Arquivos de Gastroenterologia

Publications
The responses of the upper esophageal sphincter to gastroesophageal reflux is controversial. Study the effect of upper esophageal sphincter to the esophageal acid perfusion. Thirty adult dogs of both sexes were studied, being submitted to esophageal electromanometry. The pull through technique and continuous infusion of the catheters with distilled water were employed. These exams allowed us to measure the pressure width (mm Hg) and the length (cm) of the upper esophageal sphincter in basal conditions (moment 1). After this first phase the animals were submitted to esophagic infusion, being then divided in three groups, according to the solution used in the infusion and the moment of the study, as follows: Group 1: esophagic infusion with distilled water and electromanometric studies accomplished 15 minutes (moment 2) and 30 minutes (moment 3) of the end of the infusion. Group 2: esophagic infusion with HCl 0.1 N and electromanometric studies accomplished 15 minutes after the end of the infusion (moment 2). Group 3: esophagic infusion with HCl 0.1 N and electromanometric studies accomplished 30 minutes after the end of the infusion (moment 3). This research was performed to evaluate the esophagic acidification influence on the upper esophageal sphincter. The observed results allowed us to conclude that the acidification of the esophagus did not cause any alteration on the pressure width and on the length of the upper esophageal sphincter.
 
Micrographs of myosin-V-immunoreactive myenteric neurons of the intermediate region of the jejunum in rats in the following groups: untreated normoglycemic (UN), normoglycemic treated with 0.1% vitamin E (NE1), normoglycemic treated with 2% vitamin E (NE2), untreated diabetic (UD), diabetic treated with 0.1% vitamin E (DE1), and diabetic treated with 2% vitamin E (DE2). Calibration bar: 50 μm  
Micrographs of nNOS-immunoreactive myenteric neurons of the intermediate region of the jejunum in rats in the following groups: untreated normoglycemic (UN), normoglycemic treated with 0.1% vitamin E (NE1), normoglycemic treated with 2% vitamin E (NE2), untreated diabetic (UD), diabetic treated with 0.1% vitamin E (DE1), and diabetic treated with 2% vitamin E (DE2). Calibration bar: 50 μm  
Relative frequency distribution of cell body area of (A) myosin-V-immunoreactive and (B) nNOS-immunoreactive myenteric neurons of the jejunum in rats in the following groups: untreated normoglycemic (UN), normoglycemic treated with 0.1% vitamin E (NE1), normoglycemic treated with 2% vitamin E (NE2), untreated diabetic (UD), diabetic treated with 0.1% vitamin E (DE1), and diabetic treated with 2% vitamin E (DE 2). n = 5 rats per group  
Context: Diabetes mellitus is a disease characterized by hyperglycemia that, when allowed to progress long-term untreated, develops vascular and neurological complications, which are responsible for the development of alterations in the enteric nervous system in diabetic patients. In the gastrointestinal tract, diabetes mellitus promotes motor and sensory changes, and in the reflex function of this system, causing gastroparesis, diarrhea, constipation, megacolon, slow gastrointestinal transit, gastric stasis and dilation with decreased or increased peristaltic contractions. Several studies have shown that oxidative stress is the main responsible for the vascular and neurological complications affecting the enteric nervous system of diabetics. Objective: The effects of 0.1% and 2% vitamin E on myosin-V- and nNOS-immunoreactive neurons in the jejunum of diabetic rats were investigated. Methods: Thirty rats were divided into the groups: normoglycemic, normoglycemic treated with 0.1% vitamin E, normoglycemic treated with 2% vitamin E, diabetic, diabetic treated with 0.1% vitamin E, and diabetic treated with 2% vitamin E. The neuronal density and areas of neuron cell bodies were determined. Results: Diabetes (diabetic group) significantly reduced the number of myosin-V-immunoreactive neurons compared with the normoglycemic group. The diabetic treated with 0.1% vitamin E and diabetic treated with 2% vitamin E groups did not exhibit a greater density than the D group (P>0.05). Nitrergic density did not change with diabetes (P>0.05). The areas of myosin-V- and nNOS-immunoreactive neurons significantly increased in the normoglycemic treated with 2% vitamin E and diabetic groups compared with the normoglycemic group. Conclusion: Supplementation with 2% vitamin E had a neurotrophic effect only in the area of myosin-V-immunoreactive neurons compared with the diabetic group.
 
Adherence of enteropathogenic Escherichia coli (EPEC) to enterocytes with subsequent destruction of microvilli is supposed to be their mechanism of virulence. Adhesion may be studied in vitro systems using HeLa or HEp-2 cells, to which EPEC adhere in a localized pattern. We show here that colostrum and human milk inhibit E. coli 0111ab:H2 adherence to HeLa cells in different experimental conditions. Lactose does not seem to be involved in the in vitro inhibition since no effect was observed when a concentration of 7.5% was used during the test. A bacterial growth curve performed in same conditions of adherence test showed no bacteriostatic effect of human milk. S-IgA and receptor analogues could be responsible for the adherence inhibition observed.
 
Clinical and anthropometric characteristics of patients in the intervention and control groups in a randomized clinical trial 
Context Constipation is a very common symptom in the general population. One way of non-pharmacological treatment of constipation is through the addition of probiotics to food. Obectives The aim of this study was to evaluate de effect of the consumption of a fresh cheese, enriched with Bifidobacterium lactis Bi-07 on the symptoms of constipated women. Methods A randomized controlled trial, carried out in the Basic Health Units of Guaporé's City – RS/Brazil, between january and may 2012, with 30 constipated women. The patients were randomized into two groups whom received, for 30 days, 30 g of fresh cheese enriched with Bifidobacterium lactis Bi-07 (n = 15) or regular fresh cheese (n = 15). Constipation symptoms were evaluated according to ROMA III Consensus, before and after the nutritional intervention. Also, data of clinical and anthropometric characteristics of the individuals were collected. Accepted level of significance 5% (P≤0,05). Results The medium age of the studied population was 37,5±14,4 years in the intervention group and 40,8±12,8 years in the control group. After 30 days we observed that the ingestion of fresh cheese enriched with Bifidobacterium lactis Bi-07 promoted benefic effects on the symptoms of strength to evacuate. Conclusion The consumption of 30g/day of a fresh cheese enriched with Bifidobacterium lactis Bi-07 has beneficial effects on constipation symptoms.
 
Gastrointestinal bleeding accounts for 2% of all adult hospital admissions each year. Vascular ectasia is one of the most frequently reported cause of lower gastrointestinal bleeding. In almost 80% of patients with bleeding vascular ectasia will stop spontaneously, but will often recur. Many treatments are proposed like superselective catheterization with infusion of vasoconstrictor by angiography, Laser photocoagulation, heater probe, bipolar electrocoagulation, hot biopsy forceps, have been used in colonoscopy, but some effects are short-lived others are so expensive and without an effective treatment. The authors present one case of bleeding vascular ectasia during colonoscopy submitted to a new, cheap and effective approach with injection a 1:10,000 solution of epinephrine following electrocoagulation by colonoscopy.
 
