José Murilo Robilotta Zeitune

Gastric polyps: a retrospective analysis of 26,000 digestive endoscopies

BACKGROUND Gastric polyps are small gastric lesions, asymptomatic in most cases and are generally discovered inadvertently during upper digestive endoscopy. AIM To retrospectively review the characteristics and frequency of gastric polyps, derived from the gastric mucosal epithelium in a large series of endoscopies. METHODS One hundred and fifty three patients in a series of 26,000 consecutive upper digestive endoscopies done over a 5-year period, being that each patient had only one examination were analyzed and their histological and Yamada classification, as well as their location, size, histopathological findings and treatment studied. All patients had at least one gastric polyp, as confirmed by histological examination. RESULTS The polyps were classified as hyperplastic, adenomatous and fundic gland polyps. The most of them measure less than 1 cm (hyperplastic polyps - 60,5%; adenomatous polyps - 73,6%; fundic gland polyps - 72%). Hyperplastic polyps were the most frequent and accounted for 71.3% of the cases, whereas fundic gland polyps accounted for 16.3% and adenomatous polyps for 12.4%. Hyperplastic and adenomatous polyps were primarily single, whereas fundic gland polyps tended to be multiple. A carcinoma was detected in one hyperplastic polyp (0.9%) and in two adenomatous polyps (10.5%). High grade dysplastic foci were found in four adenomatous polyps (21%). CONCLUSIONS The digestive endoscopy is the safest and efficient method for the diagnosis of the gastric polyps, that in most of the patients does not show characteristic symptoms. The histopathological definition is not possible to the endoscopic glance being needed the pathologists aid, once the conduct to be adopted will depend on the result of the biopsy.

Virulence Factors of Helicobacter pylori: A Review

Helicobacter pylori is a spiral-shaped Gram-negative bacterium that colonizes the human stomach and can establish a long-term infection of the gastric mucosa, a condition that affects the relative risk of developing various clinical disorders of the upper gastrointestinal tract, such as chronic gastritis, peptic ulcer disease, mucosa-associated lymphoid tissue (MALT) lymphoma, and gastric adenocarcinoma. H. pylori presents a high-level of genetic diversity, which can be an important factor in its adaptation to the host stomach and also for the clinical outcome of infection. There are important H. pylori virulence factors that, along with host characteristics and the external environment, have been associated with the different occurrences of diseases. This review is aimed to analyzing and summarizing the main of them and possible associations with the clinical outcome.

Absolute ethanol and 5% ethanolamine oleate are comparable for sclerotherapy of esophageal varices

BACKGROUND Endoscopic sclerotherapy is widely accepted as an effective treatment for the eradication of esophageal varices in patients with portal hypertension and a history of upper gastrointestinal bleeding. The objective of this study was to assess the effectiveness and safety of absolute ethanol as an alternative sclerosing agent to the commonly used 5% ethanolamine oleate. METHODS One hundred fifty-seven patients with portal hypertension and a history of variceal bleeding were randomly assigned to sclerotherapy with absolute ethanol (n = 66) or 5% ethanolamine oleate (n = 91) between January 1992 and July 1994. Once eradication was achieved, these patients were prospectively followed until September 1998. RESULTS Sclerotherapy with both sclerosants resulted in similar eradication rates (approximately 90%), with comparable numbers of sessions required for eradication (5.4 and 5.9 sessions for absolute ethanol and 5% ethanolamine oleate, respectively). Similar complication and recurrent bleeding rates were observed among both groups. CONCLUSION Sclerotherapy with absolute ethanol is as effective as with 5% ethanolamine oleate in preventing further bleeding in patients with portal hypertension.

Evaluation of five DNA extraction methods for detection of H. pylori in formalin-fixed paraffin-embedded (FFPE) liver tissue from patients with hepatocellular carcinoma

Since Helicobacter spp. DNA was identified in liver tissue resected from patients with hepatocelullar carcinoma (HCC), researchers have suggested a role of this bacterium in hepatic carcinogenesis. Archives of formalin-fixed, paraffin-embedded (FFPE) tissues represent an extraordinary source for clinical studies providing many advantages. However, DNA extraction from FFPE tissues is laborious, time-consuming and still remains a challenge. The aim of this study was to evaluate five protocols for DNA extraction from FFPE liver obtained from patients with HCC in order to detect Helicobacter pylori DNA. These methods were: (1) QIAamp FFPE Tissue Kit, (2) QIAamp DNA Mini Kit, (3) Wizard SV Genomic DNA Purification System, (4) RealiaPrep FFPE gDNA Miniprep System and (5) phenol-chloroform. H. pylori detection was performed using 16S rRNA gene amplification by PCR. The highest total amount of DNA was obtained using the phenol-chloroform method. Analyses of 16S rRNA gene amplification did not show statistically significant differences among the methods (p=0.466), although the highest percentage of positive cases (70%) was found in samples extracted with phenol-chloroform. We suggest that of the five methods evaluated, phenol/chloroform is the most suitable for detection of H. pylori in FFPE liver from patients with HCC.

