clinicopathological improvement, the patient began total parenteral nutrition; this led to discontinuation of corticotherapy 2 months later and complete clinical improvement. Collagenous gastritis, sprue, and colitis are of unknown pathogenesis and are frequently associated with other disorders [1]. Diagnosis is on the basis of a strip SCT greater than 10 m, with an irregular or focal distribution [1, 2]. Symptoms vary according to the gastrointestinal segment affected [1– 5]. Collagenous gastritis and colitis are rarely encountered in pediatrics. Two cases have been reported where these conditions were associated [4, 5], but there have been no previous reports where both entities were associated with collagenous sprue. As the physiopathology remains unknown, specific treatment A first report of collagenous gastritis, sprue, and colitis in a 9-month-old infant: 14 years of clinical, endoscopic, and histologic follow-up

Water-jet dissector for endoscopic submucosal dissection in an animal study: outcomes of the continuous and pulsed modes

BackgroundEndoscopic submucosal dissection (ESD) allows en bloc resection of early neoplastic lesions of gastrointestinal tract. Lesions are lifted by submucosal fluid injection before circumferential incision and dissection. High-pressure fluid injection using water jet (WJ) technology is already used for lifting and dissection in surgery. The study was designed to assess WJ for ESD submucosal lifting and dissection.MethodsAn experimental, randomized comparative, “in vivo” nonsurvival animal study on 12 pigs was designed. Stomach mucosal areas were delineated and resected using three ESD techniques: technique A—syringe injection and IT knife dissection; technique B—WJ continuous injection and IT knife dissection; technique C—WJ injection and WJ pulsed dissection. Injection and dissection speeds and complications rates were assessed.ResultsWater jet continuous injection is faster than syringe injection (B faster than A, pxa0=xa00.001 and B nonsignificantly faster than C, pxa0=xa00.06). IT knife dissection is significantly faster after WJ continuous injection (B faster than A, pxa0=xa00.003). WJ pulsed dissection is significantly slower than IT knife dissection (C slower than A and B, both pxa0<xa00.001). The overall procedure speed was significantly higher and the immediate bleedings rate was significantly lower for technique B than A and C (overall procedure speed pxa0=xa00.001, immediate bleedings pxa0=xa00.032 and 0.038 respectively). There were no perforations with any technique.ConclusionsWater jet fluid continuous injection speeds up ESD, whereas pulsed WJ dissection does not.

Potential role of endoscopic ultrasound (EUS) in the diagnosis of aortic intramural lesions

A 58-year-old woman complaining of abdominal pain suspicious for pancreatitis was referred to our institution for endoscopic ultrasound (EUS). Physical examination and laboratory tests were unremarkable except for mild elevation of the serum amylase level. EUS revealed hyperechoic foci in the pancreas, but the most relevant finding was the presence of aortic wall lesions (● Fig.1). The ascending aorta showed increased crescent-shaped wall thickness with layered structures separated by echolucent zones, and no flow on Doppler ultrasound. Below this lesion, between the abdominal and thoracic aorta, was a septum giving the impression of a double-lumen aorta. Doppler ultrasound revealed absence of flow in one of the lumens during ventricular systole. Acute aortic syndrome with an intramural hematoma (IMH) and aortic dissection was suspected. Computed tomography (CT) confirmed presence of aortic dissection extending from the thorax to the iliac artery bifurcation. However, IMH was not observed. The acute aortic syndrome includes aortic dissection, IMH, and penetrating atherosclerotic ulcer of the aorta [1]. It results from the progression of atheromatous plaque that has induced injury in the tunica intima and tunica media of the vessel wall. Aortic dissection is a medical emergency with high rates of mortality and appears subsequent to IMH. Clinical presentation varies from a silent disease to severe pain [2]. The condition is diagnosed based on abnormal findings on imaging, sometimes incidentally discovered during radiological imaging procedures [2]. Image modalities for confirming the diagnosis of acute aortic syndrome include CT, magnetic resonance imaging (MRI), transesophageal echocardiography, angiography, and intravascular ultrasound, with sensitivity and specificity varying from 78% to 100% [3–5]. Due to disadvantages and limitations associated with each modality, the diagnosis requires use of multiple imaging modalities. The unusual findings in the present case demonstrate the potential role of EUS in the diagnosis of aortic intramural pathologies. Endoscopy_UCTN_Code_CCL_1AF_2AG_3AD

Multiple Intestinal Erosions as a Result of Hemorrhage due to Parasites: Case Reports and Review of the Literature

Obscure gastrointestinal bleeding appears to be uncommon in patients with parasites. In spite of that some reports had described this relationship in patients evaluated during capsule endoscopy procedures; the characteristic of the bleeding lesions remains unclear. This paper describes two patients with a massive obscure gastrointestinal bleeding due to ascariasis, using the new capsule endoscopy technology “MiroCam”, describing the characteristic of the lesions found in our patients (observed in a better image quality), and reviewing the literature.