This is an open label, multicenter trial to determine the efficacy of the association of pantoprazole, clarithromycin and amoxicillin to eradicate Helicobacter pylori in patients with peptic ulcer. Seventy-one patients (36 females, 35 males, average age 41.9 years) from three Brazilian university centers (located in the cities of Belo Horizonte and Porto Alegre), with peptic ulcers confirmed by endoscopy, and infections by H. pylori proven by at least two diagnostic testings were admitted in the trial. An association of pantoprazole 40 mg, clarithromycin 500 mg and amoxicillin 1.0 g was administered to patients twice daily for 7 days. By the end of treatment all patients were examined for digestive symptoms, presence of adverse events, and treatment adherence. Sixty days after the end of the treatment a new endoscopy with biopsies and respiratory function testing with 13C-urea breath test was performed in order to determine the eradication rates of that microorganism. Patients showing negative results at least in the 13C-urea breath test and in one other test (urease or histology) were considered H. pylori-negative. By the end of the trial, 60/69 (87%, CI 95% = 78.9-94.8) patients had the H. pylori eradicated in the per protocol analysis and 60/71 (84.5%, CI 95% = 76-92.9) in the intention-to-treat analysis. One patient was withdrawn from the trial due to a diarrhea. Twelve (16.9%) patients showed adverse symptoms that were deemed as mild symptoms. Our conclusion is that the association of pantoprazole, amoxicillin and clarithromycin administered during 7 days is an effective and well-tolerated alternative as regards the eradication of H. pylori in patients with peptic ulcer in Brazil.
 
Etiology of intrahepatic neonatal cholestasis (NIHC) 
Intrahepatic neonatal cholestasis can be the initial manifestation of a very heterogeneous group of illnesses of different etiologies. To evaluate and compare clinical and laboratory data among intrahepatic neonatal cholestasis groups of infectious, genetic-endocrine-metabolic and idiopathic etiologies. The study evaluated retrospectively clinical and laboratory data of 101 infants, from March 1982 to December 2005, 84 from the State University of Campinas Teaching Hospital, Campinas, SP, Brazil, and 17 from the Child's Institute of the University of São Paulo, SP, Brazil. The inclusion criteria consisted of: jaundice beginning at up to 3 months of age and hepatic biopsy during the 1st year of life. It had been evaluated: clinical findings (gender, age, birth weight, weight during the first medical visit, stature at birth, jaundice, acholia/hipocholia, choluria, hepatomegaly and splenomegaly) and laboratorial (ALT, AST, FA, GGT, INR). According to diagnosis, patients were classified into three groups: group 1 (infectious) n = 24, group 2 (genetic-endocrine-metabolic) n = 21 and group 3 (idiopathic) n = 56. There were no significant differences in relation to the variables: age, gender, stature at birth, jaundice, acholia/hipocholia, choluria, hepatomegaly, splenomegaly, AST, ALT, ALP, GGT, DB and albumin. Significant differences were observed in relation to the following variables: birth weight and weight during the first medical visit. Birth weight of group 1 was lower in relation group 2 and 3. Weight during the first medical visit followed the same pattern. There was a statistically significant difference in relation to the INR, as the patients of the group 2 presented higher values in relation to groups 2 and 3, despite the median was still pointing out normal values. There were no significant differences in relation to age, gender, stature at birth, jaundice, acholia/hipocholia, choluria, hepatomegaly, splenomegaly, AST, ALT, ALP, GGT, BD and albumin. Birth weight and the weight during the first medical visit were lower in the group with infectious etiology. In addition, a significant difference in INR reflected impaired coagulation of patients of the group of the genetic-endocrine-metabolic disease.
 
Hemangiomas are the most common benign vascular tumor found in the liver. In this study, 103 cases of hepatic hemangiomas were analysed in a retrospective manner. Image aspects such as those seen in ultrassonography, computed tomography, nuclear magnetic resonance and arteriography are discussed. The incidence was higher amongst the female sex, between individuals from 40 to 60 years old, which presented predominantly without symptoms (66%) and localized mainly in the right hepatic lobe (74%). The meaning of those aspects, when adopted, permits the clinicians to differentiate benign from malignant nodular lesions in the liver.
 
Preoperative imaging assessment a) Magnetic resonance cholangiopancreatography shows a large cystic tumor in the head of the pancreas. Relationship with main pancreatic duct is observed. b) Magnetic resonance imaging detected a small tumor and shows its proximity with the main pancreatic duct. c) Endoscopic ultrasound showed neuroendocrine cystic tumor of the neck of the pancreas. This patient underwent central pancreatectomy. d) Endoscopic ultrasound showing intraductal papillary mucinous tumor with a malignant tiny nodule in the uncinate process of the pancreas. 
Patient distribution according type of laparoscopic pancreatic resection 
Laparoscopic pancreatic resections a) Intraoperative view of enucleation of a neuroendocrine tumor at the body of the pancreas. b) Intraoperative view of resection of the uncinate process of the pancreas containing a Frantz tumor. c) Overview after distal pancreatectomy with preservation of the splenic vessels and spleen. d) Intraoperative view after pylorus-preserving total pancreatectomy with preservation of the splenic vessels and spleen. 
Laparoscopic pylorus-preserving pancreato-duodenectomy with double jejunal loop reconstruction a) Schematic drawing of the technique for reconstruction after pylorus-preserving laparoscopic pancreatoduodenectomy. b) Intraoperative view of end-to-side pancreato-jejunostomy. c) Intraoperative view of end-to-side hepatico-jejunostomy. d) Intraoperative view of end-to-side duodeno-jejunostomy. 
Context Our experience with laparoscopic pancreatic resection began in 2001. During initial experience, laparoscopy was reserved for selected cases. With increasing experience more complex laparoscopic procedures such as central pancreatectomy and pancreatoduodenectomies were performed. Objectives The aim of this paper is to review our personal experience with laparoscopic pancreatic resection over 11-year period. Methods All patients who underwent laparoscopic pancreatic resection from 2001 through 2012 were reviewed. Preoperative data included age, gender, and indication for surgery. Intraoperative variables included operative time, bleeding, blood transfusion. Diagnosis, tumor size, margin status were determined from final pathology reports. Results Since 2001, 96 patients underwent laparoscopic pancreatectomy. Median age was 55 years old. 60 patients were female and 36 male. Of these, 88 (91.6%) were performed totally laparoscopic; 4 (4.2%) needed hand-assistance, 1 robotic assistance. Three patients were converted. Four patients needed blood transfusion. Operative time varied according type of operation. Mortality was nil but morbidity was high, mainly due to pancreatic fistula (28.1%). Sixty-one patients underwent distal pancreatectomy, 18 underwent pancreatic enucleation, 7 pylorus-preserving pancreatoduodenectomies, 5 uncinate process resection, 3 central and 2 total pancreatectomies. Conclusions Laparoscopic resection of the pancreas is a reality. Pancreas sparing techniques, such as enucleation, resection of uncinate process and central pancreatectomy, should be used to avoid exocrine and/or endocrine insufficiency that could be detrimental to the patient's quality of life. Laparoscopic pancreatoduodenectomy is a safe operation but should be performed in specialized centers by highly skilled laparoscopic surgeons.
 
Eleven patients with cicatricial stenosis in the junction area of hepatic ducts were evaluated. In all patients the injury occurred during cholescystectomy and no operative cholangiography was performed. In 3 patients the injury was recognized during the initial cholecistectomy. Ten patients had been operated on at least one time to correct the injury in other Services. Four cases had duct or peritoneal drainage. There was an attempt of reanastomosis in two cases. Five patients had a bilio-digestive anastomosis performed in variable occasions. Two patients were reoperated 5 times, one patient 3 times. The others were submitted to one or 2 reoperations. There were a period of 1 to 72 months between the injury and last reoperation. Jaundice was the most common presenting manifestation since it appeared in all patient except one. Five patients had biliary cirrhosis. Roux-en-Y hepaticojejunostomy was carried out in all cases after enlarging the biliar stoma by longitudinal section on the left hepatic duct and performing a termino-terminal anastomosis. The 10 or 12 caliber Kehr drain used was taken out after the control cholangiography, carried around the second postoperative week. Concerning the long term results, one patient died of recurrent cholangitis six months after the 6th reoperation and one patient 14 months after the 4th reoperation of liver failure. Both had biliary cirrhosis. Two patients, remained assymptomatic for 60 months and 3 patients for 24, 37 and 56 months. The importance of preventing this severe complication is stressed by the authors. Patients with such lesions need be referred to specialized centers where well trained surgeons are available. The technique herein presented seems us to be a good option.
 