Treatment of patients with Schistosomiasis mansoni: a double blind clinical trial comparing praziquantel with oxamniquine

A double-blind clinical trial involving 120 patients with chronic schistosomiasis was carried out to compare the tolerability and efficacy of praziquantel and oxamniquine. The patients were randomly allocated into two groups. One was treated with praziquantel, 55 mg/kg of body weight CBWT), and the other one with oxamniquine, 15mg/kg bwt, administered in a single oral dose. The diagnosis and the parasitological follow-up was based on stool examinations by quantitative Kato-Katz method and on rectal biopsies. Side-effects — mainly dizziness, sleepness, abdominal distress, headache, nausea and diarrhea — were observed in 87% of the cases. Their incidence, intensity and duration were similar for both drugs but abdominal pain was significantly more frequent after praziquantel intake and severe dizziness was more commonly reported after oxamniquine. A significant increase of alanine-aminotransferase and y-glutamyltransferase was found with the latter drug and of total bilirubin with the former one. A total of 48 patients treated with praziquantel and 46 with oxamniquine completed with negative findings the required three post-treatment parasitological controls — three slides of each stool sample on the first, third and sixth month. The achieved cure rates were 79.2% and 84.8%, respectively, a difference without statistical significance. The non-cured cases showed a mean reduction in the number of eggs per gram of feces of 93.5% after praziquantel and of 84.1% after oxamniquine. This diference also was not significant. Five patients retreated with praziquantel were cured but only one out of three treated a second time with oxamniquine. These findings show that both drugs — despite their different chemical structures, pharmacological properties and mechanisms-of-action — induce similar side-effects as well as a comparable therapeutical efficacy, in agreement with the results reported from analogous investigations.

Inflammatory bowel disease in an underdeveloped region of Northeastern Brazil

AIM To evaluate the demographic characteristics and clinical phenotypes of inflammatory bowel disease (IBD) in a geographic area in Northeastern Brazil. METHODS This retrospective study was conducted at the Hospital of the Federal University of Piauí in Northeastern Brazil. Demographic characteristics and clinical phenotypes of IBD were analyzed in relation to the time of diagnostic confirmation, which was defined as the date of disease onset. Data were collected between January 2011 and December 2012 and included all census patients 18 years of age or older during that period for whom there was diagnostic confirmation of Crohns disease (CD), ulcerative colitis (UC), or unclassified colitis according to the Montreal criteria. We also analyzed the period of time between the onset of clinical manifestations and the diagnosis of IBD (delay in the diagnosis). Statistical analyses included means and standard deviations for numeric variables and the Pearson χ2 adherence test for nominal variables. The annual index occurrence and overall prevalence of IBD at our institution were also calculated, with P values<0.05 indicating statistical significance. This study was approved by the Institutional Ethics and Research Committee. RESULTS A total of 252 patients with IBD were included, including 152 (60.3%) UC patients and 100 (39.7%) CD patients. The clinical and demographic characteristics of all patients with IBD showed a female to male ratio of 1.3:1.0 and a mean age of 35.2 (SD=14.5) years. In addition, the majority of patients were miscegenated (171, 67.9%), had received higher education (157, 62.4%), lived in urban areas (217, 86.1%), and were under the age of 40 years (97, 62.5%). For patients with CD, according to the Montreal classification, the predominant features present from the onset of disease were an age between 17 and 40 years (A2); colonic disease location (L2); and nonstricturing, nonfistulizing disease behavior (B1). However, approximately one-quarter of all CD patients demonstrated perineal involvement. We also observed considerable delay in the diagnosis of IBD throughout the entire study period (mean=35.5 mo). In addition, the annual index occurrence rose from 0.08 to 1.53 cases/10(5) inhabitants/year during the study period, and the prevalence rate was 12.8 cases/10(5) inhabitants in 2012. Over the last two decades, there was a noted increase in the frequency of IBD in the study area. CONCLUSION In this study, there was a predominance of patients with UC, young people under 40 years of age, individuals with racial miscegenation, and low annual incomes.

Acute inflammatory response in the stomach of BALB/c mice challenged with coccoidal Helicobacter pylori

An experimental murine model was used to verify the viability and pathogenicity of coccoid Helicobacter pylori. For this purpose, 27 BALB/c mice were inoculated intragastrically with 1 ml broth culture (10(8)organisms/ml) of a coccoid H. pylori clinical isolate. The animals were divided into two groups. Nine were infected on a one-time basis (GA1) and 18 were infected on two consecutive days (GA2). Other 27 mice were inoculated with Brucella broth and divided in the same way; they composed the control group. Mice were killed at 2, 3, 7, 14 and 21 days post inoculation (pi). Fragments of stomach and duodenum were collected, fixed with 12% formalin and stained by hematoxilin-eosin and Giemsa for histopathological examination. Until the 14th()day, only reinfected mice had mild-to-moderate inflammatory infiltrate in the stomach. The infiltration was predominantly lymphomonocytic, although plasma cells and eosinophils could be seen. However, at 21st day, severe eosinophilic infiltration was present in the lamina propria and submucosa of gastric corpus. In subgroup GA1, animals presented lymphomonocytic infiltration in the stomach from 14th()day pi. Our results showed that coccoid H. pylori was able to induce an acute inflammatory response in stomach of reinfected mice since the initial periods of infection.

