Sergio Gabriel Silva de Barros

Mate (chimarrão) é consumido em alta temperatura por população sob risco para o carcinoma epidermóide de esôfago

ABSTRACT – “Mate”, a popular hot infusion of a herb ( Ilex paraguayensis) drunk in large volumes, is a known risk factor for squamous cellcarcinoma of the esophagus and there is a suspicion that high temperature of boiled water used for the infusion may contribute for carcinogenesis. Methods - We measured the temperature of “mate” infusion drank by a sample of the population at risk for this carcinoma in Taquara, so uthernBrazil. We interviewed inhabitants for drinking habits and the temperature of the infusion was measured with high precision thermometers.Temperature of the infusion was asked to consumers and their estimate compared to our measurements. We considered 60 o C or higher as “hot”. Results - In 36 residencies, 107 individuals were drinking “mate”. Most individuals drunk it daily (97,2%), and the medium daily volume was1,265 ml (SD ± 1,132 mL) ranging from 250 to 6,000 mL. The measured temperature was 60 o C or higher in 72% of residencies with mediumof 63.4 o C (51-78 o

Clinical outcomes of eradication of Helicobacter pylori in nonulcer dyspepsia in a population with a high prevalence of infection : results of a 12-month randomized, double blind, placebo-controlled study

Ninety-one Helicobacter pylori-positive patients with nonulcer dyspepsia were randomized to receive either lansoprazole, amoxicillin, and clarithromycin or lansoprazole and placebo. A validated questionnaire assessed dyspeptic symptoms at baseline and at 3, 6, and 12 months. Endoscopies and biopsies were performed at baseline and at 3 and 12 months. There was an overall trend, although not statistically significant, for a benefit of H. pylori eradication. Of the patients in the antibiotics group, 16 of 46 (35%) had symptomatic improvement, versus 9 of 43 (21%) in the control group (P = 0.164). In a secondary analysis, it was found that of the patients without endoscopic gastric erosions, 15 of 34 (44%) in the antibiotics group and 5 of 33 (15%) of controls had symptomatic improvement (P = 0.015). Helicobacter pylori eradication did not prove to be clinically beneficial, although a tendency to symptomatic benefit was detected. Further studies are necessary to confirm the implications of endoscopic gastric erosions in these patients.

Is ineffective oesophageal motility associated with reflux oesophagitis

Objective To evaluate the association between ineffective oesophageal motility and reflux oesophagitis controlling for hiatal hernia, hypotensive lower oesophageal sphincter and male sex in patients with gastro-oesophageal reflux disease. Methods A total of 387 patients with reflux disease (mean age, 46 years, 42% men) were consecutively selected from a database. All patients underwent upper endoscopy, oesophageal manometry and 24 h oesophageal pH-metry in accordance with a standardized protocol. Reflux disease was confirmed either by endoscopy (oesophagitis grade I–IV according to Savary–Miller) or by pH-metry (increased acid exposure). Hiatal hernia was diagnosed endoscopically, whereas ineffective oesophageal motility and hypotensive lower oesophageal sphincter were characterized during manometry testing. The association between ineffective oesophageal motility and reflux oesophagitis was assessed by logistic regression analysis. Results A total of 166 patients with oesophagitis (mean age 45 years, 49% men) and 221 without oesophagitis (mean age 46 years, 37% men) were present. Prevalences of ineffective oesophageal motility, hiatal hernia, hypotensive lower oesophageal sphincter and male sex were significantly higher in patients with oesophagitis compared with those without oesophagitis (P<0.05). Ineffective oesophageal motility was independently associated with oesophagitis after multivariate logistic regression analysis (odds ratio=1.68; 95% confidence interval=1.04–2.70). Conclusion Ineffective oesophageal motility is associated with reflux oesophagitis, independently of hiatal hernia, hypotensive lower oesophageal sphincter and male sex.