CHEK2 mutations and related phenotypes METHODS Patient recruitment A total of 112 families with multiple diagnoses of breast and colorectal cancer fulfilling HBCC criteria (24, 26) were recruited from cancer genetics clinics located in three Brazilian capitals: Rio de Janeiro (Instituto Nacional do Câncer, INCA), São Paulo (Hospital A. C. Camargo, HCACC) and Porto Alegre (Hospital de Clínicas de Porto Alegre, HCPA) between March 2007 and October 2008. In addition, families with multiple diagnoses of breast and colorectal cancer (at least three diagnosis and at least one patient under the age  
Clinical criteria defining HBCC syndrome  
A. Pedigree of the patient identified as CHEK2 1100delC mutation carrier. Cancer-affected individuals are shown in blackened symbols. Arrowhead indicates proband; current age is indicated in parenthesis. Dx: age at diagnosis; d: age at death; wt: wild-type. B. Proband's electropherogram: direct sequencing of CHEK2 exon 10 indicating frameshift after the 1100C position  
Context: CHEK2 encodes a cell cycle checkpoint kinase that plays an important role in the DNA damage repair pathway, activated mainly by ATM (Ataxia Telangiectasia Mutated) in response to double-stranded DNA breaks. A germline mutation in CHEK2, 1100delC, has been described as a low penetrance allele in a significant number of families with breast and colorectal cancer in certain countries and is also associated with increased risk of contralateral breast cancer in women previously affected by the disease. About 5%-10% of all breast and colorectal cancers are associated with hereditary predisposition and its recognition is of great importance for genetic counseling and cancer risk management. Objectives: Here, we have assessed the frequency of the CHEK2 1100delC mutation in the germline of 59 unrelated Brazilian individuals with clinical criteria for the hereditary breast and colorectal cancer syndrome. Methods: A long-range PCR strategy followed by gene sequencing was used. Results: The 1100delC mutation was encountered in the germline of one (1.7%) individual in this high risk cohort. This indicates that the CHEK2 1100delC is not commonly encountered in Brazilian families with multiple diagnoses of breast and colorectal cancer. Conclusion: These results should be confirmed in a larger series of families and further testing should be undertaken to investigate the molecular mechanisms underlying the hereditary breast and colorectal cancer phenotype.
 
Thirteen children carrying protein-losing gastroenteropathy confirmed by the excretion fecal 51Cr albumin are presented. The ages ranged from 3 months to 12 years old, and the mean age of onset of symptom was 6 years 11 months old. Symptoms initiated between 3 to 7 years old in 11 patients. First and second grade malnutrition were detected within 10 cases. The most frequent clinical observation was diarrhea, found in 11 patients, followed by peripheral edema (10), anorexia (10), paleness (10), muscular hypotrophy (9), abdominal distension (8), ascite (7), wasted (7) and vomiting (5). The serum albumin level was below 2.5 g/100 ml in 12 patients, with and average of 1.7 g/100 ml. The gammaglobulin fraction was below 1.0 g/100 ml in 8 patients and lymphocytopenia in 5. Tests have shown a compromised fat absorption, thus, 7 among 8 lipiodol's test were negatives. The etiologic diagnosis were: paracoccidioidomycoses (5 patients), primary enteric lymphangiectasia (1), stronglyoidiasis (1), constrictive pericarditis (1), rheumatic carditis with double mitral lesion (1), Ménétrier's disease (1), short gut malabsorption syndrome (1), celiac disease (1) and cow's milk allergy (1). The responsible mechanism for the great loss of proteins to the digestive tube as well as diagnose and therapeutic aspects of the patients are commented. A report of 4 cases was done, as a way to show the pathology more characteristically due to protein losing gastroenteropathy.
 
ROC curve 
The standard doses of (13)C-urea in (13)C-urea breath test is 75 mg. To assess the diagnostic accuracy of (13)C-urea breath test containing 25 mg of (13)C-urea comparing with the standard doses of 75 mg in the diagnosis of Helicobacter pylori infection. Two hundred seventy adult patients (96 males, 174 females, median age 41 years) performed the standard (13)C-urea breath test (75 mg (13)C-urea) and repeated the (13)C-urea breath test using only 25 mg of (13)C-urea within a 2 week interval. The test was performed using an infrared isotope analyzer. Patients were considered positive if delta over baseline was >4.0‰ at the gold standard test. One hundred sixty-one (59.6%) patients were H. pylori negative and 109 (40.4%) were positive by the gold standard test. Using receiver operating characteristic analysis we established a cut-off value of 3.4% as the best value of 25 mg (13)C-urea breath test to discriminate positive and negative patients, considering the H. pylori prevalence (95% CI: 23.9-37.3) at our setting. Therefore, we obtained to 25 mg (13)C-urea breath test a diagnostic accuracy of 92.9% (95% CI: 88.1-97.9), sensitivity 83.5% (95% CI: 75.4-89.3), specificity 99.4% (95% CI: 96.6-99.9), positive predictive value 98.3% (95% CI: 92.4-99.4), and negative predictive value 93.0% (95% CI: 88.6-96.1). Low-dose (13)C-urea breath test (25 mg (13)C-urea) does not reach accuracy sufficient to be recommended in clinical setting where a 30% prevalence of H. pylori infection is observed. Further studies should be done to determine the diagnostic accuracy of low doses of (13)C-urea in the urea breath test.
 
This case was of a 45 year old female patient with a post-transfusion non-A non-B hepatitis which was accompanied since an acute phase to hepatic cirrhosis during a period of 159.7 months or 13.3 years. Four hepatic biopsies were carried out and they divided the follow-up into 5 evolutive periods. The biopsies revealed a progressive histologic from chronic persistent hepatitis to an active chronic hepatitis and cirrhosis. The aminotransferases followed a floating course in the whole period, with ALT greater than AST starting from the 3rd period. The 3rd period (from 5th to 8th year) was of least activity of the aminotransferases, and the 4th and 5th periods (from 8th to 13th year) showed the highest activity of ALT. The 2nd period (from 3rd to 5th year) showed the least portion of gamma globulin and the highest of albumin in comparison with the others. There was no connection between the levels of aminotransferases and the values of gamma globulin and albumin in the follow up process. The treatment employed in the 5th evolutive period (prednisone and colchicine) did not present any biochemical improvement.
 
Hydrogen in breath test  
Genotyping of single nucleotide polymorphism (SNP C/T(-13910)) located upstream of the lactase gene is used to determine adult-type hypolactasia/lactase persistence in North-European Caucasian subjects. The applicability of this polymorphism has been studied by comparing it with the standard diagnostic methods in different populations. To compare the lactose hydrogen breath test with the genetic test in a sample of the Colombian Caribbean population. Lactose hydrogen breath test and genotyping of SNP C/T(-13910) were applied to 128 healthy individuals (mean age 35 ± 1). A positive lactose hydrogen breath test was indicative of hypolactasia. Genotyping was done using polymerase chain reaction/restriction fragment length polymorphism. The kappa index was used to establish agreement between the two methods. Seventy-six subjects (59%) were lactose-maldigesters (hypolactasia) and 52 subjects (41%) were lactose-digesters (lactase persistence). The frequencies of the CC, CT and TT genotypes were 80%, 20% and 0%, respectively. Genotyping had 97% sensitivity and 46% specificity. The kappa index = 0.473 indicates moderate agreement between the genotyping of SNP C/T(-13910) and the lactose hydrogen breath test. The moderate agreement indicates that the genotyping of the SNP C/T(-13910) is not applicable to determine adult-type hypolactasia/lactase persistence in the population participating in this study.
 
