Decio Chinzon

Lugol's Dye Spray Chromoendoscopy Establishes Early Diagnosis of Esophageal Cancer in Patients with Primary Head and Neck Cancer

OBJECTIVE:Patients with primary head and neck cancer show a predisposition to develop esophageal cancer. The aim of this study was to investigate in these patients: the prevalence of esophageal cancer comparing the value of chromoendoscopy using Lugols solution examination to standard endoscopy, in the early diagnosis of esophageal cancer.METHODS:Prospective observational study at a state general university hospital in Sao Paulo, Brazil. 326 consecutive adult patients with primary head and neck cancer were evaluated. A standard endoscopy was performed, followed by a 2% lugols dye spray chromoendoscopy and histopathologic study. The prevalence of esophageal cancer was defined. The results of the two endoscopic methods were compared.RESULTS:Twenty-four patients with esophageal cancer and high-grade intraepithelial neoplasia were detected and had a prevalence of 7.36%. Chromoendoscopy and standard endoscopy were equivalent to the diagnosis of advanced and invasive esophageal cancer. However, standard endoscopy diagnosed 55% of high-grade intraepithelial neoplasia, in comparison to chromoendoscopy that detected 100%.CONCLUSIONS:Patients with primary head and neck cancer should be considered as high risks for the presence of esophageal cancer. Lugols dye chromoendoscopy diagnosed high-grade intraepithelial neoplasia, which went unnoticed with standard endoscopy. It permits a more exact detection of lesion boundaries and facilitates a more precise targeting of biopsy fragments.

Factors Related to Helicobacter pylori Prevalence in an Adult Population in Brazil

Background:  The prevalence of Helicobacter pylori is higher in developing countries. Sanitary facilities, crowding and ethnic group are some of the factors related to H. pylori infection. The aim of this study was to investigate in blood donors, free of dyspeptic symptoms, the prevalence and factors influencing H. pylori infection.

Association of a probiotic to a Helicobacter pylori eradication regimen does not increase efficacy or decreases the adverse effects of the treatment: a prospective, randomized, double-blind, placebo-controlled study

BackgroundThe treatment for the eradication of Helicobacter pylori (H. pylori) is complex; full effectiveness is rarely achieved and it has many adverse effects. In developing countries, increased resistance to antibiotics and its cost make eradication more difficult. Probiotics can reduce adverse effects and improve the infection treatment efficacy.If the first-line therapy fails a second-line treatment using tetracycline, furazolidone and proton-pump inhibitors has been effective and low cost in Brazil; however it implies in a lot of adverse effects. The aim of this study was to minimize the adverse effects and increase the eradication rate applying the association of a probiotic compound to second-line therapy regimen.MethodsPatients with peptic ulcer or functional dyspepsia infected by H. pylori were randomized to treatment with the furazolidone, tetracycline and lansoprazole regimen, twice a day for 7 days. In a double-blind study, patients received placebo or a probiotic compound (Lactobacillus acidophilus, Lactobacillus rhamnosus, Bifidobacterium bifidum and Streptococcus faecium) in capsules, twice a day for 30 days. A symptom questionnaire was administered in day zero, after completion of antibiotic therapy, after the probiotic use and eight weeks after the end of the treatment. Upper digestive endoscopy, histological assessment, rapid urease test and breath test were performed before and eight weeks after eradication treatment.ResultsOne hundred and seven patients were enrolled: 21 men with active probiotic and 19 with placebo plus 34 women with active probiotic and 33 with placebo comprising a total of 55 patients with active probiotic and 52 with placebo. Fifty-one patients had peptic ulcer and 56 were diagnosed as functional dyspepsia. The per-protocol eradication rate with active probiotic was 89.8% and with placebo, 85.1% (p = 0.49); per intention to treat, 81.8% and 79.6%, respectively (p = 0.53). The rate of adverse effects at 7 days with the active probiotic was 59.3% and 71.2% with placebo (p = 0.20). At 30 days, it was 44.9% and 60.4%, respectively (p = 0.08).ConclusionsThe use of this probiotic compound compared to placebo in the proposed regimen in Brazilian patients with peptic ulcer or functional dyspepsia showed no significant difference in efficacy or adverse effects.Trial registrationCurrent Controlled Trials ISRCTN04714018

Guidelines for the diagnosis and management of gastroesophageal reflux disease: an evidence-based consensus