Association between sleep bruxism and gastroesophageal reflux disease

STATEMENT OF PROBLEM Rhythmic masticatory muscle activity, including sleep bruxism (SB), can be induced in healthy individuals by experimental esophageal acidification, which plays an important role in the pathogenesis of gastroesophageal reflux disease (GERD). However, no robust evidence supports the association between SB and GERD. PURPOSE The purpose of this study was to investigate the association between SB and GERD. MATERIAL AND METHODS Forty-five individuals were eligible to participate in this observational transversal study at the Gastroenterology Service of the Clinical Hospital of Porto Alegre, Brazil. The participants were classified into 2 groups, those with and without GERD, according to the Montreal Criteria and pH-metry/endoscopy findings. The diagnosis of SB was not assessed in a sleep laboratory but was based on self-report plus clinical inspection, according to the minimal diagnostic criteria of the American Academy of Sleep Medicine. The Lipp Stress Symptom Inventory was used to evaluate self-perceived stress. Univariate and multiple logistic regression analyses were performed with SB as dependent variable and GERD, sex, age, body mass index, and stress as predictors (α=.05; 90% power). RESULTS The study population included individuals with SB without GERD (13.3%) and individuals with SB with GERD (31.1%). In participants with GERD, the prevalence of SB was 73.7%. Only the variable GERD was significantly associated with SB (P=.017; odds ratio 6.58; 95% confidence interval 1.40-30.98), although adjusted for stress and age. CONCLUSIONS Sleep bruxism is prevalent in GERD patients, and GERD is highly associated with SB.

Nocturnal reflux in children and adolescents with persistent asthma and gastroesophageal reflux.

Background. A higher frequency of nocturnal gastroesophageal reflux (GER) in adult patients with respiratory symptoms has been demonstrated. The aim of this study was to determine the prevalence of nocturnal GER by using prolonged intraesophageal pH monitoring and compare it with spirometry results in children with persistent asthma. Methods. Thirty-eight patients with persistent asthma for at least 2 years were studied. Gastrointestinal symptoms suggestive of GER were considered as regurgitation, heartburn, and abdominal pain. All patients underwent prolonged intraesophageal pH study and spirometry. GER was considered positive when a reflux index (RI) was higher than 5%. Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), forced mid-expiratory flow rate (FEF25 − 75%), and FEV1/FVC ratio were measured. Results. Median age was 10 years of age (range 5 to 15) and 58% were male; GER prevalence was 47.3%. Median (range) of reflux index during supine and upright periods from GER patients were, respectively, 8.7% (3.2 to 23.6) and 10.5% (5.2 to 15.0) (p = 0.913), and only FEF25 − 75% was below the predicted value: 54.5% (39.4 to 96.9). Reflux index was not significantly correlated with FVC, FEV1 and FEF25 − 75%. Conclusions. A high prevalence of GER was found in children and adolescents with persistent asthma, equally distributed in the supine (nocturnal) and upright positions. There was no correlation with pulmonary function test.

Predomínio de manifestações respiratórias na indicação de pHmetria esofágica prolongada em crianças

BACKGROUND: An increasing prevalence of extraesophageal complications of gastroesophageal reflux (GER) has been seen. Evaluation of clinical profiles of patients submitted to prolonged esophageal pH monitoring could help to identify the patients who could benefit from the early diagnosis of GER. OBJECTIVE: To evaluate the population, indications and results of esophageal pH-monitoring for the diagnosis of GER in a pediatric gastroenterology clinic. PATIENTS AND METHODS: Data from 190 children and adolescents who had esophageal pH-monitoring were analyzed. A descriptive analysis of the population was performed and the children were categorized in five groups according to the age. The equipment used was a Digitrapper MKIII (Synetics) and all data were analyzed by using a software EsopHogram 5.7. Reflux index was established for analysis. RESULTS: The most frequent indications for the exam were: asthma (26,8%), apnea/cianosis (20%), recurrent pulmonary infections (18,4%), wheezing infant syndrome (15,8%) and chronic cough/horseness (11%). The most frequent groups of age for the respiratory symptoms were: asthma - above 5 years (92,2%); apnea/cianosis - under 3 months (55,3%); recurrent pulmonary infections and wheezing infant syndrome - 3 to 12 months (31,4% and 83,3%). Reflux index of patients with positive exam for GER was significantly higher in patients under 2 years than above 2 years of age. CONCLUSION: Respiratory symptoms were predominant among the indications for esophageal pH-monitoring in children. The knowledge of the clinical profile of the patients who had esophageal pH monitoring could help to improve the technical quality of the exam.