The 13C-methacetin breath test is a non-invasive method to evaluate hepatic microsomal function that allows a quantitative assessment of the functional hepatic mass. To evaluate the clinical usefulness of the 13C-methacetin breath test in patients with hepatitis C chronic liver disease. Seventy eight patients with chronic hepatitis C and 13 matched healthy controls were studied. HCV patients were classified as having chronic hepatitis (n = 51), cirrhosis (n = 27), being seven with decompensated disease (presence of ascite, jaundice and/or encephalopathy). HbsAg/HIV co-infected patients, chronic alcohol drinker, having other chronic diseases and those using drugs that could interfere with hepatic cytochrome P450, were excluded. The disease stage and activity in biopsy fragments were determined according the Brazilian Society of Hepatology criteria. Breath test was performed with 75 mg of 13C-methacetin, and the 13CO2 in the expired air was measured through a nondispersive infra red spectrometry. The delta over baseline, and the cumulative recovery of 13CO2 at 40 (13C-methacetin breath test 40 min) and 120 minutes (13C-methacetin breath test 120 min) were calculated. 13C-methacetin breath test parameters correlate only with hepatic staging but not with necroinflammatory (activity) parameters, being the best correlation found between hepatic staging and the 13C-methacetin breath test 120 minutes. The mean values for 13C-methacetin breath test 120 min was significantly reduced in the cirrhotic groups (19.2 +/- 7.1% for compensated and 14.7 +/- 4.0% for decompensated cirrhotics) than in control (29.9 +/- 4.5%) and chronic hepatitis (27.8 +/- 6.1%) groups. The best diagnostic accuracy for the diagnosis of cirrhosis among HCV patients was found for 13C-methacetin breath test 120 min with 81% of sensibility and 77% of specificity. 13C-methacetin breath test is correlated with structural changes in HCV-related chronic hepatic diseases and the cumulative recovery at 120 minutes is a sensitive parameter to identify the presence of hepatic cirrhosis in these patients.
 
Experience in the treatment of 150 patients with anorectal disorders and disorders of the sacrococcygeal region who were operated on with local anesthesia at the University Hospital, ABC Medical School, São Bernardo do Campo, SP, Brazil, from March 1995 to March 1998. The anesthesia technique, the operations carried out and the tolerance to the procedure are reported. Intraoperative morbidity was 10.6% (16 patients), and postoperative morbidity was 6% (nine patients). The age of patients was between 15 and 92 years old, with mean age 42 years old; 58% of patients were male and 42% female. Surgical mean time was 45 minutes and the patients remained in the hospital for a mean time of 8 hours. All of patients was instructed about the anesthesia technique, their advantages and disadvantages, and only with their permit the surgery was programmed. Hospitalization was required in five patients (3.3%). The anesthesia technique employed was the same for all patients. Upon survey, 96.7% of the patients stated they did not feel pain during the surgery and that they would go through the procedure again. The authors conclude the surgical treatment of anorectal disorders and disorders of the sacrococcygeal region with local anesthesia is viable and safe, and in addition, is well accepted by the patients.
 
Disease activity was assessed in 10 (five males and five females) ulcerative colitis patients through the following parameters: clinical, laboratory, sigmoidoscopic and histological. Protein metabolism was also assessed with 15N-glycine and urinary ammonia as end product. Only one patient had exacerbation of the disease two months after the study started. This patient presented in the beginning of the study protein synthesis and breakdown of 4.51 and 3.47 g protein/kg/day, respectively, values higher than all other patients, showing an hypermetabolic state, suggesting an increase of the disease activity. However, this increase was not detected by others indicators and indexes utilized. These data allow to suggest the hypothesis that protein metabolism predicts precociously the exacerbation of disease activity in ulcerative colitis patients.
 
A series of sixteen patients with supra-ampullary tumours of the biliary tree is reviewed. There was no sex difference and 9 from 16 were more than 60 years old. The clinical picture was insidious in 10 patients with dyspeptic symptoms; and started suddenly in 6; jaundice was the first symptom in 3, and was always present at admission. The delay for a correct diagnosis was 5 months since the beginning of the symptoms, and it was obtained by direct visualization of the biliary tree (PTC or/and ERCP). Surgical removal of the tumour was possible only in 3 patients. Microscopic diagnosis was obtained in 12 patients: 11 carcinomas (6 non-differentiated) and 1 lymphoma. Local metastasis were found only in 5 cases, with a mean evolution longer than 6 months. Until now, surgery has been disappointing; a more aggressive diagnostic approach conducting to earlier surgical treatment can probably improve the results.
 
In the present study an attempt was made to analyse from a clinical viewpoint the descriptions in the book "Noticias do que he o achaque do bicho" by Miguel Dias Pimenta (1661-1715), which are considered by some authors to be the first reference to the chagasic megaesophagus and megacolon that appeared in history. In descriptions considered to refer megaesophagus, although dysphagia, the major symptom of this disease, is not recognized, typical manifestations of a irritating, inflammatory or ulcerative condition are identified, not affecting the esophagus but the stomach. In the description considered to refer to megacolon, the signs and symptoms suggest the diagnostic possibility of hemorrhoids and of the "achaque do bicho" itself, and do not recall the clinical picture of the chagasic megacolon in an absolute manner. On this basis, there is no reason to maintain the book "Noticias do que he o achaque do bicho" within the history of the digestive form of Chagas' disease.
 
The authors present the experience from a university service of 170 outpatients submitted to 24-hour esophageal pH recording. Indications were: typical symptoms such as heartburn (67 patients), with and without endoscopic esophagitis, chest pain (65 patients; 40% had normal coronariography), a select group with dysphagia (28), besides eight asthmatics, one chronic intractable hiccups, and one esophageal ulcer. There was abnormal reflux in 47% of the total group. pH recording showed abnormal results in 86% of patients presenting heartburn and esophagitis and in 50% of patients without esophagitis. In the chest pain group, 37% had abnormal reflux, but pain with reflux episode could be observed only in 1/5 of them. Twenty percent of dysphagia patients had pathologic reflux and 50% among asthmactics, but the number of patients is small. Authors emphasize the importance of pHmetry as a diagnostic tool and suggest that it is important the knowledge of reflux pattern in healthy Brazilian people.
 
To evaluate the possibility of occult hepatitis B virus (HBV) infection in alcoholics carriers of "anti-HBc alone", and to verify the behavior of this serological pattern after a single dose of hepatitis B vaccine, 18 alcoholics who had this serological profile were evaluated by the polymerase chain reaction method, and 17 of them were vaccined. All were negative for HBV DNA. Nine (52.9%) of those vaccined had anamnestic response, mainly those with positive anti-HBe (8/10; 80%). "Anti-HBc alone" was compatible with low levels of anti-HBs in half of the patients, and probably with false positive results for anti-HBc in the others.
 
