Julio Cesar Pisani

The nasogastric feeding tube as a risk factor for aspiration and aspiration pneumonia.

&NA; Sometimes it is possible to differentiate whether the aspirate is gastric or pharyngeal. The kind of bacterial contamination is, however, more difficult to establish. Oral or dental disease, antibiotic therapy, systemic illness or malnutrition and reduction of salivary flow are responsible for colonization of Gramnegative bacteria in oral and pharyngeal flora in nasogastrictube‐fed patients. The use of a nasogastric feeding tube and the administration of food increase gastric pH and lead to colonization of gastric secretions. It has also been suggested that gastric bacteria could migrate upward along the tube and colonize the pharynx. Purpose of review Aspiration is one of the most common complications in enterally fed patients. The source of aspiration is due to the accumulation of secretions in the pharynx of reflux gastric contents from the stomach into the pharynx. The true prevalence of aspiration is difficult to determine because of vague definitions, poor assessment methods, and varying levels of clinical recognition. Recent findings There is evidence in the literature showing that the presence of a nasogastric feeding tube is associated with colonization and aspiration of pharyngeal secretions and gastric contents leading to a high incidence of Gram‐negative pneumonia in patients on enteral nutrition. However, other aspects may be equally important and should also be considered when evaluating a patient suspected of having aspiration and aspiration pneumonia. The mechanisms responsible for aspiration in patients bearing a nasogastric feeding tube are (1) loss of anatomical integrity of the upper and lower esophageal sphincters, (2) increase in the frequency of transient lower esophageal sphincter relaxations, and (3) desensitization of the pharyngoglottal adduction reflex.

Celiac Disease Prevalence in Brazilian Dilated Cardiomyopathy Patients

AbstractCeliac disease (CD) is a permanent condition of gluten intolerance and a number of autoimmune diseases have been associated with it. In the past few years, a relation between CD and dilated cardiomyopathy (CM) was described in Europe and United States. The aim of this study was to evaluate the prevalence of CD among south Brazilian precardiac transplant patients with advanced CM. A total of 74 patients on a list for heart transplantation were evaluated for the presence CD. The presence of anti-endomisial antibody (IgA-EmA) was determined by indirect immunofluorescence and for the anti-transglutaminase antibody (IgA anti–h-tTG) by ELISA. Serologically positive patients were submitted to upper endoscopy with intestinal biopsy. Two individuals (2.63%) were positive for IgA-EmA and 5 (6.75%) for IgA anti–h-tTG; 1 (1.35%) had both tests positive. Histologic confirmation of CD occurred only in the IgA-EmA positive patients. In conclusion, data from the present study allows recommend the screening for CD in patients with CM using IgA-EmA test as the method of choice.

Avaliação da densidade mineral óssea em pacientes com doença inflamatória intestinal

ABSTRACT – Background - Inflammatory bowel disease patients have shown greater reduction of the bone mineral density compared to healthy people. Aim – To evaluate the bone mineral density in a population of patients with inflammatory bowel disease. Methods - Ninety patients from 20 to 50 years old, of the Inflammatory Bowel Disease Ambulatory of the Gastroenterology Service of the Clinics Hospital, Curitiba, PR, Brazil, were selected for the evaluation. From those, 76 completed all the stages of the evaluation. The densitometry was made from lumbar column and right femur with a dual-energy x-ray absortiometry (Hologyc QDR 1000/W) device. Results - The inflammatory bowel disease patients had a significant reduction of the bone mineral density in all the evaluated parts, femur neck, total femur and lumbar column. The analysed variables, disease activity index, usage of corticoids, the lack of physical activities, the index body mass and previous surgeries did not have influence in the results.

