Fernanda Prata Borges Martins Thuler

Chemical esophagitis after chromoendoscopy with Lugol's solution for esophageal cancer: case report

Lugol’s iodine solution, a vital stain, can be used to improve the detection of esophageal squamous cancer. Normal mucosa changes from pink to dark brown as a result of iodine binding to glycogen in the squamous epithelium. Areas containing inflammatory, dysplastic, or malignant cells remain unstained. Chromoendoscopy with Lugol’s solution has been strongly recommended for populations at high risk for esophageal cancer, including those with a history of esophageal or head and neck cancers, 1-5 as well as patients who consume large amounts of alcohol and/or smoke tobacco. 2,6,7 Iodine can induce mucosal irritation, leading to oropharyngeal burning, heartburn, pain, and discomfort, and can even induce erosion or ulceration in the esophagus and stomach. 1,6 A case is presented of esophagitis that occurred after chromoendoscopy with Lugol’s iodine solution. Case report. A 48-year-old man was referred with a history of epigastric pain, heartburn, and regurgitation. Endoscopy revealed an advanced esophageal cancer in the distal third that biopsy specimens confirmed as squamouscell carcinoma. There had been no weight loss, and the patient denied dysphagia. However, he reported heavy use of alcohol and tobacco for more than 20 years. Three brothers also had esophageal cancer. On examination, enlarged lymph nodes were palpable in the neck. Further evaluation by bronchoscopy and CT confirmed the diagnosis, and the patient was referred for combined chemoradiotherapy. The chemotherapy protocol included cisplatin (100 mg/m 2 on day 1) and continuous infusion of 5-fluorouracil (600 mg/m 2 /day from day 1 to day 4). A total radiotherapy dose of 4500 cGy was given. Three months after the initial therapy, the lymphadenopathy had disappeared, which was considered an objective response. Two months later, a second endoscopic examination revealed no lesion, and approximately 10 mL of a 1.0% solution of Lugol’s iodine was sprayed over the entire esophageal mucosa. One unstained area was encountered in the proximal third, but biopsy specimens from this region disclosed only chronic esophagitis. One day after the chromoendoscopic examination, the patient presented with severe retrosternal pain. Treatment with orally administered analgesics and proton pump inhibitors provided no relief of the pain. At upper endoscopy 48 hours later, severe esophagitis was present, with many erosions distributed over the entire length of the organ (Fig. 1). Treatment was continued with analgesics and proton pump inhibitors for 2 weeks, and the pain resolved. Endoscopy 50 days later revealed normal mucosa except for a 6-mm elevated round lesion in the proximal esophagus (Fig. 2) in the same area that did not stain

Neoplasia avançada de esôfago: diagnóstico ainda muito tardio

BACKGROUND Esophageal cancer is one of the 10 most common cancers in Brazil. Diagnosis is usually late and mean survival ranges from 4 to 6 months, no matter the treatment. Relief of dysphagia and increase in life quality are the main targets of palliative therapy. AIM To evaluate patients with advanced esophageal tumor submitted to various palliative treatment options. PATIENTS AND METHOD We prospectively evaluated 38 patients with advanced esophageal cancer, with dysphagia and no chance of curative treatment, between September 2001 and June 2005. Patients were treated according to available resources, patient or referring physicians preference: 14 patients were treated with esophageal stent (9 self-expandable metallic, 4 plastic, 1 expandable plastic), 4 with palliative surgery, 8 gastrostomy (7 surgical and 1 endoscopic) and 12 nasogastric tube. RESULTS The mean dysphagia score 30 days after the procedure was improved in all groups except in the gastrostomy. Karnofsky score, reflecting quality of life, showed no improvement. The number of hospital admissions was not different among groups. Although the length of hospitalization was longer in the surgical group (42 days), it did not reach statistical significance. There was not statistically significant difference in the mean survival time among all patients. CONCLUSION An ideal palliative treatment does not exist. The method must be individualized for each patient. Surgical treatment is the most expensive, once it requires longer periods in hospital. Unfortunately, the diagnosis of esophageal tumors is still delayed, limiting the benefits of top endoscopic palliation therapy.

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.

Quantos exames são necessários para adquirir aptidão em colonoscopia

BACKGROUND: Competency for colonoscopy implies technical and cognitive skills. The American Society for Gastrointestinal Endoscopy has suggested 100 supervised procedures might be necessary. There are no specific recommendations in Brazil. AIM: To evaluate technical progress of trainees during a regular colonoscopy training program. MATERIALS AND METHOD: Two gastrointestinal fellows at Federal University of Sao Paulo, SP, Brazil, were prospectively evaluated during first year training. The frequency and time of reaching the cecum, total procedure duration, ability to identify lesions and patient discomfort were recorded. RESULTS: Two hundred and seventy one colonoscopies were preformed by both fellows (fellow A: 186 and B: 85). Twenty-seven cases were excluded of obstructive lesions or previous surgery, leading 171 and 72 exams, respectively. The mean success rate of reaching the cecum was 82.5% and 56.9%, respectively. For the first 72 exams it was 72.2% and 56.9%. Fellow A reached the cecum in 76% of first 100 colonoscopies, improving to 91.5% after the 101st. Mean time for trainees to complete the procedure was 17.7 and 23.5 minutes to fellows A and B. Trainee A took 19.8 and 14.7 minutes before and after the 100th colonoscopy. DISCUSSION: Success rate and time taken to reach the cecum progressively improved over the number of procedures with statistical significance. However, because of individual differences, 100 colonoscopies may be insufficient to acquisition of technical skills. CONCLUSION: Although analyzing the learning curve of two fellows only, we could notice a statistically significant improve in reaching the cecum with experience over time. However, depending on individual skills more than 100 procedures may be necessary during training.

