Maria do Carmo Friche Passos

3rd BRAZILIAN CONSENSUS ON Helicobacter pylori

Signicant progress has been obtained since the Second Brazilian Consensus Conference on Helicobacter pylori Infection held in 2004, in São Paulo, SP, Brazil, and justify a third meeting to establish updated guidelines on the current management of H. pylori infection. The Third Brazilian Consensus Conference on H pylori Infection was organized by the Brazilian Nucleus for the Study of Helicobacter, a Department of the Brazilian Federation of Gastroenterology and took place on April 12-15, 2011, in Bento Gonçalves, RS, Brazil. Thirty-one delegates coming from the five Brazilian regions and one international guest, including gastroenterologists, pathologists, epidemiologists, and pediatricians undertook the meeting. The participants were allocated in one of the five main topics of the meeting: H pylori, functional dyspepsia and diagnosis; H pylori and gastric cancer; H pylori and other associated disorders; H pylori treatment and retreatment; and, epidemiology of H pylori infection in Brazil. The results of each subgroup were submitted to a final consensus voting to all participants. Relevant data were presented, and the quality of evidence, strength of recommendation, and level of consensus were graded. Seventy per cent and more votes were considered as acceptance for the final statement. This article presents the main recommendations and conclusions to guide Brazilian doctors involved in the management of H pylori infection.

Cystic fibrosis, gastroduodenal inflammation, duodenal ulcer, and H. pylori infection: the "cystic fibrosis paradox" revisited.

BACKGROUND In cystic fibrosis (CF) patients a duodenal impaired bicarbonate secretion and unbuffered gastric acid are always described and the development of duodenal ulceration is uncommon (CF paradox). Helicobacter pylori (HP) infection is the main cause for duodenal ulceration and its prevalence in CF patients is controversial. AIM The objective of this study is to evaluate HP prevalence, gastric histology, and duodenal ulceration in adult FC patients. METHODS 32 adult CF patients were submitted to (13)C-urea breath test and serum immunoblotting test for HP diagnosis. Among them, 20 patients were submitted to endoscopy. RESULTS 19/32 (68%) patients showed positive serology. Endoscopy showed erosive duodenitis (15%), and duodenal ulcer scar in 10%. On duodenal histology, 94.5%, showed active inflammation and 66.7% gastric metaplasia. CONCLUSION HP infection prevalence in adult CF patients was similar to that of general Brazilian population. CF patients have all the duodenal spectrum of alterations, including duodenal ulcer. CF paradox may not exist.

Enterografia por tomografia computadorizada: experiência inicial na avaliação das doenças do intestino delgado

OBJECTIVE: The present study was aimed at demonstrating the value of computed tomography enterography (CT enterography) and how this imaging method can be useful in the diagnostic elucidation and assessment of patients with small bowel diseases. MATERIALS AND METHODS: Retrospective evaluation of 35 patients submitted to CT enterography in a 16-row multidetector CT equipment from May/2008 to March/2009. All the patients received intravenous and neutral oral iodinated contrast agents (polyethylene glycol). Main indications were: Crohn’s disease, diarrhea of undetermined origin and suspicion of neoplasia. RESULTS: A good correlation was observed between CT enterography findings and clinical, laboratory and endoscopic data related to the disease activity in patients with Crohn’s disease. In 15 cases alterations compatible with Crohn’s disease were identified, nine of them suggesting disease activity. A diagnosis was achieved in the majority of the patients with diarrhea. Carcinoid tumors were identified in two patients. CONCLUSION: CT enterography is a simple and effective method in the evaluation of inflammatory/neoplastic small bowel diseases, particularly in cases of Crohn’s disease, indicating disease activity. One of the main advantages of this method is the possibility of evaluating associated mesenteric and extraintestinal alterations.

Once-daily Helicobacter pylori treatment to family members of gastric cancer patients.

