Diniz Freitas

External validation of a classification for methylene blue magnification chromoendoscopy in premalignant gastric lesions

BACKGROUND Conventional endoscopy has low sensitivity, specificity, and interobserver agreement for the diagnosis of gastric atrophy, intestinal metaplasia, and dysplasia. Magnification chromoendoscopy (ME) may optimize the evaluation of premalignant gastric lesions. OBJECTIVE AND DESIGN As part of a multicenter trial, we aimed at validating a previously proposed classification for gastric methylene blue ME at a different center. SETTING, PATIENTS, AND INTERVENTIONS: A sample of patients (n = 42) with previously diagnosed chronic atrophic gastritis with or without intestinal metaplasia underwent ME (Pentax EG-3430Z) with 1% methylene blue by 2 endoscopists. MAIN OUTCOME MEASUREMENTS A simplified version of a previously published ME classification (group I, group II [further divided into subgroups IIE and IIF], and group III) was used for macroscopic lesions (n = 203) with Sydney-Houston and Vienna classifications being used for histologic analysis (n = 479 biopsy specimens). RESULTS AND LIMITATIONS Excellent reproducibility (wK = 0.92 [95% CI, 0.88-0.96]) was observed for classification in groups and substantial reproducibility (wK = 0.78 [95% CI, 0.72-0.84]) was found for classification in subgroups. Global validity was 82% (range 78%-86%), showing no false negatives (sensitivity of 100% [1/1 biopsy]) and a very low rate of false positives (specificity 99% [297/299 biopsies]) for dysplasia detection. CONCLUSIONS This classification for methylene blue ME was highly reproducible and valid for the diagnosis of premalignant gastric lesions when used in a center different from that involved in its conception. Despite requiring an unconventional endoscope and a longer procedure, these results could reinforce ME as a valuable technique in the surveillance of patients at risk for gastric cancer.

Screening for pancreatic exocrine insufficiency in patients with diabetes mellitus

OBJECTIVES:Fecal elastase 1 (E1) is a relatively sensitive and specific indirect test of pancreatic exocrine function. Despite the high functional reserve of the pancreas, it is recognized that a significant proportion of diabetic patients may also have a deficit of the exocrine function. The aim of this study was to screen patients with diabetes mellitus (DM) for pancreatic exocrine insufficiency.METHODS:A total of 80 patients were enrolled in this prospective study, including 42 patients with DM and 38 nondiabetic controls. Exclusion criteria were as follows: age >75 yr; alcohol intake >40 g/day; intake of orlistat or acarbose; and history of diarrhea, pancreatitis, GI surgery, immunodeficiency, or cancer. All patients underwent the same study protocol, which included clinical evaluation, determination of fecal E1, plain x-rays of the abdomen, and abdominal ultrasound. An immunoenzymatic method (ScheBoTech, Wettenburg, Germany) was used for E1 determination. Diagnosis of pancreatic insufficiency was established for a fecal E1 <200 μg/g.RESULTS:The DM and control groups were comparable regarding age (62 ± 10 yr vs 56 ± 10 yr), sex (18 men and 24 women vs 15 men and 23 women), and proportion of patients with excess weight (50% vs 42%). Patients had DM diagnosed for 11.5 ± 8 yr, with structural changes of the pancreas detected on ultrasound in three cases and calcifications in one case. There was no relationship between E1 determination <200 μg/g and the duration or the type of therapy for DM. Fifteen patients (36%) in the DM group had a fecal E1 <200 μg/g, compared with two patients (5%) in the control group (p < 0.05). In the DM group (n = 42), 11 patients with excess weight presented a fecal E1 <200 μg/g, whereas four patients with a BMI <25 presented this result (p < 0.05).CONCLUSIONS:Pancreatic exocrine insufficiency occurs more frequently in diabetic patients than in controls. Diabetic individuals with excess weight (BMI >25) may be at increased risk for underlying exocrine pancreatic insufficiency.

Fosinopril-induced prolonged cholestatic jaundice and pruritus: first case report.