The book entitled "Brazil and the Brasilians", written by the Reverends Kidder and Fletcher and firstly published in the United States in 1857, reports the travels of these two missionaries throughout Brazil and includes a section entitled "A new disease". This section contains data regarding the clinical picture, the natural history and the epidemiology of a commom disease in Brazilian hinterland, which was known as "mal de engasgo". These informations were collected in 1855 by Rev. Fletcher from an anonymous North American physician, who worked in Limeira, State of São Paulo, and is called in the book merely as "Dr.-". The present work reports the results of an investigation carried out aiming at the identification of "Dr.-" and discloses documental evidence that "Dr.-" was actually Dr. Joseph Cooper Reinhardt (1809/10-1883). Dr. Reinhardt worked for many years in the citites of Limeira and Campinas, State of São Paulo, and probably had an extensive knowledge regarding the main features of this particular disease, which would be known, nearly 100 years later, as chagasic megaesophagus. The authors point out that, from now on, any account of the history of chagasic megaesophagus must include the name of Dr. Joseph Cooper Reinhardt.
 
Early peritoneal recurrence of gastric carcinoma following curative resection remains a great challenge in the treatment and prevention of this disease. To analyze the relationship between levels of tumor markers, carcinoembryonic antigen (CEA) and CA 19-9 in the sera and peritoneal washing, and anatomopathological aspects of the gastric carcinoma. Of the 46 patients in the study, 29 (63.0%) were males and 17 (37.0%) females. Mean age was 63.6 +/- 11.7 years (31 to 91 years). Peripheral venous blood samples were collected from the upper limb vein from both patient groups after anesthetic induction, in order to determine serum levels of CEA and CA 19-9. After the end of the procedure, 50 mL of physiologic solution was introduced into the bottom of the Douglas sack and a portion aspirated to determine CEA and CA 19-9 levels in the peritoneal washing. Levels of CEA and CA 19-9 in the sera and peritoneal washing were compared to the following variables: lesion diameter < or = 4 cm or > 4 cm, lymph node involvement, angiolymphatic invasion, depth of invasion into gastric wall, and initial or late stage. Sera CEA levels were significantly higher in patients with lesions >5 cm. CEA levels in the sera and peritoneal washing were significantly greater in patients with signet ring cell gastric carcinoma. In addition, levels of CEA in peripheral blood and peritoneal washing showed significant association with the degree of carcinoma penetration into the gastric wall, while sera CEA was significantly higher in patients at more advanced stages. There was no significant difference between sera and peritoneal CEA values regarding grade of differentiation. Patients with gastric lesions measuring > 5 cm and more differentiated lesions had significantly higher sera CA 19-9 values. In patients with lymph nodes invasion by gastric carcinoma, CA 19-9 levels in peritoneal washing were significantly higher than in peripheral blood. Levels of CA 19-9 in peritoneal washing were significantly greater at advanced stages than the initial stage of the gastric carcinoma. Elevated levels of CA 19-9 in peritoneal washing were significantly associated with more advance stages of gastric carcinoma and was more reliable predictive factor for staging than sera CA 19-9 levels. CEA levels in the sera more accurately reflected neoplasia stage than levels in peritoneal washing.
 
Background: Trends of peptic ulcer mortality rates were studied in São Paulo State (Brazil) among 1970 and 1989. Material: Deaths from PU, ICD-9 531-534. Results: The PU rates in São Paulo are comparable with those in Europe and rank second place for males and in third place for females. During this period there was a downward trend either for males or females. Conclusions: For women, the decline was less impressive and the male/female ratio decreased. A cohort effect was suspected for the explanation of female mortality trends.
 
Crohn's disease and ulcerative colitis are regarded as uncommon in developing countries, but studies on their occurrence in Brazil are scarce. Aims - To determine the occurrence of Crohn's disease and ulcerative colitis in a Brazilian university hospital throughout a 20-year period, and analyze the demographical, clinical and evolutive features of these cases. The frequencies of new cases of Crohn's disease and ulcerative colitis admitted from January 1980 up to December 1999 were calculated and a descriptive analysis of the features of all cases seen from January 1990 up to December 1999 was performed. A total of 257 new cases (126 with Crohn's disease and 131 with ulcerative colitis) was recorded. The frequencies of admissions for both Crohn's disease and ulcerative colitis have increased progressively from 40 up to 61 cases/10.000 new admissions and Crohn's disease gradually became more common than ulcerative colitis. For both diseases, there was predominance of women, age at admission in the range of 30-40 years, Caucasian origin, married state and non-smokers. Digestive symptoms presented were similar to those already described for both diseases and there were no differences between Crohn's disease and ulcerative colitis regarding the frequencies of general complaints and extra-intestinal manifestations (29.5% vs 23.3%), including thromboembolism (5.9% vs 5.4%). Obstruction and/or perforation were seen in up to 59.2% of Crohn's disease cases, whereas 53.7% of all ulcerative colitis cases presented as severe forms. In Crohn's disease cases with obstruction, smoking was significantly more common than in non-complicated cases. In ulcerative colitis cases of increased severity, general complaints, extra-intestinal manifestations and pancolitis were significantly more frequent than in less severe forms. For the last 20 years, there have been an increased frequency of admission of inflammatory bowel diseases, and Crohn's disease have become more prevalent than ulcerative colitis. Demographical, clinical and evolutive features of these diseases seems to be similar to those already described, but there seems to be a predominance of more severe forms of both diseases.
 
In Brazil, colorectal tumors are among the five more important sites of neoplasms, for both sexes, in terms of mortality. The etiology of colon and rectal cancer is complex and some of the factors involved in its genesis are related to diet. Brazilian geographic regions present heterogeneous alimentary profiles, that could be influencing the distribution of the mortality rates for these tumors. To describe the patterns of mortality from cancers of the colon and the rectum in Brazilian State capitals in the period 1980-1997. Mortality data for individuals of both sexes, residents in Brazilian State capitals (except Palmas, Tocantins) was obtained from the Ministry of Health Mortality System (SIM/MS). We considered as death from colon and rectum cancers those whose underlying cause of death was coded as 153.0 to 153.9, 154.0 and 154.1, according to ICD 9, in the period 1980-95; C18.0 to C18.9, C19 and C20,according to ICD 10, in the period 1996-97. The trends of the standardized mortality rates from colon and rectum cancer were analyzed through linear regression models. The highest standardized mortality rates for colorectal cancer were observed in the South and Southeastern regions and varied between 8,0 and 10,7/100000 inhabitants. Porto Alegre (11,9), São Paulo (10,8) and Rio de Janeiro (9,6) presented the greatest rates among the State capitals in the study period. In the South region, rates of mortality for Porto Alegre and Florianópolis presented an increasing trend in the study period and the same behavior was observed for São Paulo and Vitória in the Southeastern region. Brasilia and the other capitals of the Midwest, with the exception of Goiânia, showed a tendency of increment of the mortality rates. Among the capitals of the North and Northeast regions, an increasing trend of mortality was observed in Rio Branco and Fortaleza. The separate analysis of the mortality rates for tumors of the colon and for tumors of the rectum showed a similar pattern, with higher values being observed for colon neoplasia. Regional differences in the mortality rates for colon and rectum neoplasias have been discussed for different authors, who point to the contribution of cultural and alimentary habits, and differences of life style and socioeconomic status to this heterogeneity, besides other aspects related to access to health services and quality of hospital care and preventive services. These factors must be considered in the evaluation of the differences observed in Brazilian capitals. Although the State capitals situated in South and Southeastern regions presented higher rates than the others, mortality rates of Porto Alegre (9,8/100.000) and Rio de Janeiro (9,0/100.000), in period 1983- 85, were about three times lower than those observed in the United States, Canada and France, in 1985. The sex distribution pattern of the mortality rates in Brazilian capitals was not uniform, with higher rates in men. We observed a trend of increment of the mortality rates of colorectal cancer in all Brazilian regions, similar to that was observed in some countries of the world, although with different gradients. The standardized mortality rates for colon and rectum neoplasias presented important regional differences among Brazilian State capitals. The highest rates were observed in the South and Southeastern regions. A trend of increment of the standardized mortality rates for cancers of the colon and the rectum was observed in all Brazilian regions in the period 1980-1997.
 
