Elisa Baba

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.

Dietary habits, ethanol and tobacco consumption as predictive factors in the development of esophageal carcinoma in patients with head and neck neoplasms.

Patients with primary head and neck cancers have a higher risk of developing esophageal cancer. The aim of this study was to investigate esophageal cancer prevalence, its risk factors (ethanol and tobacco consumption) and dietary habits in patients with head and neck cancer. Three hundred and twenty-six adults with primary head and neck cancer were followed by a retrospective observational study in a general university hospital in Sao Paulo, Brazil. Flexible videoendoscopy with lugol chromoscopy was the method used to investigate esophageal cancer prevalence. All subjects were interviewed face-to-face, revealing detailed information about their tobacco and alcohol use, as well as their dietary habits. Thirty-six patients with esophageal cancer were diagnosed and the overall prevalence rate was 11.04%. Patients who developed second esophageal tumors had the following characteristics: earlier age of initial ethanol consumption (P < 0.05), longer duration period of ethanol consumption (P < 0.05) and higher weekly consumption rate (P < 0.05). There was an increased risk of esophageal carcinoma in those patients who both smoked and drank (P < 0.05). There was no association between carcinoma of the esophagus and dietary habits in patients who developed esophageal neoplasms, compared with those who did not. Prevalence rate of esophageal neoplasms was 11.04% in patients with head and neck carcinoma, whose ethanol consumption was associated with esophageal cancer. There was an increased risk between ethanol and tobacco consumption and esophageal carcinoma development. On the other hand, there was no association regarding dietary habits between patients who developed esophageal cancer and those who did not.

Histology assessment of bipolar coagulation and argon plasma coagulation on digestive tract.

AIM To analyze the effect of bipolar electrocoagulation and argon plasma coagulation on fresh specimens of gastrointestinal tract. METHODS An experimental evaluation was performed at Hospital das Clinicas of the University of São Paulo, on 31 fresh surgical specimens using argon plasma coagulation and bipolar electrocoagulation at different time intervals. The depth of tissue damage was histopathologically analyzed by single senior pathologist unaware of the coagulation method and power setting applied. To analyze the results, the mucosa was divided in superficial mucosa (epithelial layer of the esophagus and superficial portion of the glandular layer of the stomach and colon) intermediate mucosa (until the lamina propria of the esophagus and until the bottom of the glandular layer of the stomach and colon) and muscularis mucosa. Necrosis involvement of the layers was compared in several combinations of power and time interval. RESULTS Involvement of the intermediate mucosa of the stomach and of the muscularis mucosa of the three organs was more frequent when higher amounts of energy were used with argon plasma. In the esophagus and in the colon, injury of the intermediate mucosa was frequent, even when small amounts of energy were used. The use of bipolar electrocoagulation resulted in more frequent involvement of the intermediate mucosa and of the muscularis mucosa of the esophagus and of the colon when higher amounts of energy were used. In the stomach, these involvements were rare. The risk of injury of the muscularis propria was significant only in the colon when argon plasma coagulation was employed. CONCLUSION Tissue damage after argon plasma coagulation is deeper than bipolar electrocoagulation. Both of them depend on the amount of energy used.

Endoscopic Aspects of Gastric Syphilis

Introduction. Considered as a rare event, gastric syphilis (GS) is reported as an organic form of involvement. Low incidence of GS emphasizes the importance of histopathological analysis. Objective. We aim to characterize GS endoscopic aspects in an immunocompetent patient. Case Report. A 23-year-old man presented with epigastric pain associated with nausea, anorexia, generalized malaise and 11 kg weight loss that started 1 month prior to his clinical consultation. Physical examination was normal except for mild abdominal tenderness in epigastrium. Endoscopy observed diminished gastric expandability and diffuse mucosal lesions, from cardia to pylorus. Gastric mucosa was thickened, friable, with nodular aspect, and associated with ulcers lesions. Gastric biopsies were performed, and histopathological analysis resulted in dense inflammatory infiltration rich in plasmocytes. Syphilis serologies were positive for VDRL and Treponema pallidum reagents. Immunohistochemical tests were positive for Treponema pallidum and CD138. The patient was treated with penicillin, leading to resolution of his clinical complaints and endoscopic findings. Conclusion. Diagnosis suspicion of GS is important in view of its nonspecific presentation. Patients with gastric symptoms that mimic neoplastic disease should be investigated thoroughly based on the fact that clinical, endoscopic, and histological findings can easily be mistaken for lymphoma or plastic linitis.