Improved Detection of Helicobacter pylori DNA in Formalin-fixed Paraffin-embedded (FFPE) Tissue of Patients with Hepatocellular Carcinoma Using Laser Capture Microdissection (LCM)

Dear Editor, Helicobacter DNA has been detected in hepatic tissues from patients with various hepatobiliary diseases, mainly cirrhosis and hepatocellular carcinoma (HCC). Although the role of Helicobacter spp. in pathogenesis of these diseases remains unclear, the available data suggest that Helicobacter infection may play a role in hepatic carcinogenesis [1]. Considering that HCC is one of the most common malignancies with more than 500.000 new tumors diagnosed annually [2], further studies related to H. pylori and development of HCC have fundamental importance on the understanding of its pathogenesis. Formalin-fixed paraffin-embedded (FFPE) tissue represents an extraordinary source for molecular studies as genomic DNA can be extracted from this sample. However, DNA extraction from FFPE tissues is challenging because nucleic acids are commonly fragmented and cross-linked with proteins. Furthermore, methods of DNA extraction from FFPE tissue are generally laborious and time-consuming. Laser capture microdissection (LCM) is a recently developed technique for isolation of pure populations of cells from tissue sections by microscopic visualization. Because of its high precision and accuracy, LCM has been employed in cancer-related studies. In this work, we used LCM technique to improve the detection of H. pylori in FFPE liver from patients with HCC. With this aim, six H. pylori-positive samples detected by polymerase chain reaction (PCR) with H. pylori-specific 16S rRNA primers were selected. The sequence of the sense primer (JW21) was 5′-GCGACCTGCTGGAACATTAC-3′(position 691-710) and the antisense primer (JW22) was 5′-CGTTAGCTCCATTACTGGAGA-3′ (position 829-809) [3]. Tissue samples were cut on 0.17 mm PEN membrane-covered slides (Carl Zeiss, MicroImaging GmbH, G€ ottingen, Germany) and then routine staining with carbol fuchsin was performed [4]. Thereafter, stained bacteria were microdissected using a PALM MicroBeam system (Carl Zeiss, MicroImaging GmbH, G€ ottingen, Germany) and then ejected into the Eppendorf tube cap by a single laser shot (Fig. 1C,D). After microdissection, a digestion buffer was added into Eppendorf for DNA extraction. The crude lysate was directly employed as template for PCR [4]. The samples were further amplified using H. pylori 16S rRNA primers as previously described [3], and amplicons were identified by sequence analysis. Microorganisms resembling H. pylori were observed in hepatic sinus from HCC samples (Fig. 1A,B). The number of cocci was greater than of bacilli as previously described [5]. PCR results showed that all six microdissected samples were positive for 16S rRNA gene and showed 98% similarity to 16S rRNA gene of H. pylori by sequence analysis (GeneBank accession number CP003419.1). Nevertheless, we cannot exclude the possibility of cross-reaction of these primers with other Helicobacter spp. These results demonstrated that LCM can be extensively applied for identification of H. pylori in FFPE liver tissue of HCC patients. Considering that bacteria were mainly found in peritumoral tissue, this technique was highly effective for obtaining a targeted bacterial population within a selected area in the HCC tissue. Beyond that, LCM simplified the H. pylori detection because extracted DNA was used directly as a template for PCR amplification. Further studies will be performed to isolate H. pylori from other tissues using LCM technique.

Eradication Treatment of Helicobacter pylori Infection: Its Importance and Possible Relationship in Preventing the Development of Gastric Cancer

Helicobacter pylori is the most important carcinogen for gastric adenocarcinoma. Bacterial virulence factors are essential players in modulating the immune response involved in the initiation of carcinogenesis in the stomach; host genetic factors contribute to the regulation of the inflammatory response and to the aggravation of mucosal damage. In terms of environmental factors, salt intake and smoking contribute to the development of lesions. Various therapeutic schemes are proposed to eradicate H. pylori infection, which could potentially prevent gastric cancer, offering the greatest benefit if performed before premalignant changes of the gastric mucosa have occurred.

Comparative analysis of two-dimensional electrophoresis maps (2-DE) of Helicobacter pylori from Brazilian patients with chronic gastritis and duodenal ulcer: a preliminary report.

Helicobacter pylori is a bacterium recognized as the major cause of peptic ulcer and chronic gastritis. Recently, a proteome-based approach was developed to investigate pathogenic factors related to H. pylori. In this preliminary study, H. pylori strains were isolated from gastric biopsies of patients with chronic gastritis and duodenal ulcers. A partial proteomic analysis of H. pylori strains was performed by bacterial lyses and proteins were separated by two-dimensional gel electrophoresis (2-DE). A comparative analysis was performed to verify a differential protein expression between these two 2-DE maps. These data should be useful to clarify the role of different proteins related to bacterial pathogenesis. This study will be completed using a larger number of samples and protein identification of H. pylori by MALDI-TOF mass spectrometry.