We report a case of fosinopril-induced prolonged cholestatic jaundice and pruritus in a 61-year-old man, with no previous hepatobiliary disease, who presented with asthenia, jaundice and itching 3 weeks after starting fosinopril therapy. Other drugs taken by the patient were not considered probable causes. The diagnostic evaluation showed no biliary obstruction and other possible causes of intra-hepatic cholestasis were excluded. Liver biopsy showed cholestasis without bile duct damage. The disease ran a severe course during the 2 months of hospitalization, with prolonged itching for 6 months, eventually controlled with oral naltrexone. Jaundice subsided after 4 months, with anicteric cholestasis persisting for more than 18 months. Similar occurrences have been reported with other inhibitors of angiotensin-converting enzyme (mostly captopril), but this is the first case of an important adverse reaction to fosinopril.

Ticlopidine-induced prolonged cholestasis: a case report.

We report a case of ticlopidine-induced prolonged cholestasis in a 60-year-old man with no previous hepatobiliary disease who presented with sudden right upper abdominal pain, jaundice and pruritus three months after starting ticlopidine therapy. Other drugs taken by the patient were not considered probable causes. The diagnostic evaluation showed no biliary obstruction and other possible causes of intra-hepatic cholestasis were excluded. The liver biopsy showed a cholestatic hepatitis with bile duct damage. The disease ran a severe and protracted course, but symptoms and jaundice eventually subsided five months after drug withdrawal. More than a year later, relevant abnormalities of liver function tests consistent with anicteric cholestasis still persist, fulfilling criteria for a minor form of drug-induced prolonged cholestasis. This syndrome has been reported infrequently in relation to several drugs, mainly chlorpromazine, and only once with ticlopidine.

Oesophageal lichen planus

Lichen planus is a common skin and mucosal disease, with very rare symptomatic oesophageal involvement. We report a case of painful dysphagia due to oesophageal lichen planus in a 60-year-old woman who also had oral, cutaneous and genital lichen planus lesions. Steroid treatment produced considerable improvement of all lesions and a rapid symptomatic remission.

Severe acute liver failure as the initial manifestation of haematological malignancy.

Acute liver failure is rarely secondary to lymphoma or leukaemia and it is extremely uncommon as the initial presentation of malignancy. We report a case of a young adult patient with severe acute liver failure referred for liver transplant, in which a Burkitt acute lymphoblastic leukaemia was diagnosed by bone marrow examination. A complete recovery and long remission were obtained with chemotherapy.

Desgarro esofágico espontáneo extenso con hemorragia digestiva alta tratado con la aplicación de un endoclip

A 61-years-old male presented with emesis after some retching episodes. He had liver cirrhosis but no previous bleeding. An upper endoscopy revealed an extensive 10 cm tear involving the mucosa and submucosa layers of the distal esophagus sparing a 2 cm long segment proximal to the Z-line (Fig. 1). The laceration presented a slowly oozing haemorrhage that was stopped with the injection of 6 cc of epinephrine 1:10,000 and application of 17 endoclips to close the laceration. Recurrent bleeding 8 days later was controlled with further application of 4 endoclips. No further haemorrhagic recurrence occurred and an endoscopy procedure was repeated at week 6 (Fig. 2) and week 24 when no lesion was seen. Spontaneous extensive esophageal tear with upper digestive haemorrhage treated by endoclip application