A doenca do refluxo gastroesofagico e uma das enfermidades mais comuns na pratica medica. Numerosas diretrizes e recomendacoes de conduta para seu diagnostico e tratamento tem sido publicadas em varios paises, mas no Brasil ainda nao havia sido realizado um trabalho de consenso baseado em padroes de Medicina baseada em evidencias. Com esse objetivo, estabeleceu-se um grupo brasileiro representativo de especialistas (Grupo de Consenso da DRGE - doenca do refluxo gastroesofagico) para estabelecer diretrizes de conduta de Medicina baseada em evidencias para a doenca do refluxo gastroesofagico que pudessem ser utilizadas tanto por medicos em cuidados primarios de saude, como por especialistas, seguradoras e agencias regulatorias. Foram propostas 30 questoes e a busca das respostas baseou-se em pesquisa sistematica da literatura para a identificacao dos temas e respectivos graus de evidencia. Foram selecionadas 11.069 publicacoes sobre doenca do refluxo gastroesofagico, das quais 6.474 sobre diagnostico e 4.595 sobre terapeutica. Em relacao ao diagnostico, 51 trabalhos alcancaram as exigencias de Medicina baseada em evidencias: 19 foram classificadas como grau A e 32 como grau B. Em relacao a terapeutica, 158 alcancaram as exigencias de Medicina baseada em evidencias: 89 foram classificadas como grau A e 69 como grau B. No item Diagnostico as respostas sustentadas por publicacao de graus A e B foram aceitas. No item Tratamento, somente publicacoes grau A foram aceitas: as respostas apoiadas por publicacoes grau B foram submetidas a votacao pelo Grupo de Consenso. A presente publicacao apresenta as respostas as questoes propostas com os trabalhos mais representativos seguidos por comentarios pertinentes. Exemplos: 1) em pacientes com manifestacoes atipicas a pHmetria convencional pouco contribui para o diagnostico de doenca do refluxo gastroesofagico. A sensibilidade, entretanto, aumenta com o emprego de pHmetria de duplo canal. 2) Em pacientes com manifestacoes atipicas a impedância-pHmetria contribui substancialmente para o diagnostico de doenca do refluxo gastroesofagico. O exame, entretanto, e oneroso e pouco disponivel em nosso pais. 3) A avaliacao dos sinais histologicos de esofagite eleva a probabilidade diagnostica da doenca do refluxo gastroesofagico, considerando-se que a observacao das dimensoes do espaco intercelular da mucosa esofagica aumenta a probabilidade de certeza diagnostica e tambem permite a analise da resposta terapeutica. 4) Nao ha diferenca na resposta clinica ao tratamento com inibidor da bomba protonica administrado em duas doses diarias quando comparado a uma unica dose diaria. 5) A longo prazo (>1 ano) a erradicacao do H .pylori em pacientes com doenca do refluxo gastroesofagico nao reduz a presenca de sintomas ou a elevada recurrencia da enfermidade, embora reduza os sinais histologicos de inflamacao. E muito provavel que nao ocorra associacao entre a erradicacao do H. pylori e as manifestacoes da doenca do refluxo gastroesofagico. 6) A presenca de hernia hiatal exige doses maiores de IBP para o tratamento clinico. A ocorrencia de migracao permanente da juncao esofago-gastrica e as dimensoes da hernia (>2 cm) sao fatores de pior prognostico na doenca do refluxo gastroesofagico. Nesses casos, as hernias hiatais associadas a doenca do refluxo gastroesofagico, especialmente as fixas e maiores do que 2 cm devem ser consideradas para tratamento cirurgico. Os resultados da fundoplicatura laparoscopica tem se mostrado adequados.Gastroesophageal reflux disease (GERD) is one of the most common disorders in medical practice. A number of guidelines and recommendations for the diagnosis and management of GERD have been published in different countries, but a Brazilian accepted directive by the standards of evidence-based medicine is still lacking. As such, the aim of the Brazilian GERD Consensus Group was to develop guidelines for the diagnosis and management of GERD, strictly using evidence-based medicine methodology that could be clinically used by primary care physicians and specialists and would encompass the needs of physicians, investigators, insurance and regulatory bodies. A total of 30 questions were proposed. Systematic literature reviews, which defined inclusion and/or exclusion criteria, were conducted to identify and grade the available evidence to support each statement. A total of 11,069 papers on GERD were selected, of which 6,474 addressed the diagnosis and 4,595, therapeutics. Regarding diagnosis, 51 met the requirements for the analysis of evidence-based medicine: 19 of them were classified as grade A and 32 as grade B. As for therapeutics, 158 met the evidence-based medicine criteria; 89 were classified as grade A and 69 as grade B. In the topic Diagnosis, answers supported by publications grade A and B were accepted. In the topic Treatment only publications grade A were accepted: answers supported by publications grade B were submitted to the voting by the Consensus Group. The present publication presents the most representative studies that responded to the proposed questions, followed by pertinent comments. Follow examples. In patients with atypical manifestations, the conventional esophageal pH-metry contributes little to the diagnosis of GERD. The sensitivity, however, increases with the use of double-channel pH-metry. In patients with atypical manifestations, the impedance-pH-metry substantially contributes to the diagnosis of GERD. The examination, however, is costly and scarcely available in our country. The evaluation of the histological signs of esophagitis increases the diagnostic probability of GERD; hence, the observation of the dimensions of the intercellular space of the esophageal mucosa increases the probability of diagnostic certainty and also allows the analysis of the therapeutic response. There is no difference in the clinical response to the treatment with PPI in two separate daily doses when compared to a single daily dose. In the long term (>1 year), the eradication of H. pylori in patients with GERD does not decrease the presence of symptoms or the high recurrence rates of the disease, although it decreases the histological signs of gastric inflammation. It seems very likely that there is no association between the eradication of the H. pylori and the manifestations of GERD. The presence of a hiatal hernia requires larger doses of proton-pump inhibitor for the clinical treatment. The presence of permanent migration from the esophagogastric junction and the hernia dimensions (>2 cm) are factors of worse prognosis in GERD. In this case, hiatal hernias associated to GERD, especially the fixed ones and larger than 2 cm, must be considered for surgical treatment. The outcomes of the laparoscopic fundoplication are adequate.