Gastric cancer incidence and mortality have been declining in many countries, including Brazil. Nevertheless, it still constitutes an important public health problem in our country, particularly in the state of Pará where mortality rates present values over the Brazilian average rates. To analyze the patterns of gastric cancer mortality in Pará State and in the City of Belém, in the last two decades. Mortality data were obtained through Brazil's Mortality Information System and population data came from the Brazilian Institute of Geography and Statistics. Age standardized mortality rates were calculated for the whole population and by sex, for every triennium in the period 1980-97 for Pará State and City of Belém. Trends of the standardized mortality rates from stomach cancer were analyzed through linear regression models. In comparison with other state Capitals and countries, standardized mortality rates for stomach cancer in Belém were elevated (27.2 a 15.8/100,000) during all the study period. Rates in men were higher than for women with a sex ratio of 3.0 in Belém, in all study periods, except 1995-97. During the study period, it was observed a decreasing trend in the mortality rates for both sexes, although more prominent in men, in the State of Pará. In Belém, it was also seen a decline in rates for all age groups. In spite of the observed trend, gastric cancer mortality rates in Belém at the last period of the series (1995-97) were still higher than those exhibited by some of the other State Capitals in 1980-82.
 
Results from trend analysis for stomach cancer mortality. Brazilian regions, 1980-2009 
Rates of stomach cancer mortality adjusted for age (by the world's population), by sex, per 100,000 people in Brazil, according to regions, between 1980 and 2009
The most recent global estimate revealed the presence of about one million new cases of stomach cancer for the year 2008, setting itself as the fourth most common cause of cancer. The present study aims to assess the trend of mortality from stomach cancer in Brazil according to regions between 1980 and 2009. Data on deaths from stomach cancer were obtained from the Mortality Information System, and the demographic data, from the Brazilian Institute of Geography and Statistics. The rates of mortality were standardized by age according to world population. The trend curves were calculated for Brazilian regions by sex. The technique used was polynomial regression and joinpoint. The tendency for males and females is similar in all regions, although the magnitude is higher among men in all places. Regions Midwest, South, Southeast tended to decline, while the Northern region showed no significant trend, and the Northeast tended to increase. It is therefore a need to evaluate public health policies for gastric cancer aimed at the demographic transition (change of urbanization and lifestyle) that is occurring throughout the country.
 
Spontaneous bacterial peritonitis is a frequent complication that occurs in patients with cirrhosis and ascites and has a recurrence rate of 70% in 1 year. In addition, this infection determines a poor short and long-term prognosis and a shorter survival rate. Evaluate the prevalence of spontaneous bacterial peritonitis in cirrhotic patients with ascites and the effect of its occurrence on the survival. One thousand and thirty admissions of patients with cirrhosis and ascites were reviewed and 114 episodes of spontaneous bacterial peritonitis were documented in 94 patients. The ascitic analysis was accomplished in all patients. The diagnosis of this infection was established when the ascitic fluid polymorphonuclear count was equal or above 250 cells mm3. The prevalence of this infection was 11.1% and the mortality rate 21.9%. Spontaneous bacterial peritonitis was community acquired in 61.4% and hospital acquired in 37.7%. The mortality rate was 18.6% and 27.9%, respectively. The infection resolved in 91.1% of the episodes by the analysis of ascitic fluid at 48 hours on antibiotics. The use of prophylactic antibiotics was documented in 22.3% of the episodes, but there are not significant differences on the mortality or type of bacteria isolated when comparing the patients with or without this treatment. Spontaneous bacterial peritonitis is a common complication in patients with cirrhosis and ascites and determines a worse prognosis, mainly when related with absence of initial response to antibiotics.
 
The duodenal ulcer always represented a very prevalent pathology among the gastrointestinal tract diseases worldwide. The average prevalence is approximately 10% of the world population. In the 90s the literature (both European and North American) begin to show a crescent reduction of this prevalence in many countries. To show through a retrospective analysis the annual prevalence of the duodenal ulcer in the last 10 years in a Digestive Endoscopy Service which is referred to public medical system in Porto Alegre and its suburban area and countryside of the State of Rio Grande do Sul, Brazil. The data analyzed is from March 1996 to December 2005. Specific data: transversal retrospective study with documented analysis of endoscopic diagnosis of upper gastrointestinal endoscopy. A retrospective analysis of the diagnosis of the 13.130 procedures of upper gastrointestinal endoscopy between 1996 and 2005. The Sakita classification was used to verify the duodenal ulcer activity taking into consideration the patients who have lesions on A1 to S1 levels. To verify if there was a statistical significant results, a linear regression test was done (linear regression model). A graduate decrease of the prevalence percentuals was observed, year after year, it began with 8.3% of prevalence in 1996 and finished with 3.3% in the beginning of 2006. The average annual reduction of this prevalence was calculated following the regression test and it was placed in the 1.3% a year in the studied period of time. In 2003, in an isolated way, it was an exception in the decrease of the percentage because it presented a prevalence increase of (6.5%) comparing to the first 6 years of study. In this study it was observed a decrease of duodenal ulcer prevalence, 1.3% a year to be more accurate in 10 years of study, showing a statistical significance in the linear regression test.
 
Survival curve in adult liver transplanted patients (Kaplan-Meyer)  
Total of non-mucocutaneous infections in adult liver transplanted patients  
Microorganisms obtained from blood cultures in adult liver transplanted patients
Infections after liver transplantations are the most important cause of morbi-mortality. In this study, we assessed the main characteristics of these infections in a southern Brazilian university hospital. We conducted a retrospective cohort with 55 patients who underwent orthotopic liver transplantation between 1996 and 2000 in the "Hospital de Clínicas de Porto Alegre", Porto Alegre, RS, Brazil, to characterize the infections that occurred in the group. One or more infections (average 2.10) were diagnosed in 47 patients, especially during the first month after transplantation. The most common were bacteremia, intra-abdominal infections and pneumonia, predominantly with bacteria, especially Staphylococcus sp (and particularly S. aureus) and E. coli. The mortality rate attributed to infections was high: 17 cases of all deaths (total 27 deaths). Significant risk factors for infections included reoperation, diabetes, biliary stenosis and higher Child-Pugh scores. Infections remain a severe threat in liver transplant patients, and special efforts should be made to prevent and manage them correctly.
 
This work show the levels of the salivary secretion volume in 5 min., the salivary amylase concentration in U/ml and the salivary amylase secretion in U/kg/5 min. in 10 children at 4, 15, 30, 45, 60, 90, 120, 150, 180 days of life and at 9 and 12 months. All the children had the same nourishment orientation and showed a good weight and neuromotor development during the period of the observation. The datas were compared with datas of 18 children with 20-36 months of age and 18 healthy young man. It was standardized the technic and the time-table to collect the salivary secretion. It was observed that the salivary secretion is higher between 90 and 180 days of age preceding theeth eruption. At 12 months of life the levels of the amylase salivary concentration reach the levels of infants and adults. The salivary amylase secretion is high after the 60 days of life. Probably this is responsible by the good starch tolerance at this time.
 