TO THE EDITOR: Nearly 1 million new cases of gastric cancer occur worldwide each year, mainly in developing countries (1).Helicobacter pylori(H. pylori) is now considered a group I carcinogen to gastric cancer and H. pylori eradication in family members is being recommended by different consensus conferences (2–4). Although very effective, the current antiH. pylori regimens have problems related to cost and compliance. After approval by the Ethics Committee of our institution, we recruited 106 first-degree family members ofH. pylori-positive gastric cancer patients. After informed consent, all participants were submitted to aC-urea breath test (UBT) (IRIS, Wagner Analysen-Technik, Bremen, Germany) to detect H. pylori. If positive, they were randomly allocated to receive one tablet of lanzoprazole 30 mg, one-tablet of clarithromycin OD (extended release formulation) 500 mg, and two tablets of furazolidone 200 mg, once daily, in the morning, for 7 days (group A), or the same regimen with only one tablet of furazolidone 200 mg (group B). Compliance was checked by medication count, considering “noncompliant” to mean the intake of,80% of the prescribed regimen. Adverse effects were checked by telephone calls either during or at the end of treatment, and by a scoring system (5). H. pylori eradication was confirmed by UBT performed 6 wk after stopping treatment. Positive test results were those with any delta over baseline (DOB) value .4‰. Statistics were performed using thex test, Student test, and Fisher’s exact test. Twenty-seven participants (25 H. pylori-negative and two H. pylori-positive who refused to sign the informed consent) were excluded. Therefore, 79 participants (41 male, mean age 37 yr) were studied. A total of 40 participants (26 male, 14 female) were allocated to group A and 39 (15 male, 24 female) in group B. All participants were compliant and completed the treatment. Adverse effects were observed in 13% of participants from group A and in 16% from group B ( p 5 0.8, NS), and included mainly nausea, taste disturbances, dizziness, and

The effect of probiotic fermented milk that includes Bifidobacterium lactis CNCM I-2494 on the reduction of gastrointestinal discomfort and symptoms in adults: a narrative review

AIM determine the effectiveness of fermented milk that included Bifidobacterium lactis CNCM I-2429 for reducing gastrointestinal (GI) discomfort in healthy adults. METHODS we conducted a systematic literature search to identify studies reporting the use of B. animalis spp. lactis for GI discomfort/comfort in healthy adults. A total of 5329 records were identified, of these 99 full-text articles were assessed. Searches for additional trials were conducted using the names of authors of each identified study and several relevant databases. The study selection was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they were randomized controlled trials; the included subjects were healthy adults; and the intervention group received B. lactis CNCM I-2494. Studies were excluded if they were non-randomized trials, if they included adults who were not healthy, if they included the use of any other intervention, or if they compared different products without a placebo group. The methodological quality of the studies was evaluated using the Oxford Quality Scale and the Cochrane Concealment Assessment. A meta-analysis was not possible. RESULTS the search strategy identified two studies that included a total of 538 healthy women, aged 18-60 years, normal weight or overweight (BMI 18-30 kg/m2). GI well-being was significantly improved in the Probiotic group vs. the Control group in one study, with no differences in the other. The percentage of responders for GI well-being was higher in the Probiotic group vs. the Control group in the first study but not in the second. GI symptoms were significantly decreased in the Probiotic group vs. the Control group in both studies. Bowel function was assessed by one study; the stool frequency did not differ between the groups, but a decrease in stool consistency was observed in the Probiotic group but not in the Control group. Possible mechanisms of action (gut motility, hypersensitivity, gut permeability, and gut microbiota) were also described. CONCLUSION probiotic fermented milk containing B. lactis CNCM I-2494 by healthy women may improve GI well- being and decrease the frequency of GI symptoms.