Comorbidities are frequent in patients with gastroesophageal reflux disease in a tertiary health care hospital

INTRODUCTION Several aspects of gastroesophageal reflux disease (GERD) have been studied, but the frequency of comorbidities is not yet fully understood. OBJECTIVES To study the prevalence of GERD comorbidities in a tertiary care hospital. METHODS We prospectively studied 670 consecutive adult patients from the outpatient department of our facility. A diagnosis was established using clinical, endoscopic and/or pHmetry-related findings. Each patient’s medical file was reviewed with respect to the presence of other medical conditions and diagnoses. RESULTS Of the 670 patients, 459 (68.6%) were female, and the mean age was 55.94 (17–80 years). We registered 316 patients (47.1%) with the erosive form of GERD and 354 patients (52.9%) with the non-erosive form. A total of 1,664 instances of comorbidities were recorded in 586 patients (87.5%), with the most common being arterial hypertension (21%), hypercholesterolemia (9%), obesity (9%), type II diabetes mellitus (5%) and depression (4%). Two or more comorbidities were present in 437 individuals (64.8%). The occurrence of comorbidities increased with age and was higher in patients with the non-erosive form of GERD. CONCLUSIONS In a tertiary referral population, comorbidities were very common, and these may have worsened the already impaired health-related quality of life of these patients. Clinicians caring for GERD patients in this setting must be aware of the likelihood and nature of comorbid disorders and their impact on disease presentation and patient management.

Factors affecting Helicobacter pylori eradication using a seven-day triple therapy with a proton pump inhibitor, tinidazole and clarithromycin, in brazilian patients with peptic ulcer

UNLABELLED Triple therapy is accepted as the treatment of choice for H. pylori eradication. In industrialized countries, a proton pump inhibitor plus clarithromycin and amoxicillin or nitroimidazole have shown the best results. Our aims were: 1. To study the eradication rate of the association of a proton pump inhibitor plus tinidazole and clarithromycin on H. pylori infection in our population. 2. To determine if previous treatments, gender, age, tobacco, alcohol use, and non-steroidal anti-inflammatory drugs (NSAIDs) change the response to therapy. METHODS Two hundred patients with peptic ulcer (upper endoscopy) and H. pylori infection (histology and rapid urease test - RUT) were included. A proton pump inhibitor (lanzoprazole 30 mg or omeprazole 20 mg), tinidazole 500 mg, and clarithromycin 250 mg were dispensed twice a day for a seven-day period. Eradication was assessed after 10 to 12 weeks of treatment through histology and RUT. RESULTS The eradication rate of H. pylori per protocol was 65% (128/196 patients). This rate was 53% for previously treated patients, rising to 76% for not previously treated patients, with a statistical difference p<0.01. No significant difference was observed regarding sex, tobacco use, alcohol consumption, and NSAID use, but for elderly patients the difference was p = 0.05. Adherence to treatment was good, and side effects were mild. CONCLUSIONS A proton pump inhibitor, tinidazole, and clarithromycin bid for seven days resulted in H. pylori eradication in 65% of the patients. Previous treatments were the main cause of treatment failure.