Since the sixties, when the optic fibers were reported, colonoscopy had emerged as the first line imaging investigation of the colon. To review the results of diagnostic and therapeutic colonoscopy at the Discipline of Coloproctology of the University of São Paulo Medical School, São Paulo, SP, Brazil, respecting the characteristics of an institution of medical education. Retrospective analysis of basis related to 2,567 fibro colonoscopies between 1984 and 2002. The procedure was performed in hospitalized and in outpatients. The most common indications for colonoscopy were investigation of rectal bleeding and anemia (22.4%), change of bowel habit (14.76%), inflammatory bowel disease (8.65%) and carcinoma (7.25%). Bowel preparation with manitol was used by most of the patients. Sedation, when not contra-indicated, was administered. The most common combination was meperidine and benzodiazepine. All the exams were monitored with pulse oximeter. A normal colonoscopy to the point of maximum insertion was reported in 42.42% of procedures. The most common diagnosis was polyps (15.47%), followed by diverticular disease (12.86%). Inflammatory disease was recorded in 11.88% and carcinoma in 10.21%. Polypectomy was undertaken in 397 patients (2.21 polypectomy per patient with polyps). Colonoscopy was considered incomplete (when the colonoscope did not pass to the cecum or terminal ileum) in 181 (7.05%) cases. Perforation was reported in one patient who had a subestenosing retossigmoid tumor. In 0.42%, reasons for failing to complete the procedure included complication related to sedation, with no further prejudice for the patients. Colonoscopic examination of the entire colon remains the standard for visualization, biopsy and treatment of colonic affections. The incidence of complication of endoscopy of the large bowel is quite low, even in a school hospital.
 
Correlation between socioeconomic indicators and CRC mortality rates in Brazil. Brazil, 2001-2009 
ContextSeveral international studies have observed a correlation between the improvement of socio-demographic indicators and rates of incidence and mortality from cancer of the colon and rectum.Objective The objective of this study is to estimate the correlation between average per capita income and the rate of colorectal cancer mortality in Brazil between 2001 and 2009.Methods We obtained data on income inequality (Gini index), population with low incomes (½ infer the minimum wage/month), average family income, per capita ICP and mortality from colon cancer and straight between 2001-2009 by DATASUS. A trend analysis was performed using linear regression, and correlation between variables by Pearson's correlation coefficient.ResultsThere was a declining trend in poverty and income inequality, and growth in ICP per capita and median family income and standardized mortality rate for colorectal cancer in Brazil. There was also strong positive correlation between mortality from this site of cancer and inequality (men r = -0.30, P = 0.06, women r = -0.33, P = 0.05) income low income (men r = -0.80, P<0.001, women r = -0.76, P<0.001), median family income (men r = 0.79, P = 0.06, women r = 0.76, P<0.001) and ICP per capita (men r = 0.73, P<0.001, women r = 0.68, P<0.001) throughout the study period.Conclusion The increase of income and reducing inequality may partially explain the increased occurrence of colorectal cancer and this is possibly due to differential access to food recognized as a risk factor, such as red meat and high in fat. It is important therefore to assess the priority of public health programs addressing nutrition in countries of intermediate economy, as is the case of Brazil.
 
Twenty-one patients with carcinoid tumors have been analysed. Out of 18 patients the diagnostic was made at operation and out of 3 by autopsy. The most frequent sites of the primary tumors were the appendix (38.1%), ileum (23.8%) and colon (19.9%). Asymptomatic tumors were found incidentally in 10 patients (55.5%). The symptomatic neoplasms were more common in the ileum. No one patients in this series obtained the diagnostic of carcinoid tumors before operation or autopsy. It was not observed the malignant carcinoid syndrome. Sixteen patients (88.8%) were submitted to resection and the mean survival was 10.7 years. Two patients (11.1%) were submitted to palliative operations and the mean survival was 3.5 months. The incidence of metastases in cases with carcinoid greater than 2.0 cm in diameter was 71.4%; on the other hand, the patients with carcinoids 2.0 cm in diameter or smaller than this size disclosed metastases in 7.6%. No patients with appendix carcinoid showed metastases and all patients with metastases presented ileum or colon carcinoids. In this series, the prognostic was related with the lesion's size, the localization of the tumor in the gastrointestinal tract and with the resection or not of the primary neoplasm.
 
In this study, we compared the clinical aspects of the patients with hepatocarcinoma treated in the Clinical and Surgical Gastroenterology Division, Federal University of São Paulo Medical School. Thirty three patients with hepatocarcinoma were treated between 1989 and 1997, 23 were treated surgically or by chemotherapy. Ten of them, in bad clinical conditions, were treated only with supportive treatment. Among the 23 treated patients, 12 were treated surgically, 10 with transcatheter arterial chemoembolization and one with systemic chemotherapy. The liver nodes size varied from 2.6 to 20 cm, being 82% greater than 5 cm. The mean survival was 14.8 months for the surgical treated patients and 9.8 months for the transcatheter arterial chemoembolization treated patients. These differences were not significant by the Kaplan-Meyer curve. The patients with liver nodes under 5 cm had better survival (P < 0.05). We can conclude that independent of the clinical stage, the size of the liver node is an important factor on prognosis. Patients with live nodes smaller than 5 cm have better survival than the others with greater tumors.
 
Actuarial survival curve of patients with colonic carcinoids (Kaplan-Meier plot estimating cumulative risk) 
Colonic carcinoids, excluding those arising in the appendix, have proved to be extremely rare. Due to their rarity, the characteristics and behavior of this unusual malignancy remain unclear. To review the clinicopathologic features of patients operated on carcinoid tumors of the colon. Twenty-three patients (12 males and 11 females) were operated on colonic carcinoids. The mean age of the patients was 63.0 +/- 12.9 years (42 to 85 years). The clinical and histopathological data of patients who were pathologically diagnosed as having carcinoid tumors and submitted to surgical treatment over a 30-year period (1977-2007) were gathered. Actuarial patient survival was estimated using the Kaplan-Meier method, with carcinoid-specific death as the outcome. The mean time elapsed between onset of symptoms and surgical treatment was 8.3 months (1.5 to 20 months). The most frequent symptoms or signs encountered were abdominal pain followed by anorexia or weight loss, diarrhea, abdominal tenderness, palpable abdominal mass, and rectal bleeding. No carcinoid syndrome was noted. The lesion was located in the cecum in 16 (69.6%) patients, in the sigmoid in 3 patients (13.0%), in the ascending colon in 3 patients (13.0%), and in the transverse colon in one patient (4.3%). Twenty-one (91.3%) patients were operated on curative intent. Spreading of the disease to the liver and peritoneum was found in two (8.7%) patients who submitted to intestinal bypass. The mean size of the largest mass was 3.7 +/- 1.2 cm (1.5 to 6.2 cm). There were multiple (two or more) lesions in three cases (13.0%). In the resected cases, the lymph nodes were compromised in 10 patients (47.6%) and disease-free in 11 (52.4%). Venous invasion and neural infiltration were both present in five (23.8%) patients. The tumors had penetrated the muscularis propria in all resected cases. Four (17.4%) patients had a second non-carcinoid primary tumor. Three (13.0%) patients died due to postoperative complications and five (21.7%) patients died from metachronous metastases or local recurrence. Fifteen patients (65.2%) remain alive without evidence of active disease. The mean follow-up period was 12 years (1.2 to 18 years), whereas the mean global survival was 50.7 +/- 34.2 months and the crude survival rate at 5 years was 62.7%. Carcinoid tumors of the colon are frequently right-sided and may be clinically occult until an advanced stage is reached. Based on the relatively poor survival rates reported, it is recommended that, in addition to standard surgical resection, vigorous surveillance for metastatic disease must be performed, particularly during the first 2 years after surgery. In addition, these patients require evaluation of the entire gastrointestinal tract for evidence of coexisting malignancy, along with an extended period of follow-up, because tumor recurrences after 5 years are not uncommon.
 