IVTH BRAZILIAN CONSENSUS CONFERENCE ON HELICOBACTER PYLORI INFECTION

Significant progress has been obtained since the III Brazilian Consensus Conference on H. pylori infection held in 2012, in Bento Gonçalves, Brazil, and justify a fourth meeting to establish updated guidelines on the current management of H. pylori infection. Therefore, the Núcleo Brasileiro para Estudo do Helicobacter pylori e Microbiota (NBEHPM), association linked to Brazilian Federation of Gastroenterology (FBG) held its fourth meeting again in Bento Gonçalves, RS, Brazil, on August 25-27, 2017. Twenty-six delegates, including gastroenterologists, endoscopists, and pathologists from the five regions of Brazil as well as one international guest from the United States, participated in the meeting. The participants were invited based on their knowledge and contribution to the study of H. pylori infection. The meeting sought to review different aspects of treatment for infection; establish a correlation between infection, dyspepsia, intestinal microbiota changes, and other disorders with a special emphasis on gastric cancer; and reassess the epidemiological and diagnostic aspects of H. pylori infection. Participants were allocated into four groups as follows: 1) Epidemiology and Diagnosis, 2) Dyspepsia, intestinal microbiota and other afections, 3) Gastric Cancer, and, 4) Treatment. Before the consensus meeting, participants received a topic to be discussed and prepared a document containing a recent literature review and statements that should be discussed and eventually modified during the face-to-face meeting. All statements were evaluated in two rounds of voting. Initially, each participant discussed the document and statements with his group for possible modifications and voting. Subsequently, during a second voting in a plenary session in the presence of all participants, the statements were voted upon and eventually modified. The participants could vote using five alternatives: 1) strongly agree; 2) partially agree; 3) undecided; 4) disagree; and 5) strongly disagree. The adopted consensus index was that 80% of the participants responded that they strongly or partially agreed with each statement. The recommendations reported are intended to provide the most current and relevant evidences to management of H. pylori infection in adult population in Brazil.

DRUG RESISTANCE IN HELICOBACTER PYLORI

H. pylori infection determines an important acute and chronic gastric mucosa inflammation. If untreated, the inflammation may remain forever, being infrequently spontaneously eliminated. It is known that chronic gastritis caused by this infection may lead to atrophic gastritis, intestinal metaplasia and dysplasia, thus setting the role of H. pylori in gastric carcinogenesis cascade(4,7). Therefore recent meetings on the subject suggest to eradicate this organism in all infected individuals(2,3,8). The most widely used treatment consists of an association of clarithomycin, amoxyllin and a proton pump inhibitor (PPI) during 7 days(3,8). However, it is noticed that the currently used treatments in order to eradicate H. pylori present decreasing levels of success. The Maastricht IV Consensus Report. draws attention to some factors that may commit the efficacy of the threefold scheme, such as high resistance to antibiotics, specially to clarithomycin; incomplete treatment compliance; high gastric acidity, high bacterial load and different strains of H. pylori(8). This months’ edition of Archives of Gastroenterology journal publishes an excellent review paper on the resistance of H. pylori to antimicrobials, written by Vianna et al.(12). The authors carried a careful and comprehensive literature review on available methods to diagnose bacterial resistance, further highlighting the current susceptibility to each of the antibiotics used to treat this infection and the main factors associated with resistance in these cases. In fact, recent molecular studies showed high levels of H. pylori resistance to some antibiotics that are routinely used in eliminating schemes, especially clarithomycin and fluoroquinolones(7). Many of these studies have shown that resistance to clarithomycin is really high in some regions of the world, directly affecting the eradication of H. pylori. An European multicenter study comprising 18 countries showed high levels of resistance to both clarithomycin (17.5%) and fluoroquinolones (14.1%), varying widely according to the regions(9,13). For this reason, the latest Maastricht Consensus do not recommend the use of this antibiotic as first line of treatment in regions where resistance to clarithomycin rates are higher than 15%20%(8). This is the case, for example, of some regions in Italy and in Poland, where the first choice schemes no longer include the macrolide(1,10,13). DRUG RESISTANCE IN HELICOBACTER PYLORI

Pós-graduação no exterior: vale a pena?