Endoscopic ultrasound elastography in the diagnosis of incidental malignant mesothelioma

10.4103/2303-9027.175926 A 32-year-old female was referred to our institution for endoscopic ultrasound (EUS) evaluation due to a weight loss history (10 kg in 2 months) and serum carcinoembryonic antigen elevation (100 ng/mL). Physical examination was normal. Previously test including thorax and abdominal CT, upper and lower endoscopy, and capsule endoscopy were normal. EUS showed one round, well-delimited, black lymph node near to the aorta and another one with similar characteristics, but heterogeneous (black-white) near to the esophagus. EUS-elastography was performed showing a hard tissue (blue color) with a quantitative strain ratio (SR) of 131.1 [Figure 1] and the second one with a green-blue color pattern with a quantitative SR of 6.85, the first one being suspected for malignancy. EUS fi ne-needle aspiration (EUS-FNA) was performed and histopathology showed a mesothelioma [Figure 2].

Endoscopic Chemotherapy with 5-Fluorouracil in Advanced Gastric Cancer

IntroductionIt has been reported that a local injection of 5-fluorouracil (5-FU) administered endoscopically can have a favorable result in patients with early gastric cancer.MethodsWe report the application of a local injection of 5-FU administered endoscopically in three patients with advanced gastric cancer (AGC) who refused or were not suitable for surgery or systemic chemotherapy. The benefits of locally applied endoscopic chemotherapy (EC) with 5-FU as an alternative therapy were evaluated.ResultsGood tolerance with an important reduction of the tumor size and no adverse reactions was observed in all three patients.ConclusionEC with 5-FU is a feasible technique that can be applied in a certain group of patients with AGC. Further studies will be required to corroborate these results.

Gastrointestinal lymphoid pseudotumoral hyperplasia: report of four pediatric cases

(l Table 1, l Fig. 1 ± 3) with lymphoid pseudotumoral hyperplasia (LPH), two with an atypical localization (diffuse dis− ease). The lesion diameters varied from 7 to 30 mm. In our patients, the treatment was: con− servative (patient 1), surgery (patient 2), corticosteroids (patient 3), and a milk− free diet (patient 4). Complete remission of lesions and/or clinical improvement were seen in all cases. In the three clini− cally managed cases, there were no changes during the follow−up (6 years for patient 2, 4 years for patient 3, and 6 months for patient 4). Lymphoid nodular hyperplasia (LNH) is a common, nonpathologic finding in chil− dren [1]. The ileum and colon are com− monly affected [1,2]. An atypical form is the pseudotumoral presentation, defined as a tumoral presentation of LNH asso− ciated with inflammatory mesenteric lymph nodes [1,2]. The imperative differ− ential diagnosis is low−grade lymphoma. In such cases, a diagnosis of malignancy is based on morphologic and immuno− phenotypic (histologic) features with mo− lecular evidence of clonality [3]. LPH and LNH are similar, differing only in their endoscopic appearance. LNH ap− pears as micronodules 1 ±2 mm in size, of a whitish−rose color, surrounded by nor− mal mucosa [1]. In LPH, the micronodular endoscopic appearance is absent, giving a misleading picture of tumor [2] ± as was observed in our cases. It is very important to take a large number of biopsies (some− times macrobiopsies) to establish the di− agnosis [2, 4]. The physiopathology is not completely understood, but probably re− flects an unspecific exacerbated lymphoid response to various stimuli (e. g., infec− tions, allergies, immunodeficiency, auto− immunity) [1, 2], which were identified in three−quarters of our patients. There is no consensus about treatment, which is reserved for patients with severe symptoms. Treatments include surgery and hydrostatic barium enema (in the case of intestinal obstruction or intussus− ception), or the use of corticosteroids (with previous histologic confirmation of LPH) [2,5]. Due to its rarity, the natural history, and the increased risk of malig− nant transformation, many aspects such as clinical and endoscopic features and treatment follow−up remain uncertain. Endoscopy_UCTN_Code_CCL_1AD_2AC