Relationship between serum concetrations of type III procollagen, hyluronic acid and histopathological findings in the liver of HCV-positive blood donors

RACIONAL: Marcadores sorologicos tem sido propostos para monitorar fibrose hepatica em doenca cronica do figado. Dentre os marcadores de fibrose, acido hialuronico e procolageno tipo III tem sido estudados nestes pacientes. OBJETIVO: Avaliar a associacao de marcadores sericos de fibrose com achados histologicos. METODOS: Foi realizado estudo transversal prospectivo em doadores de sangue anti-HCV positivos. A populacao estudada incluiu homens e mulheres com idade entre 18-60 anos com provas de funcao hepatica alteradas (niveis de alanina aminotransferase >1.5 vezes do normal e alteracoes de dois ou mais dos seguintes: qualquer alteracao nos niveis de alanina aminotransferase, aspartato aminotransferase, bilirrubina conjugada, gamaglobulina, gamaglutamiltranspeptidase, albumina, plaquetas, niveis de fosfatase alcalina >1,5 vezes o valor normal, tempo de protrombina abaixo de 70% e acima de 60%). Quarenta e nove pacientes foram submetidos a biopsia hepatica e coleta de sangue para analise de procolageno tipo III, acido hialuronico e provas funcionais hepaticas. RESULTADOS: Nao houve relacao entre elevacao de provas de funcao hepatica e a presenca de fibrose - ALT (>1,5 vezes acima do normal, risco de fibrose = 18,8%; <1,5 vezes, 11,8%). Procolageno tipo III elevado foi correlacionado com 66,7% chances de fibrose, enquanto nivel normal, 9,3%. Acido hialuronico, quando elevado, demonstrou chance de 33,3% de fibrose; quando normal, 12.5%. CONCLUSOES: Nao houve associacao entre provas de funcao hepatica, acido hialuronico e fibrose, mas houve entre esta ultima e procolageno tipo III. Talvez este marcador possa ser util para avaliar fibrose em pacientes com hepatite cronica pelo virus C.BACKGROUND Serologic markers have been proposed for monitoring hepatic fibrosis in chronic liver disease. Among fibrosis markers, type III procollagen (PIIIP) and hyaluronic acid have been studied in these patients. AIM To evaluate the association between these serum markers with histological findings. METHODS A prospective cross-sectional study was carried out with HCV-positive blood donors. The studied population included men and women whose age ranged from 18 to 60 years, with elevated liver function tests [ALT levels > 1.5 times the normal value and alterations of two or more of the following: any changes in the levels of ALT, aspartate aminotransferase, conjugated bilirrubin, gammaglobulin, gammaglutamyltranspeptidase, albumin, platelet count; alkaline phosphatase levels >1.5 times the normal value, or prothrombin time below 70% and above 60%]. Fourty-nine patients were submitted to liver biopsy, blood analysis of PIIIP, hyaluronic acid, besides liver function tests. RESULTS Liver function tests were not associated with tissular fibrosis, as assessed by ALT (>1.5 times above normal, fibrosis risk=18.8%; <1.5 times, 11.8%). Elevated PIIIP was correlated with 66.7% chance of fibrosis, whereas normal levels, 9.3%. Hyaluronic acid, when elevated, gave a chance of 33.3% of fibrosis; when normal, 12.5%. CONCLUSION There was no association between liver function tests, hyaluronic acid and fibrosis. However, PIIIP was related with liver fibrosis. Maybe, this marker should be useful to assess fibrosis in patients with chronic hepatitis C.

Contribution of standard oesophageal manometry in sliding hiatal hernia: From the gastro-oesophageal pressure gradient to the diagnosis

OBJECTIVE We tested whether gastro-oesophageal pressure gradient is augmented in sliding hiatal hernia and the yield of oesophageal manometry in diagnosing sliding hiatal hernia. METHODS Patients with equivalent body mass index were categorised according to manometry and endoscopy in groups: (1) no sliding hiatal hernia (n=147); (2) sliding hiatal hernia solely at endoscopy (n=46); and (3) sliding hiatal hernia at manometry (n=22). The yield of manometry was assessed taking endoscopy as referential. RESULTS Gastro-oesophageal pressure gradient was similar between groups both at inspiration (13.3+/-5.7 mm Hg vs. 13.6+/-5.4 mm Hg vs. 12.6+/-4.4 mm Hg; P=0.874) or expiration (5.1+/-3.8 mm Hg vs. 5.2+/-3.6 mm Hg vs. 5.1+/-3.7 mm Hg; P=0.767). Group 3 patients were older than those of groups 1 and 2 (59+/-10 vs. 42+/-15 vs. 45+/-13 years; P<0.001). Sliding hiatal hernia was larger when characterised by manometry than at endoscopy [4 cm (2.25-4.75) vs. 2 cm (2-3); P<0.001]. Manometry showed sensitivity of 28% (95%CI 19-40%), specificity of 97% (95%CI 93-99%) and positive predictive value of 82% (95%CI 63-92%) in diagnosing sliding hiatal hernia. CONCLUSIONS By using manometry in patients with equivalent body mass index, sliding hiatal hernia presence and size are related with age rather than gastro-oesophageal pressure gradient. This technique may be clinically useful when positive for sliding hiatal hernia.