Epidemiology of upper gastrointestinal symptoms in Brazil (EpiGastro): A population-based study according to sex and age group

AIM To determine the prevalences of symptoms consistent with gastroesophageal reflux disease (GERD) and dyspepsia in South America. METHODS A telephone survey was conducted among adult owners of land-based telephones in São Paulo, Brazil, using previously validated computer-assisted sampling and survey protocols. The Portuguese-language survey included (1) sociodemographic characteristics (e.g., weight, height, smoking) and comorbidities; (2) dietary habits; (3) presence of symptoms consistent with GERD or dyspepsia within the prior 3 mo; and (4) use of medications and other therapies to manage symptoms. Data were stratified post-hoc into three homogeneous geographical regions of São Paulo according to the Social Exclusion Indices of the districts and postal codes. Survey response data from each respondent were weighted by the numbers of adults and landline telephones in each household. The analyses were weighted to account for sampling design and to be representative of the São Paulo population according to city census data. RESULTS Among 4570 households contacted, an adult from 3050 (66.7%) agreed to participate. The nonresponse rate was 33.3%. The mean (SE) respondent age was 42.6 (16.0) years. More than half of all respondents were women (53.1%), aged 18 through 49 years (66.7%), married or cohabitating (52.5%), and/or above normal-weight standards (i.e., 35.3% overweight and 16.3% obese). A total of 26.5% of women were perimenopausal. More than 20% of respondents reported highly frequent symptoms consistent with GERD (e.g., gastric burning sensation = 20.8%) or dyspepsia (e.g., abdominal swelling/distension = 20.9%) at least once per month. Prevalences of these symptoms were significantly (approximately 1.5- to 2.0-fold) higher among women than men but did not vary significantly as a function of advancing age. For instance, 14.1% of women reported that they experienced stomach burning (symptom of GERD) at least twice per week, compared to 8.4% of men (P = 0.012 by χ(2) test). A total of 15.7% of women reported that they experienced abdominal swelling (symptom of dyspepsia) at least twice per week, compared to 6.4% of men (P < 0.001 by χ(2) test). Despite frequent manifestations of GERD or dyspepsia, most (≥ 90%) respondents reported that they neither received prescription medications from physicians, nor took behavioral measures (e.g., dietary modifications), to manage symptoms. CONCLUSION Symptoms consistent with dyspepsia and GERD are prevalent in Brazil and represent major public-health and clinical challenges.

Avaliação da eficácia, segurança e tolerabilidade de rabeprazol no tratamento de doenças ácido-pépticas

Racional - Rabeprazol sodico e um derivado benzimidazolico com potente acao inibidora da bomba de protons. Aprovado na maioria dos paises do mundo, inclusive no Brasil, a substância tem se mostrado muito eficaz para o tratamento das doencas acido-pepticas, especialmente a doenca por refluxo gastroesofagico. Objetivos - Avaliar a eficacia e tolerabilidade de rabeprazol em pacientes com esofagite por refluxo e/ou ulcera peptica gastrica e/ou duodenal na pratica clinica, bem como avaliar o tempo necessario para a obtencao de alivio dos sintomas. Pacientes/Metodos - Foram avaliados 171 pacientes que procuraram consulta com gastroenterologista e que tiveram como diagnostico a doenca por refluxo ou ulcera peptica. Todos os pacientes eram ambulatoriais, de ambos os sexos, com idade superior a 18 anos. O diagnostico, assim como o controle pos-tratamento foi obtido atraves do exame endoscopico. Todos os pacientes receberam 20 mg de rabeprazol ao dia por 4 a 8 semanas, dependendo do diagnostico e a criterio do medico. Os pacientes receberam um diario para registro do inicio do alivio dos sintomas. Os dados obtidos no inicio e ao final do tratamento foram analisados atraves do teste nao-parametrico de Wilcoxon para amostras pareadas. Resultados - Dos 171 pacientes iniciais 162 completaram o estudo. Destes, 78 (48,1%) tiveram como diagnostico a doenca por refluxo. Onze (6,8%) apresentaram associacao desta com ulcera duodenal e 7 (4,3%) associado a ulcera gastrica. Em 39 (24,1%) o diagnostico foi de ulcera duodenal. A ulcera gastrica isoladamente estava presente em 24 (14,8%) e associada a ulcera duodenal em 3 (1,9%) casos. O tratamento foi de 4 semanas em 94,2% dos pacientes. Apenas 7 necessitaram 6 semanas e 3 foram tratados por 8 semanas. Mais da metade dos pacientes obtiveram alivio dos sintomas apos o 1 dia de tratamento e apos 7 dias, 89,5% estavam totalmente assintomaticos. O indice de cicatrizacao das lesoes foi de 88,3% dos casos. Vinte e sete pacientes (15,2%) relataram eventos adversos leves que nao necessariamente estavam relacionados a medicacao, sendo os mais frequentes: diarreia, cefaleia e tonturas. Conclusoes - O rabeprazol mostrou-se altamente eficaz para o alivio dos sintomas de pacientes com doencas acido-pepticas. Da mesma forma, a droga proporcionou altos indices de cicatrizacao das lesoes. O medicamento mostrou ser seguro, com efeitos colaterais transitorios e sem maiores consequencias para os pacientes.

