Fabio Guerrazzi

Bleeding Duodenal Varices Successfully Treated with TIPS

Upper gastrointestinal hemorrhage is a life-threatening complication of liver cirrhosis and portal hypertension. It is well recognized that, despite adequate pharmacologic and endoscopic therapy, there is a 20–35% mortality ratio in the first occurrence of gastrointestinal bleeding [1, 2]. Ruptured esophageal varices, peptic ulcer disease, portal hypertensive gastropathy, and ruptured gastric varices are most commonly associated with bleeding events, and the severity seems to be associated with the degree of liver dysfunction. The most common site of variceal bleeding is the lower esophagus, followed by gastric varices. These can be detected in up to 25% of portal hypertensive, cirrhotic patients [3–5]. Duodenal varices are uncommon among cirrhotic patients [6], and bleeding duodenal varices represent a major challenge for management, as both pharmacological and endoscopic therapy may not fully control hemorrhage. We report a case of a patient diagnosed with liver cirrhosis and portal hypertension on a waiting list for liver transplantation who developed upper gastrointestinal bleeding secondary to duodenal varices, managed with transjugular intrahepatic portosystemic shunt (TIPS). Endoscopic features preand post-TIPS are reviewed.

Performance of the Rockall scoring system in predicting the need for intervention and outcomes in patients with nonvariceal upper gastrointestinal bleeding in a Brazilian setting: a prospective study.

Background/Aims: This prospective study investigated the performance of pre-endoscopy and the complete Rockall scores in predicting the occurrence of adverse outcomes and the need for endoscopic or surgical intervention in patients with nonvariceal upper gastrointestinal bleeding. Methods: All 656 consecutive patients who underwent endoscopy due to nonvariceal upper gastrointestinal bleeding between 2007 and 2011 were included. Receiver operating characteristic (ROC) curves were plotted for the outcomes of therapeutic intervention, rebleeding and death. The discriminative accuracy of the risk scores was assessed by the area under the ROC curve. Results: Endoscopic treatment was performed in 55.2% of the patients. Rebleeding and mortality rates were 7.6 and 3.8%, respectively. The pre-endoscopy Rockall scores showed unsatisfactory accuracy in predicting the need for intervention, rebleeding or death, as shown by the respective area under the ROC curve values of 0.52, 0.52 and 0.65. The accuracy of the complete Rockall score in predicting rebleeding was poor (area under ROC: 0.52), but it was higher for mortality (area under ROC: 0.69). Conclusions: The pre-endoscopy Rockall score was not useful for predicting the need for therapeutic intervention or adverse outcomes. The complete Rockall score showed an acceptable performance in predicting mortality, but was unable to predict rebleeding.

Immunochemical Fecal Occult Blood Test for Detection of Advanced Colonic Adenomas and Colorectal Cancer: Comparison with Colonoscopy Results

Background. Fecal immunochemical tests (FITs) have been used for colorectal cancer (CRC) screening in several countries. There is lack of information concerning diagnostic performances of this method in Brazil. Methods. Patients scheduled for elective colonoscopy provided one stool sample one week before colonoscopy. The accuracy of a qualitative FIT for detection of CRC and advanced adenomas was determined. Results. Overall 302 patients completed the study. Among them, 53.5% were high risk patients referred for screening or surveillance. Nine (3%) CRCs and 11 (3.6%) advanced adenomas were detected by colonoscopy. Sensitivity and specificity for CRC were, respectively, 88.9% and 87.6%. For advanced adenomas, sensitivity was 63.6% and specificity 87.6%. Conclusion. Our results showed good sensitivity and specificity of the FIT for detecting advanced neoplasias. This method may be a valuable tool for future screening programs in Brazil.

Helicobacter pylori infection and the severity of gastritis are not associated with iron deficiency in a group of Brazilian patients

Abstract Background: Helicobacter pylori (H. pylori) infection has been associated with iron deficiency anemia. However, results reported in the literature are contradictory. The goal of the present study was to study the possible association between H. pylori infection and iron deficiency in a sample of adults. Methods: One hundred and fifty individuals were studied (H. pylori-positive n=75; H. pylori-negative n=50). The presence of anemia was determined using red cell indices and reticulocyte hemoglobin content (CHr). Iron status was assessed based on serum iron and ferritin levels. Possible involvement of inflammatory activity in erythropoiesis was investigated by measuring the correlation between C-reactive protein (CRP) and red cell indices and iron status. Results: There were no significant differences in the hematological or biochemical parameters for the two groups. Iron deficiency was diagnosed in six individuals, but no difference in prevalence was found between the H. pylori-positive and H. pylori-negative groups. A weak but significant inverse correlation was observed between CRP and CHr concentrations and between serum gastrin and CHr in the H. pylori-positive group. These results suggest a reduction in iron availability for reticulocyte hemoglobinization, but insufficient to cause anemia. Conclusions: H. pylori infection was not a determining factor for development of iron deficiency in our study population. Clin Chem Lab Med 2010;48:1809–12.

Ranitidine is unable to maintain gastric pH levels above 4 in septic patients.

PURPOSE The study aimed to evaluate whether ranitidine and pantoprazole are able to maintain gastric pH >or=4 in septic patients. MATERIALS AND METHODS Twenty intensive care unit patients from a university teaching hospital with sepsis were included in this study. Ten patients received ranitidine (50 mg as an intermittent bolus 3 times a day) and 10 received pantoprazole (40 mg as an intermittent bolus twice a day). Gastric pH was measured continuously for 48 hours. Endoscopy of the upper digestive tract, gastric biopsy, and investigation for Helicobacter pylori were carried out before and at the end of the study. RESULTS pH values >or=4 were maintained for 46.27% +/- 38.21% and 81.57% +/- 19.65% of study time in the ranitidine and pantoprazole groups, respectively (P = .04). CONCLUSIONS Intravenous ranitidine was unable to maintain gastric pH above 4 in septic patients. All cases in the ranitidine group in whom pH remained above 4 had gastric hypotrophy or atrophy. Pantoprazole successfully maintained pH levels above 4.