Se eu tivesse que responder a esta pergunta com apenas uma unica palavra escreveria que SIM (com letras maiusculas), claro que sim, alias, qualquer experiencia de residir e trabalhar fora do pais e importante para o profissional. O contato com outras culturas, o aprendizado em outras universidades e hospitais e, especialmente, o convivio direto com pesquisadores e especialistas renomados tem enorme valor para quem trabalha em um mundo cada vez mais globalizado. Sabemos bem que o medico moderno precisa agucar seus atributos humanos, adaptar-se a contextos variados e manter a educacao permanente. Para mim foi um grande privilegio poder realizar duas pos-graduacoes no exterior. Fiz parte do meu doutorado (bolsa de doutoradosanduiche concedida pelo CNPq) na Universidade Autonoma de Barcelona durante todo o ano de 2001. A escola de Barcelona, capitaneada pelos professores Juan Malagelada, Fernando Azpiroz e Jorgi Serra, se dedica, ha anos, de forma pioneira, ao estudo da dinâmica dos gases intestinais. No Hospital Vall d’Hebron, sob a orientacao desses tres pesquisadores realizamos um estudo denominado Resposta sensorial e dinâmica dos gases intestinais entre individuos com distensao abdominal funcional e voluntarios assintomaticos, onde comparamos os efeitos da distensao retal sobre o trânsito de gas intestinal em pacientes com sindromes gastrointestinais funcionais e individuos saudaveis. Durante o meu estagio em Barcelona trabalhei em varios outros projetos, o que me proporcionou a publicacao de tres artigos em revistas de alto impacto cientifico. Em 2007 realizei o pos-doutorado na Universidade de Harvard, em Boston, tambem com a concessao de uma bolsa do CNPq. No Hospital Beth Israel eu tive a oportunidade de trabalhar com diferentes linhas de investigacao sob a orientacao de dois excepcionais pesquisadores, Antony Lembo e Felipe Fregni. Com o Prof. Lembo realizei um trabalho de revisao de mais de 300 prontuarios de pacientes com disturbios funcionais digestivos, determinando fatores de gravidade e qualidade de vida desses pacientes, alem de outro estudo sobre a prevalencia de supercrescimento bacteriano em pacientes com sindrome do intestino irritavel (dados ainda nao publicados). Sob a orientacao do Dr. Felipe Fregni, que e neurologista, foi iniciado um estudo para avaliar o efeito clinico da Estimulacao Magnetica Transcraniana em pacientes com disturbios gastrointestinais funcionais, trabalho que ainda se encontra em fase de finalizacao. Conseguimos ainda realizar uma meta-analise sobre o tratamento da dispepsia funcional, comparando o efeito de medicamentos rotineiramente empregados com aqueles de acao central, sendo o artigo publicado na integra na revista Pain Physician ha dois meses (CNS or classic drugs for the treatment of pain in functional dyspepsia? A systematic review and meta-analysis of the literature). Durante o estagio no exterior, com todo o tempo disponivel para a pos-graduacao, praticamos verdadeira imersao na investigacao cientifica, o que e formidavel. Ao mesmo tempo, a visao de quem vive e estuda no exterior se amplia consideravelmente, o mesmo acontecendo com a capacidade de entender e interagir com diferentes culturas, novos amigos e novos idiomas. Para ficar um periodo no exterior e obvio que alguns desafios, nem sempre faceis, precisam ser vencidos, especialmente a saudade da familia, dos amigos e da rotina da vida no Brasil. Viver em um pais diferente significa uma serie de mudancas em diversos aspectos da vida de qualquer pessoa. Antes de se pensar em fazer um investimento em uma pos-graduacao no exterior, o profissional deve analisar cuidadosamente sua area de atuacao e a oportunidade real de sair do pais. A seguir, abordaremos alguns aspectos praticos que devem ser lembrados para realmente valer a pena sair do Brasil. 1) Quando vale a pena fazer a pos-graduacao fora do Brasil? E importante ressaltar primeiramente que temos inumeros cursos excepcionais de Pos-Graduacao no Brasil, que em determinadas areas nao deixam nada a desejar aos programas academicos de universidades do exterior. • Se for um candidato ao mestrado nao ha nenhuma razao essencial para ir para o exterior. A maioria dos mestrados no Brasil bem avaliados pela CAPES sao melhores do que os cursos ditos “mestrado” no exterior;