Argon plasma coagulation for the endoscopic treatment of gastrointestinal tumor bleeding: A retrospective comparison with a non-treated historical cohort

Background The endoscopic use of argon plasma coagulation (APC) to achieve hemostasis for upper gastrointestinal tumor bleeding (UGITB) has not been adequately evaluated in controlled trials. This study aimed to evaluate the efficacy of APC for the treatment of upper gastrointestinal bleeding from malignant lesions. Methods Between January and September 2011, all patients with UGITB underwent high-potency APC therapy (up to 70 Watts). This group was compared with a historical cohort of patients admitted between January and December 2010, when the endoscopic treatment of bleeding malignancies was not routinely performed. Patients were stratified into two categories, grouping the Eastern Cooperative Oncology Group (ECOG) performance status scale: Category I (ECOG 0–2) patients with a good clinical status and Category II (ECOG 3–4) patients with a poor clinical status. Results Our study had 25 patients with UGITB whom underwent APC treatment and 28 patients whom received no endoscopic therapy. The clinical characteristics of the groups were similar, except for endoscopic active bleeding, which was more frequently detected in APC group. We had 15 patients in the APC group whom had active bleeding, and initial hemostasis was obtained in 11 of them (73.3%). In the control group, four patients had active bleeding. There were no differences in 30-day re-bleeding (33.3% in the APC group versus 14.3% in the control group; p = 0.104) and 30-day mortality rates (20.8% in the APC group, versus 42.9% in the control group; p = 0.091). When patients were categorized according to their ECOG status, we found that APC therapy had no impact in re-bleeding and mortality rates (Group I: APC versus no endoscopic treatment: re-bleeding p = 0.412, mortality p = 0.669; Group II: APC versus no endoscopic treatment: re-bleeding p = 0.505, mortality p = 0.580). Hematemesis and site of bleeding located at the esophagus or duodenum were associated with a higher 30-day mortality. Conclusions Endoscopic hemostasis of UGITB with APC has no significant impact on 30-day re-bleeding and mortality rates, irrespective of patient performance status.

Endoscopic versus surgical resection for early colorectal cancer—a systematic review and meta-analysis

BACKGROUND To investigate the available data on the treatment of early colorectal cancer (CRC), either endoscopically or surgically. METHODS Two independent reviewers searched MEDLINE, EMBASE, CENTRAL COCHRANE, LILACS and EBSCO for articles published up to August 2015. No language or dates filters were applied. Inclusion criteria were studies with published data about patients with early colonic or rectal cancer undergoing either endoscopic resection (i.e., mucosectomy or submucosal dissection) or surgical resection (i.e., open or laparoscopic). Extracted data items undergoing meta-analysis were en bloc resection rate, curative resection rate, and complications. A complementary analysis was performed on procedure time. The risk of bias among studies was evaluated with funnel-plot expressions, and sensitivity analyses were carried out whenever a high heterogeneity was found. The risk of bias within studies was assessed with the Newcastle score. RESULTS A total of 12,819 articles were identified in the preliminary search. After applying inclusion and exclusion criteria, three cohort studies with a total of 768 patients undergoing endoscopic resection and 552 patients undergoing surgical resection were included. The en bloc resection rate risk difference was -11% [-13%, -8% confidence interval (CI)], demonstrating worse outcome results for the endoscopic resection group as compared to the surgical resection group [number need to harm (NNH) =10]. The curative resection rate risk difference was -9% [(-12%, 6% CI)] after a sensitivity analysis was performed, which also demonstrated worse outcomes in the intervention group (NNH =12). The complications rate exhibited a -7% risk difference [(-11%, -4% CI)], denoting a lesser number of complications in the endoscopic group [Number Need to Treat (NNT =15). A complementary analysis of procedure time with two of the selected studies demonstrated a mean difference of -118.32 min [(-127.77, -108.87 CI)], in favor of endoscopic resection, even though such data lacks homogeneity across studies, and could be heavily influenced by local expertise. Long-term results were found in only one study and therefore were not included in the final analysis. CONCLUSIONS According to the current available data, the treatment of early CRC by surgical resection is associated with higher curative resection rates and higher en bloc resection rates, despite of higher complications rates, as compared to endoscopic resection. Shorter procedure times are associated with the endoscopic methods of treatment, however high heterogeneity levels limit this conclusion.

DOUBLE-BALLOON ENTEROSCOPY IN THE DIAGNOSIS OF AN ADENOCARCINOMA OF THE FOURTH PORTION OF THE DUODENUM: REPORT OF A CASE

due to a coincident bariatric jejunum-ileal bypass sur-gery at that time.Upper gastrointestinal endoscopy showed antral ery-thematous gastritis, and no alteration was noted in the firstor second portions of the duodenum. Fecal stool occultblood testing was positive (3+), but colonoscopy showedno alterations. Scintigraphy with 99 Tc and marked eryth-rocytes was performed and revealed positivity for intesti-nal bleeding, probably at the proximal small bowel.DBE demonstrated first, second and third portions ofthe duodenum with no abnormalities. In the fourth portionof the duodenum a vegetative, infiltrative and friable le-sion was noted, extending about 10 cm, involving almostall the circumference and the lumen of the organ, allow-ing however the transposition of the double-balloonenteroscope. Multiple biopsies were performed. Histologi-cal examination demonstrated moderately differentiatedadenocarcinoma of the duodenum. The immunohistochemi-cal evaluation was consistent with adenocarcinoma. Afterthe diagnosis, the patient and his family elected treatmentat a private hospital and we lost the follow-up.

