Erika Pereira Macedo

Obstructive jaundice secondary to bile duct involvement with Hodgkin's disease: a case report

CONTEXT Obstructive jaundice due to lymphoma is very rare. It may be difficult to distinguish between this condition and a large number of causes of extrahepatic bile duct obstruction, even by endoscopic retrograde cholangiography. Its prognosis is poor. Combined chemotherapy and/or radiotherapy with bile duct drainage is a therapeutic option. CASE REPORT We describe a case of obstructive jaundice as the initial presentation of Hodgkins disease. After chemotherapy and endoscopic bile duct stenting, it was noted that the enlarged lymph nodes, jaundice and bile duct dilation disappeared.

COMPARATIVE STUDY AMONG THREE METHODS FOR ORAL COLONOSCOPY PREPARATION: MANITOL, POLYETHYLENE GLYCOL and ORAL SODIUM PHOSPHATE ENEMA

Background:  Only appropriate colon cleansing enables total and detailed evaluation of the whole colonic mucosa, essential for safe colonoscopy, and good diagnostic and therapeutic results. The present study compared three methods of outpatient colonoscopy preparation (manitol, polyethylene glycol and oral sodium phosphate enema).

Sedation in gastrointestinal endoscopy: a prospective study comparing nonanesthesiologist-administered propofol and monitored anesthesia care

Introduction: Adequate sedation is one of the cornerstones of good quality gastrointestinal endoscopy (GIE). Propofol sedation has increased significantly but there has been much debate over whether it can be administered by endoscopists. The aim of this prospective trial was to compare nonanesthesiologist-administered propofol (NAAP) and monitored anesthesia care (MAC). Methods: A total of 2000 outpatients undergoing GIE at Hospital Albert Einstein (São Paulo, Brazil), a tertiary-care private hospital, were divided into two matched groups: NAAP (n = 1000) and MAC (n = 1000). In NAAP, propofol doses were determined by the endoscopist. A second physician stayed in the room during the entire procedure, according to local regulations. In MAC, the anesthesiologist administered propofol. Results: In total, 1427 patients (71.3 %) were ASA (American Society of Anesthesiologists) class I and 573 were ASA class II. In NAAP, patients received more propofol + fentanyl (61.1 % vs. 50.5 %; P < 0.05) and there were fewer cases of deep sedation (44.7 % vs. 66.1 %; P < 0.05). Hypoxemia rates were similar (12.8 % for NAAP and 11.2 % for MAC; P = 0.3) but these reverted more rapidly in MAC (4.22 seconds vs. 7.26 seconds; P < 0.05). Agitation was more frequent in MAC (14.0 % vs. 5.6 %; P < 0.05). No later complications were observed. Patient satisfaction was very high and similar in both groups. Conclusion: In this setting, NAAP was as safe and effective as MAC for healthy patients undergoing GIE. Clinical trial ref. no.: U1111-1134-4430

Endoscopic follow-up of cyanoacrylate obliteration of gastric varices

Bleeding from gastric varices is a life-threatening condition. We report our experience with cyanoacrylate injection. Twenty three patients with portal hypertension and gastric varices underwent intra-variceal injection of a cyanoacrylate/lipiodol solution (1:1). Study endpoint was variceal obliteration. Mean follow-up was 25.3 months. Variceal obliteration was achieved in 87% of patients. Recurrence occurred in one patient (4.3%) and rebleeding in another case (4.3%). Mild abdominal pain was described in 13% of patients. Overall mortality was 21.7% and rebleeding related mortality rate was 4.3%. Our results confirm that cyanoacrylate injection is effective and safe to eradicate gastric varices.

SAFETY OF MANNITOL USE IN BOWEL PREPARATION: a prospective assessment of intestinal methane (CH4) levels during colonoscopy after mannitol and sodium phosphate (NaP) bowel cleansing.