Cromoendoscopia com azul de metileno para diagnóstico de esôfago de Barrett

BACKGROUND Barretts esophagus is a condition in which the normal stratified squamous epithelium of the esophagus is replaced by specialized intestinal metaplasia, that carries an increased risk for the development of adenocarcinoma of the esophagus. Dysplasia and initial stage carcinoma generally precede this neoplasm; the increased risk has led to attempts at early detection of these lesions through periodic upper endoscopy and biopsies. The continued rise in the incidence of adenocarcinoma of the esophagus has fueled resurgent interest in the use of a variety of endoscopic techniques, like methylene blue chromoendoscopy, to improve the diagnosis of Barretts esophagus and associated complications. AIM To determine if methylene blue chromoendoscopy directed biopsies offer advantage over the conventional technique in the detection of Barretts esophagus. MATERIAL AND METHOD Forty-five patients with previous diagnosis of Barretts esophagus were enrolled in this study; all of them underwent upper endoscopy with random biopsies and upper endoscopy with methylene-blue directed biopsies within 4 weeks, in the period between April and October, 2002. RESULTS Results of histologic examination of random biopsies and those of methylene blue directed biopsies were compared. Sensitivity, specificity, positive and negative predictive values were 62,5%, 15,4%, 57,7% and 18,2%, respectively. No significant differences were found in the total number of biopsy specimens. Differences were found in the total amount of time spent during each procedure (chromoendoscopy x conventional technique), with chromoendoscopy being significantly longer. CONCLUSION We concluded that methylene blue chromoendoscopy offered no advantage over the conventional method in the diagnosis of Barretts esophagus.

A TAXA DE RESPOSTA SUSTENTADA DA HEPATITE C CRÔNICA AO TRATAMENTO COM OS DIVERSOS INTERFERONS-ALFA E RIBAVIRINAS DISTRIBUÍDOS PELO GOVERNO BRASILEIRO É SEMELHANTE À DA LITERATURA MUNDIAL

BACKGROUND: The sustained response rates of chronic hepatitis C therapy to interferons alpha 2A and 2B associated to ribavirin are described as approximately 40%. Nevertheless, studies on the sustained response rates in a setting of frequent changes of type of interferon as well as of supplies of interferons and ribavirin are lacking. AIMS: To evaluate the prevalence of sustained response and to determine the predictors of response to chronic hepatitis C therapy, in a cohort of outpatients at Curitiba, PR, south Brazil, in a setting of heterogeneous therapy regarding type and supply of the medications. POPULATION AND METHODS: A cohort of 87 chronic hepatitis C patients submitted to therapy with interferon alpha 2 and ribavirin were followed from August 1999 to August 2002. The prevalence of sustained response and the influence of gender, age, genotype and severity of liver fibrosis in the response were evaluated. RESULTS: A sustained response prevalence of 32.1% was found, positively associated to genotypes 2 and 3. CONCLUSIONS: Despite the frequent changes on product type and/or procedence, the sustained response prevalence rate found in this study was similar to that described in the literature.

Diagnóstico de esofagite de refluxo em lactentes: a histologia do esôfago distal deve complementar a endoscopia digestiva alta

OBJETIVO: O objetivo deste estudo foi o de validar os resultados do exame de endoscopia digestiva alta contra a histologia do esofago distal para o diagnostico da esofagite de refluxo em lactentes. METODOS: Foram revisados os prontuarios de 167 pacientes (88 do sexo masculino e 79 do sexo feminino) com idade de 38 a 364 dias, encaminhados para investigacao de esofagite de refluxo no periodo de janeiro de 1995 a dezembro de 2000. Analisou-se a associacao entre as variaveis nominais (presenca ou ausencia de esofagite) e ordinais (graus de esofagite) atraves da comparacao entre os resultados da endoscopia digestiva alta e histologia. RESULTADOS: A endoscopia digestiva alta, quando comparada a histologia, apresentou sensibilidade de 45%, especificidade de 71%, valores preditivos positivo de 89% e negativo de 21%, e acuracia de 50%. Verificou-se baixa concordância entre os achados endoscopicos e histologicos na endoscopia digestiva alta normal ou na esofagite grau I (eritema leve ao nivel da transicao epitelial, apagamento, friabilidade e perda do brilho da mucosa) (p = 0,10). A endoscopia digestiva alta normal nao identificou 79,2% dos pacientes com esofagite histologica. Entre os pacientes com esofagite grau I a endoscopia digestiva alta, 12,1% nao apresentaram alteracoes histologicas. CONCLUSOES: Concluiu-se que, enquanto a endoscopia digestiva alta apresentou especificidade de 71%, nao atingiu sensibilidade aceitavel (45%) para justificar sua realizacao sem biopsia; e que a presenca de esofagite grau I (nao-erosiva) na endoscopia digestiva alta nao aumentou a capacidade deste exame de prever a anormalidade histologica.