4579 Eus doppler-guided manometry of esophageal varices.

`Background and Aims: Variceal size and the presence of red signs on esophageal varices (EV) are considered to be the most important endoscopic factors to predict the risk of variceal rupture. However, endoscopic parameters alone cannot reliably anticipate the eminence of variceal bleeding. Variceal pressure (VP) is a major determinant of the risk of variceal bleeding and has been assessed by direct needle puncture of EV. This method, however, is invasive and may cause bleeding requiring immediate sclerotherapy. Reliability of non-invasive techniques to assess VP remains controversial. The endoscopic balloon technique is strongly observer-dependent: the ideal time for pressure reading is often difficult to decide, resulting in inter- and intra-observer variances. In this study we assessed the feasibility and accuracy of a new method based on EUS power doppler for monitoring EV blood flow during balloon manometry. Methods: Experimental assessment of this technique was performed with an in vitro model consisting of a plastic tube containing artificial latex varices, perfused with water and connected to a manometer. A linear array echoendoscope featuring power doppler was used to assess flow within the varices.A specially designed balloon for EV manometry was attached to the tip of the echoendoscope. Insufflation of this balloon resulted in compression of the varices until flow ceased on EUS power doppler. At this time, pressure readings were made. This procedure was then performed in 12 patients with portal hypertension and EV. Patients were sedated with midazolam and esophageal peristalsis was minimized with iv hyoscine butylbromide. Results: In vitro studies showed a good correlation between the measured pressure and the actual pressure (r=0.92). Determination of VP was technically successful in all patients. VP was 26.2 ± 6.8 mm Hg. Conclusions: Our preliminary results indicate that EUS dopplerguided manometry of EV is feasible and accurate. This technique may become a more reliable method for VP measurement and warrants further investigation. This research was funded in part by the Portuguese Health Ministry Committee for Investigation in Health Care.

7049 Endoscopic placement of esophageal expandable metal stents without fluoroscopic guidance.

The insertion of expandable metal stents (EMS) is a fundamental palliative treatment for esophageal malignant neoplasia. Endoscopic placement of stents is usually performed under fluoroscopic guidance. Aims: Evaluation of feasability, efficacy and safety of the endoscopic insertion of EMS in esophageal malignant neoplasia without fluoroscopic guidance. Patients and Methods: Retrospective study of 60 patients (pts) with nonresectable esophageal cancer in whom 72 EMS were placed. The EMS used were distal release Ultraflex™ (Microvasive®, Boston Scientific Corporation), 7-15 cm long and 18 mm in diameter (22 covered stents). 91% of the patients were previously submitted to dilation and/or Nd:YAG laser. The procedures were done under sedation with midazolam and EMS were placed under endoscopic control with no fluoroscopic guidance. Severity of dysphagia was graded in a 0 to 4 score according to the consistency of food causing symptoms: 0 no dysphagia; 1 solid food; 2 semi-solid food; 3 liquid food; 4 total dysphagia. Results: 49 men and 11 women. Mean age 65±11 years. The indications for EMS insertion were dysphagia (78%) and esophagorespiratory fistulas (22%). Mean stricture length: 7.0±1.9 cm.The neoplasia were located in the upper esophagus in 23%, in the middle in 47% and in the lower in 30%. A significant improvement in dysphagia after stent placement was observed (mean pre-treatment score: 3.1±0.7; mean score after stenting: 1.5±0.5 - p

4474 Prognostics factors of death in ischemic colitis.

BACKGROUND & AIMS: Ischemic colitis (IC) is considered a disease of elderly patients who have associated diseases. The aim of this study was to evaluate the mortality prognostic factors in patients with IC. PATIENTS AND METHODS: Analysis of 66 consecutive patients (30 men and 36 women) with this disease. We evaluated clinical, analytic, endoscopic, histologic and evolutionary data. Odds Ratio (OR) and the χ 2 test were used. RESULTS: The patients age ranged from 49 to 94 years (mean : 73 years). Mean hospitalization was 15±12 days. Patients presented mainly with hematochezia (97 %) and abdominal pain (74 %). Co-morbility were present in 56 of 66 patients (85 %). Fourteen of 66 patients (22 %) were found to have more than two segments affected. The majority of lesions occured in the sigmoid colon (89 % cases). The severity endoscopic features ( Ann. Gastroenterol. Hepatol., 1990, 26 : 181-183 ) was grade I (29 %), grade II (63 %) and grade III (8 %). Ten of 66 patients (15 %) presented colonic strictures. Five of 66 patients (8 %) required surgery. Seven patients (11 %) died. The death was significantly associated with LDH>600U/l (OR=26,2; IC=2,9-240), >2 segments of colon affected (OR=37,5; IC=3,8-353,9) and subocclusion (OR=23,2; IC=1,8-302,7). Normal LDH was associated with favourable evolution (OR=0,04; IC=0-0,35). CONCLUSIONS: Increased LDH (>600U/l), extension of colitis and subocclusion were significant prognostics factors of death.