BACKGROUND - Adequate bowel preparation is critical for the quality of colonoscopy. Despite reported occurrence of colonic explosion due to methane and hydrogen production by bacterial fermentation during colonoscopy, gas exchange during the procedure is believed to be effective in lowering existing methane concentration, allowing for safe utilization of mannitol for bowel preparation. Thus, mannitol is widely used for bowel cleansing prior to colonoscopy, considering its low cost and effectiveness for bowel preparation. OBJECTIVE - The aim of this study was to assess the safety of mannitol for bowel preparation, when compared to sodium phosphate (NaP). METHODS - We conducted a prospective observational study in which 250 patients undergoing colonoscopy at Universidade Federal de São Paulo and Hospital Albert Einstein (São Paulo, Brazil) were approached for inclusion in the study. Patients received either mannitol (n=50) or NaP (n=200) for bowel preparation, based on physician indication. Study was conducted from August 2009 to December 2009. The main outcome of interest was presence of detectable levels of methane (CH4) during colonoscopy and reduction in such levels after gas exchange during the procedure. Methane concentrations were measured in three intestinal segments during scope introduction and withdrawal. Safety was assessed as the absence of high levels of methane, defined as 5%. Measurements were made using a multi-gas monitor (X-am 7000, Dräger Safety AG & Co. KGaA, Lübeck, Germany) connected to a plastic catheter introduced into the working channel of the colonoscope. Additional outcomes of interest included levels of O2. Methane and O2 levels are reported as ppm. Mean, difference and standard deviation of levels of gas measured in both moments were calculated and compared in both groups. Proportions of patients with detectable or high levels of methane in both groups were compared. Continuous variables were analyzed using t test and categorical variables using qui-square tests. The Ethics Committee in both study sites approved the study protocol. RESULTS - Patients in both groups were similar regarding demographics, colonoscopy indication, ASA status and quality of bowel preparation. Seven (3.5%) patients in the NaP group had methane detected during introduction of the endoscope. Methane levels became undetectable during withdrawal of the scope. None of the patients in the mannitol group had detectable levels of methane. O2 levels did not differ in the groups. CONCLUSION - This is the largest study to assess the safety of mannitol for bowel preparation, considering methane measurements. Our results indicate that mannitol use is as safe as NaP, and gas exchange was efficient in reducing methane concentrations.

Endoscopic and Echoendoscopic Evaluation of Gastric Varices Eradication with Cianoacrilate

Endoscopic and Echoendoscopic Evaluation of Gastric Varices Eradication with Cianoacrilate Erika Macedo, Fernanda Thuler, Veruska Di Sena, Gustavo De Paulo, Frank Nakao, Jose Ardengh, Angelo P. Ferrari Jr. Introduction: bleeding from gastric varices rupture is more severe than from esophageal varices. Usual endoscopic techniques (sclerotherapy and banding) are not good choices for gastric varices eradication. Cianoacrilate endoscopic injection has been reported as the best choice for such patients. Aim: to asses the value of echoendoscopy in monitoring gastric varices eradication by cianoacrilate injection. Method: 17 patients with Sarin type GEV2 varices were submitted to endoscopic injection of a cianoacrilate and lipiodol solution (1 ml each). Patients younger than 18 years and/or with severe systemic disease were excluded from the study. All patients were submitted to EUS and endoscopy before and at 3, 6 and 12 months after index treatment. Doppler signal was used during EUS. After each 3-month interval the injection was repeated if there was endoscopic evidence of remaining or recurrent varices. Results: our study group consisted of 10 men and 7 women, mean age 50.6 years (range 22 76, median 51 years). Portal hypertension was secondary to cirrhosis due to schistosomiasis (4), chronic B or C viral hepatitis (3 and 8) and alcohol abuse (2). Endoscopic injection was successfully performed in the U turn position, with no immediate complications. Three patients are still waiting for the first 3-month re-evaluation and two patients died of hepatic insufficiency, unrelated to bleeding. Among the remaining 12 patients, 8 finished the study (1 year follow-up), 4 had their 3and 6month follow-up (2 in each group). In seven patients there was a need for additional injection sessions: a mean of 1.8 sessions/patient (range 1-3). Endoscopic follow up showed complete eradication of variceal novel in every patient. EUS follow up showed absence of variceal flow (negative Doppler signal) in every patient considered eradicated by conventional endoscopy. There were no complications. Conclusion: endoscopic injection of cianoacrilate plus lipiodol is a safe and effective method for gastric varices eradication. EUS evaluation allows detection of variceal flow andmay help in planning additional treatment as well as in monitoring the patient.