Standard Triple Therapy versus Sequential Therapy in Helicobacter pylori Eradication: A Double-Blind, Randomized, and Controlled Trial

Aim. To compare 10-day standard triple therapy versus sequential therapy as first-line treatment in patients infected with H. pylori. Methods. One hundred H. pylori positive patients (diagnosed by rapid urease test and histology), with average age of 47.2, M/F = 28/72, were randomized to receive either standard triple treatment (TT) as follows: lansoprazole 30 mg, clarithromycin 500 mg, and amoxicillin 1 g, b.i.d. for ten days, or sequential treatment (ST) as follows: lansoprazole 30 mg, amoxicillin and placebo 1.0 g b.i.d for the first five days, followed by lansoprazole 30 mg, clarithromycin 500 mg, and tinidazole 500 mg b.i.d, for the remaining five days. Eradication rates were determined 60 days after treatment by urease, histology, or 13C-urea breath test. Results. In intention to treat (ITT) analysis, the rate of H. pylori eradication in the TT and ST groups was the same for both regimens as follows: 86% (43/50), 95% CI 93,3 to 73.4%. In Per protocol (PP) analysis, the rate of H. pylori eradication in the TT and ST groups was 87.8% (43/49), 95% CI 94,5 to 75.3% and 89.6% (43/48), 95% CI 95,8 to 77.3%, respectively. Conclusions. In Brazil, standard triple therapy is as equally effective as sequential therapy in eradicating Helicobacter pylori patients. This study was registered under Clinical Trials with number ISRCTN62400496.

Ulcer and bleeding complications and their relationship with dyspeptic symptoms in NSAIDs users: a transversal multicenter study

Abstract Objectives. To evaluate the prevalence of lesions and digestive complications secondary to the use of non-steroidal anti-inflammatory drugs (NSAIDs), the clinical profile seen for digestive complaints and the relation with the endoscopic findings. Methods. Prospective, multicentric, open study, evaluating consecutively 1231 patients, divided as follows: group I – NSAID and group II – non-NSAID. All patients answered questionnaire to evaluate the onset, the type of clinical complaint, the use of medication and possible complications associated to digestive bleeding. Results. A total of 1213 patients were evaluated. Among them, 65% were female and 13.1% were smokers; 15.6% mentioned they ingested alcoholic beverages. The main signs and symptoms reported were epigastralgy and pyrosis (67% and 62%, respectively). The upper gastrointestinal (UGI) endoscopy was normal in 3.9% in group I and in 10.7% in group II (p < 0.001). Patient who do not use NSAID will be 2.5 times more likely to have normal UGI endoscopy (p = 0.001). The presence of erosive or ulcer lesions in the stomach and duodenum was more frequent in group I. The incidence of lesions in the stomach when compared to the duodenum is observed (erosions: 49.12% vs. 13.60%, p = 0.001; ulcers: 14.04% vs. 11.84%, p = 0.05). The risk of digestive bleeding is 12 times higher (6.14% vs. 0.51%) in those who used NSAIDs, and the stomach is the site in which bleeding occurs more frequently. Conclusions. The frequency of gastric ulcer, duodenal ulcer and digestive bleeding was higher in patients who used NSAIDs. There was no connection found between endoscopic findings and dyspeptic symptoms.