Metaplasia intestinal especializada de esôfago distal na doença do refluxo gastroesofágico: prevalência e aspectos clínico-epidemiológicos

BACKGROUND: Specialized intestinal metaplasia can be categorized according endoscopic and histological findings in long segment Barrett, short segment Barrett and specialized intestinal metaplasia of cardia. Barretts esophagus is an acquired disease that is found in about 10%-13% of patients undergoing endoscopy for symptoms of gastroesophageal reflux disease and it is well established as predisposing to esophageal adenocarcinoma. The columnar epithelium with goblet cells replaces the normal squamous epithelium. OBJECTIVE: To determine the prevalence and clinical-demographic characteristics of specialized intestinal metaplasia of distal esophagus in the gastroesophageal reflux disease. METHODS: From April to October 2002, 402 patients referred to upper endoscopy due gastroesophageal reflux disease were evaluated through of a symptom questionnaire about clinical and demographic features and submitted to upper endoscopy with four-quadrant biopsies 1 cm below escamocolumnar junction. RESULTS: Eighteen point four percent of patients had specialized intestinal metaplasia, 0.5% long segment Barrett esophagus, 3.2% short segment Barretts esophagus and 14.7% specialized intestinal metaplasia of cardia. Patients with Barretts esophagus showed a tendency to be male and specialized metaplasia of cardia to be female. All patients with Barretts esophagus were white. There was not association between symptoms of gastroesophageal reflux disease and specialized intestinal metaplasia, but patients with Barretts esophagus showed a tendency to have symptoms over 5 years and had more hiatal hernia and esophagitis. The use of alcohol and tobacco was not related to the presence of specialized intestinal metaplasia. CONCLUSIONS: Barretts esophagus was more related to the male gender, gastroesophageal reflux disease symptoms for 5 years or longer, more intense esophagitis and hiatal hernia, but was not related to the use of tobacco and alcohol.

Complicações biliares pós-transplante hepático intervivos

OBJETIVO: A reconstituicao biliar no transplante hepatico intervivos e associada a elevada taxa de complicacoes. O objetivo do presente estudo e apresentar a nossa experiencia com as complicacoes biliares pos-transplante hepatico intervivos e o seu tratamento. METODO: De um total de 300 transplantes hepaticos, 51 (17%) foram com doadores vivos. Todos receptores tinham o grupo sanguineo ABO identico aos dos doadores. Os prontuarios eletronicos dos receptores foram avaliados para determinar a presenca e o tipo de anomalia da via biliar, o tipo de reconstituicao da via biliar, presenca de complicacoes vasculares e biliares e o metodo e o resultado do tratamento das complicacoes. RESULTADOS: A via biliar era dupla em sete enxertos (16,7%) e tripla em dois (4,8%) enxertos do lobo hepatico direito. Nos demais, ela era unica. O tipo de reconstituicao mais comum foi a hepaticohepaticostomia unica ou dupla (38 transplantes; 75%). Complicacoes biliares ocorreram em 21 pacientes (41,2%) e incluiram fistula biliar em 11 (21,6%), estenose biliar em seis (11,8%) e fistula com estenose em quatro (7,8%). O local da fistula foi na anastomose biliar em 11 pacientes (21,6%) e na superficie cruenta do figado em quatro (7,8%). O tratamento consistiu de insercao de protese biliar em oito, papilotomia em um, retransplante em dois que tinham trombose da arteria hepatica e sutura do ducto em um. A fistula fechou com o tratamento conservador em tres pacientes. A maioria dos pacientes com estenose biliar foi tratada com dilatacao seguida da colocacao de protese biliar. CONCLUSOES: As complicacoes biliares sao frequentes apos o transplante hepatico intervivos e sao associadas a elevada taxa de morbidade e mortalidade.