A colangiopancreatografia retrógrada endoscópica pode ser realizada com segurança em caráter ambulatorial

RACIONAL: A colangiopancreatografia endoscopica retrograda e tecnica efetiva no manejo das doencas biliopancreaticas. A seguranca da realizacao do exame em ambulatorio tem sido alvo de estudo. OBJETIVO: Avaliar a seguranca da realizacao da colangiopancreatografia endoscopica retrograda em ambulatorio e descrever as complicacoes do exame. CASUISTICA E METODO: Acompanharam-se, prospectivamente, pacientes ambulatoriais encaminhados para colangiopancreatografia endoscopica retrograda durante o periodo de 2001 a 2003. Complicacoes foram definidas segundo criterios de consenso, incluindo todos os efeitos adversos relacionados ao exame. RESULTADOS: Foram incluidas 195 colangiopancreatografias endoscopicas retrogradas, 79 (40,5%) diagnosticas e 116 (59,5%) terapeuticas. O grupo incluiu 112 mulheres, com media de idade de 51 anos (±18,9). Os diagnosticos encontrados mais frequentemente foram: calculo biliar (30,2%), estenose benigna (13,8%), neoplasia (10,2%) e pancreatite cronica (10,2%). Obteve-se sucesso em 88,6% dos exames diagnosticos e 78,5% dos terapeuticos. Dos 195 pacientes, 10 (5,1%) necessitaram de observacao, dentre os quais 7 (3,6%) foram internados, (2 pacientes com pancreatite aguda, 2 com perfuracoes, 1 com hemorragia, 1 com complicacao cardiorespiratoria e 1 com febre). Dos 188 casos liberados apos o exame, 8 (4,2%) foram readmitidos (1 pancreatite aguda, 1 hemorragia, 1 perfuracao, 3 colangite, 2 dor abdominal). Ao comparar o grupo das complicacoes identificadas imediatamente contra o segundo, nao se encontrou diferenca estatisticamente significante quanto a idade, sexo, diagnostico e/ou grau de dificuldade do exame. CONCLUSAO: O tamanho da amostra e os resultados negativos da analise estatistica impediram a determinacao de fatores de risco, independentes para complicacoes pos- colangiopancreatografia endoscopica retrograda. Contudo, nao houve nenhum obito ou complicacoes com ma evolucao nos pacientes inicialmente liberados, confirmando a seguranca na realizacao da colangiopancreatografia endoscopica retrograda em ambulatorio.BACKGROUND Endoscopic retrograde cholangiopancreatography is effective technique to approach various biliary and pancreatic disorders. Safety of endoscopic retrograde cholangiopancreatography on an outpatient basis has been questioned. OBJECTIVES To evaluate the safety of outpatient endoscopic retrograde cholangiopancreatography and describe procedure complications. PATIENTS/METHOD We prospectively assessed outpatients endoscopic retrograde cholangiopancreatography during 2001 to 2003 period. Complications were defined according to consensus criteria and all adverse effects related to procedure were included. RESULTS One hundred and ninety five outpatients endoscopic retrograde cholangiopancreatography were performed, 79 (40.5%) diagnostic and 116 (59.5%) therapeutic. The study group included 112 women, mean age 51 (+/- 18.9) years. The most common diagnoses were: biliary calculi (30.2%), benign stenosis, (13.8%), malignant obstruction (10.2%) and chronic pancreatitis (10.2%). Success was achieved in 88.6% of diagnostic endoscopic retrograde cholangiopancreatography and 78.5% in therapeutic. Complications necessitating observation developed in 10 (5.1%) of 195 endoscopic retrograde cholangiopancreatography, among them, 7 (3.6%) were hospitalized, (2 acute pancreatitis, 2 perforations, 1 bleeding, 1 cardio-respiratory e 1 fever). Among 188 patients initially discharged 8 (4.2%) needed readmission (1 acute pancreatitis, 1 bleeding, 1 perforation, 3 cholangitis, 2 abdominal pain). Comparing the first group where complications were immediately identified to the second, no significant statistical difference concerning to age, sex, diagnoses and procedure difficulty degree was found. CONCLUSION Sample size and negative statistical results failed to determinate independent risk factors for outpatients endoscopic retrograde cholangiopancreatography complications. However, there were no deaths or bad evolution in patients released after examination, confirming the safety of outpatient endoscopic retrograde cholangiopancreatography.

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.