⁎3521 METHYLENE BLUE CAN DISCLOSE INTESTINAL METAPLASIA IN BARRETT'S ESOPHAGUS?

Barretts esophagus(BE)is a change in the esophageal epithelium of any lenght that can be recognized at endoscopy and is confirmed to have intestinal metaplasia(IM)by biopsy. Intestinal metaplasia of the esophagus is the premalignant lesion for adenocarcinoma.Multiple biopsies are necessary because of the often focal nature of IM, dysplasia and cancer in these patients. Methylene blue(MB)is a vital stain taken up by actively absorting tissues, such as small intestinal and colonic epithelium. The potential of MB directed biopsy for intestinal metaplasia in BE was suggested in a pilot study by Canto et al.We report preliminary results of a study that prospectively evaluated the use of MB staining in patients previously proven to have BE. Methods:A total of 30 patients underwent upper G.I endoscopy with 0.5% MB staining after cleaning the mucosa with 10% solution of N-acetylcystein.Water was gently sprayed on the esophageal mucosa to wash off excess dye.Positive staining was defined as blue-stained esophageal mucosa that persisted despite water irrigation. Biopsy specimens from positively stained and negatively stained mucosa were obtained and compared.All specimens were independently examined by two pathologists. The mean lenght of BE was 5.7 cm(range 2 to 14)and 18 subjects had long barretts and 12 with short barretts. We obtained 296 endoscopic biopsy specimens from stained and nonstained ares(medium 9.86 biopsies/patient, see table). The sensitivity, specificity, positive predictive value and negative predictive value of MB staining for detecting IM was 73%, 59%, 93% and 21% respectively. Conclusion: In patients previously diagnosed to have Barretts esophagus MB had good sensitivity but a hight frequency of false negatives.

Acid and Weakly Acidic Gastroesophageal Reflux and Pepsin Isoforms (A and C) in Tracheal Secretions of Critically Ill Children

BACKGROUND Gastroesophageal reflux (GER) and pulmonary aspiration are frequent in patients in the ICU. The presence of pepsin in airways seems to be the link between them. However, pepsin isoforms A (gastric specific) and C (pneumocyte potentially derived) need to be distinguished. This study aimed to evaluate GER patterns and to determine the presence of pepsin A and C in tracheal secretions of critically ill children receiving mechanical ventilation. METHODS All patients underwent combined multichannel intraluminal impedance-pH (MII-pH) monitoring. Tracheal secretion samples were collected to determine the presence of pepsin. Pepsin A and C were evaluated by Western blot. MII-pH parameters analyzed were number of total GER episodes (NGER); acid, weakly acidic, and weakly alkaline GER episodes; and proximal and distal GER episodes. RESULTS Thirty-four patients (median age, 4 months; range, 1-174 months) were included. MII-pH monitoring detected 2,172 GER episodes (77.0% were weakly acidic; 71.7% were proximal). The median NGER episodes per patient was 59.5 (25th-75th percentile, 20.3-85.3). Weakly acidic GER episodes per patient were significantly more frequent than acid GER episodes per patient (median [25th-75th percentile], 43.5 [20.3-68.3] vs 1.0 [0-13.8], respectively; P < .001). Only three patients had an altered acid reflux index (44.9%, 12.7%, and 13.6%) while not taking antacid drugs. Pepsin A was found in 100% of samples and pepsin C in 76.5%. CONCLUSIONS The majority of GER episodes of children in the ICU were proximal and weakly acidic. All patients had aspiration of gastric contents as detected by pepsin A in tracheal fluid. A specific pepsin assay should be performed to establish gastropulmonary aspiration because pepsin C was found in > 70% of samples.