Esophageal Intramural Pseudodiverticulosis: A Rare Endoscopic Finding

A 76-year-old woman, presenting with a 4-year history of progressive dysphagia, was submitted to endoscopic examination. The upper endoscopy revealed a proximal esophageal stricture and inflammatory mucosa associated with multiples small orifices in the esophageal wall, some of them fulfilled with white spots suggestive of fungal infection. This was a typical endoscopic finding of esophageal intramural pseudodiverticulosis, a benign and rare condition, related to chronic esophagitis and others comorbid states, such as gastroesophageal reflux disease or infectious esophagitis, diabetes mellitus, alcohol consumption, and achalasia. Dysphagia is the predominant symptom and can be accompanied by esophageal stricture in 80% to 90% of patients. The pathogenesis is unknown, and as the pseudodiverticulosis is an intramural finding, endoscopy biopsies are inconclusive. The main histological finding is dilation of the submucosal glands excretory ducts, probably obstructed by inflammatory cells. The treatment consists in management of the underlying diseases and symptoms relief. In this particular case, the patient was submitted to antifungal drugs followed by endoscopic dilation with thermoplastic bougies, with satisfactory improvement of dysphagia.

Double-balloon endoscopy reveals sea-blue histiocytosis affecting the small bowel (with video)

1 ommentary chinococcus granulosus is the most common of the 4 species of the worldwide tapeworm Echinococcus to infect humans; the others re E multilocularis, E vogeli, and E oligarthus. The name Echinococcus probably derives from the fact that Echinococcus embryos have ultiple hooklets that give them a spiny appearance (Greek: echinos, hedgehog, sea urchin). The eggs of E granulosus are passed ith the feces of the definitive host (dogs and other canines), and it is the ingestion of these eggs by sheep, goats, swine—and umans—that leads to infection in the intermediate host. Although intermediate hosts ingest eggs to get infected, definitive hosts ust eat infected, cyst-containing organs. Ingested eggs hatch in the small intestine of the intermediate host to release oncospheres hat penetrate the intestinal wall and migrate via arteries and lymphatics to distant organs—in particular the liver and lungs—where hey develop into hydatid cysts and can survive for many years. Cysts develop 3 layers: a host-derived outer membrane that can alcify and offer a radiologic clue to diagnosis; a middle, acellular layer; and a thin, germinal epithelium from which brood capsules evelop and subsequently give rise to daughter cysts, in which protoscolices asexually develop and then eventually mature into dult worms. Think of hepatobiliary echinococcosis whenever you see a patient from an area where dogs are used in the presence f grazing livestock, and the patient has fever, tender hepatomegaly, and eosinophilia. As for cholangitis, this has been reported to esult from cyst rupture into the bile duct, bacterial superinfection of cysts, and from use of formalin to sterilize cyst contents. Surgical emoval of the cysts combined with chemotherapy (albendazole and/or mebendazole) before and after surgery is the standard herapy. For cysts in multiple organs or in high-risk locations, chemotherapy alone or PAIR (puncture-aspiration-injectioneaspiration) alone or with chemotherapy is a therapeutic option. ERCP can be used to diagnose the type and extent of disease, to xclude concomitant disease, to remove echinococcal material, to help plan surgery, and to treat postoperative complications. I am gain reminded that in the shrinking world in which we live, we are likely to see things we think we recognize but which are, in fact, utside our usual experience. We all should broaden our differential diagnoses—even when findings appear familiar. Surprise may orce quick decisions, but an appropriate and well-thought-out plan is always preferable. Lawrence J. Brandt, MD Associate Editor for Focal Points

Plasmocytoma of the jejunum: diagnosis by double-balloon enteroscopy

Multiple myeloma (MM) or Kahler’s disease is a malignant neoplasia of the lymphoplasmocyte lineage, characterized by uncontrolled and progressive proliferation of an abnormal plasmocyte clone within the bone marrow (BM) with subsequent production of monoclonal immunoglobulin. On the other hand, focal plasmocyte tumors (plasmocytomas) with formation of tumorous masses without medullary involvement may rarely affect the gastrointestinal tract (GIT) and are denominated solitary extramedullary plasmocytomas. The main extramedullary site of plasmocytoma is the jejunum. We report a patient who presented with jejunal plasmocytoma and emphasize the importance of the double-balloon endoscope for diagnosis of the lesion. 2