Diagnostic methods for the detection of anterograde aspiration in enterally fed patients.

Purpose of reviewThe diagnosis of aspiration and its origin in patients on enteral tube feeding is challenging to the physician and provides an important means to prevent pneumonia. This review examines the most recent studies and developments in the field with an approach to the technical aspects of diagnostic methods. Recent findingsThe methods more commonly used to detect anterograde aspiration in clinical practice are fiberoptic endoscopic evaluation of swallowing and modified barium swallowing. Recent studies have shown that although these methods may provide the diagnosis of aspiration, their use for clinical monitoring is not appropriate. The studies comparing fiberoptic endoscopic evaluation of swallowing and modified barium swallowing have demonstrated that both tests present similar sensitivity, specificity and predictive values. SummaryThe different methods used to diagnose anterograde aspiration are appropriate for clinical practice, with a low complication rate and few contraindications. In most instances, the early diagnosis of aspiration and evaluation of other factors such as laryngeal sensibility, may predict the occurrence of aspiration pneumonia.

Prevalência de alterações proliferativas gástricas em pacientes com uso crônico de inibidores de bomba de prótons

RACIONAL: As medicacoes mais frequentemente prescritas e usadas de forma cronica por pacientes com queixas dispepticas pertencem ao grupo dos inibidores de bomba de protons cujo principal representante e o omeprazol, utilizado clinicamente a cerca de 20 anos. Estudos recentes tem postulado a relacao entre o uso cronico desta medicacao e alteracoes proliferativas macroscopicas e microscopicas da mucosa do fundo e corpo gastrico, principalmente os polipos de glândulas fundicas. OBJETIVO: Analisar a frequencia e o tipo de alteracoes proliferativas gastricas em usuarios cronicos de inibidores de bomba de protons e sua associacao com idade, dose utilizada, tempo de uso, sintomatologia e infeccao pelo Helicobacter pylori. METODO: Estudo transversal de prevalencia realizado no Servico de Endoscopia Digestiva do Hospital de Clinicas da Universidade Federal do Parana. Aplicado questionario com informacoes quanto ao uso destas drogas e realizada endoscopia digestiva alta em sujeitos em uso continuo desta classe de medicamentos ha pelo menos 12 meses. Realizadas biopsias de fundo, corpo e antro gastrico em todos os pacientes. Polipos eram retirados ao serem identificados, para analise histopatologica. Realizada pesquisa do Helicobacter pylori por teste de urease e analise histopatologica. RESULTADOS: Vinte e dois individuos foram incluidos sendo que seis (27,3%) apresentaram alteracoes proliferativas da mucosa oxintica. Destes, dois (9,1%) apresentavam polipos fundicos esporadicos e quatro apresentavam exclusivamente alteracao proliferativa microscopica como formacao cistica glandular. Houve significância estatistica (p 60 anos e estas alteracoes. Nao houve associacao entre dose de uso, tempo de uso, sintomatologia e infeccao pelo Helicobacter pylori. CONCLUSOES: Ocorrem alteracoes proliferativas de mucosa oxintica em individuos em uso cronico de inibidores de bomba de protons. A associacao entre idade e alteracoes proliferativas apresentou significância estatistica.