By internationally accepted standardization, the esophageal pH-meter distal sensor is positioned 5 cm above the superior border of the lower esophageal sphincter, identified by esophageal manometry. However, several authors suggest alternative positioning techniques that leave out the manometry; among such techniques, the pH step-up is the one to be pointed out. This subject is controversial; some publications state that the step-up technique is not reliable while some others consider it reliable. Considering the existent controversy and the small number of prospective works with suitable sample and methodology, we have idealized the present study, that aims the evaluation of the suitability of the pH-meter distal sensor positioning based on the step-up technique, by analyzing the presence, the type and the degree of the error of positioning that such technique provides and the influence of the position adopted by the patient during the procedure. One thousand and thirty one patients conducted to the esophageal pH-meter procedure were studied in a prospective way. During the clinical interview, the demographic data and the presented clinical complaints were registered. All the patients were submitted to both esophageal manometry in order to localize the lower esophageal sphincter and the pH step-up technique, that consists of the introduction of the pH-meter sensor in the gastric chamber and in the sensor's gradual traction until the pH steps up to levels over 4. The step-up point was identified by two distinct ways, characterizing two study groups: with the sitting patient (group I - 450 patients) and with the patient in supine position (group II - 581 patients). After the step-up point identification, the pH-meter distal sensor was placed in the standard position (based on the sphincter manometric placement). It was registered where the pH sensor would be positioned if the step-up technique were adopted. To evaluate the positioning suitability, the error was considered to be represented by the difference (in centimeters) between the suitable placement (manometry) and the one that would be adopted in case the step-up technique were adopted. The positioning error was considered rough if it were larger than 2 cm. The most frequent type of error was also analyzed (if above or below the standard position). It was observed that if the step-up technique were adopted, there would be error in the sensor positioning in 945 patients (91.6%). In terms of error degree, there would be a rough error in 597 (63.2%) cases. Concerning the type of error, the sensor would be positioned below the standard place in 857 (90.7%) patients. As to the interference of the position adopted by the patient during the step-up technique, it was observed that there was no significant difference among the groups of study in any of the analyzed parameters. 1. The positioning of the pH-meter distal sensor by the step-up technique is not reliable; 2. the step-up technique provides expressive error margin; 3. the most common type of error that such technique mode provides is the placement of the sensor below the standard positioning, which may overestimate the reflux occurrence; 4. there is no influence in the position adopted by the patient during the pH step-up technique procedure, in terms of method efficiency.
 
The sensitivity of endoscopic examinations, acid perfusion test and 24-hour esophageal pH-monitoring, were studied in patients with heartburn. Thirty six adult patients with histological esophagitis were included in this prospective study. Endoscopy showed esophageal lesion in 18/36 (sensitivity of 50%): esophagitis grade I in 10 (55.6%) and, grade II in eight (44.4%). Acid perfusion test was positive in 10/25 (sensitivity of 40%) of the patients submitted to the test. Twenty-four-hour pH-monitoring was positive in 17/29 patients (sensitivity of 58.6%): eight (61.5%) did not have esophageal lesion at endoscopy, two (25%) had esophagitis grade I and seven (87.5%) had esophagitis grade II. In the patients submitted to 24-hour pH-monitoring, a greater number or reflux episodes in orthostatic position than in supine position (P < 0.0001) was observed. The total number of reflux episodes, the most prolonged reflux and the total pH time < 4 were statistically higher in post-prandial period than during meals (P = 0.005).
 
The electromanometry and 24-hour esophageal pHmetry has been proposed as objective method in postoperative evaluation of antireflux surgery. Prospective evaluation of the results of cruroplasty and total fundoplication in the treatment of non-complicated gastroesophageal reflux disease based on comparative results of pre and post operative manometry and pHmetry findings. Fifty-nine consecutive individuals with typical symptoms of gastroesophageal reflux disease were prospectively studied. All patients were submitted to a laparoscopic short floppy Nissen fundoplication between March, 2002 and August, 2003. All patients were submitted pre and postoperatively (3 months) to upper digestive endoscopy, manometry and pHmetry 24 hours. Eighteen (30.5%) patients were male and 41 (69.5%) female, their average age was 43.8 years. There were differences comparing the pre and post operative period in the manometrical findings in the following items: localization of the lower esophageal sphincter (41.2 cm and 42.3 cm). Extension o f the lower esophageal sphincter preoperative (2.0 cm and 2.5 cm), resting pressure of the lower esophageal sphincter (15.0 mm Hg and 21.5 mm Hg), and pressure of the esophageal body (78.0 mm Hg and 70.0 mm Hg). There were differences comparing the pre and post operative period in the pHmetrical findings in the following items: total number of acid refluxes (68.0 and 3.0), total number of acid refluxes more than 5 minutes (2.0 and 0.0), acid reflux more than 5 minutes in supine position (1.0 and 0.0), acid reflux more than 5 minutes in upright position (0.0 and 0.0), acidification period (5.5 and 0.1 min), DeMeester score (33.0 and 0.8). The esophageal manometry and pHmetry findings were improved in the post operative period with statistical significance when compared to the pre operative period. The exams were considered efficient in the evaluation of the surgical procedure.
 
The reflux gastroesophageal patients can be divided in three patterns, according with ambulatorial esophageal 24 h-pHmetry: orthostatic, which the reflux episodes occur when the patients are upright; supine, which the reflux episodes occur when the patients are sleeping; combined, when the reflux episodes are both observed in upright or lay down position. There are presented 56 patients with endoscopic reflux esophagitis who are divided according to the patterns of reflux by 24 h-pHmetry. The results are similar to those of international reports. Complicated esophagitis is more common in the combined refluxers following by supine refluxers. In the orthostatic refluxers were not observed complicated esophagitis. The 24 h-pHmetry is an useful tool for clinical use and prognosis in the gastroesophageal reflux disease.
 
Little change was observed in the histological criteria of reflux esophagitis since the studies of Ismail-Beiji, Pope (1970) and Weinstein (1975). The 24-hour esophageal pHmetry has been proposed as a high sensitivity method in diagnosis of gastroesophageal reflux disease patients. In this study we selected 35 patients with histological esophagitis and submitted them to 24-hour esophageal pHmetry. We determined histological differences according to reflux pattern, endoscopic esophagitis grades and age. The sensitivity of 24-hour esophageal pHmetry was 60.0% in our patients. There are higher histological alterations in patients with more severe patterns of reflux (supine and combined) and significant difference (P < 0.05) in observed quantitative exocytosis between moderate and severe endoscopic esophagitis. There are no difference between histological esophagitis criteria and age groups.
 
Portal vein thrombosis represents one of the most frequent causes of portal hypertension in childhood. The aim of the present study was to describe the clinical and laboratorial characteristics of portal vein thrombosis in pediatric patient. We studied 26 children with diagnosis of portal vein thrombosis through splenoportography (two patients) and ultrasound scan (24 patients) which ages varied from 2 months to 11 years and 4 months (median-5 years and 3 months). Data of the patient history, physical and laboratories examination were used to a retrospective study which was done through medical record analysis. The main complaint of the examination was hematemesis, which was found in 57.6%. In 26.9% a possible risk factor for portal vein thrombosis was found [catheterization of the umbilical vein (four), sepsis (two), omphalitis (one)]. Splenomegaly was present in all cases and the associated illness to portal vein thrombosis were: hepatoportal sclerosis (three), cytomegalovirus infection (two), blastomycosis (two), virus C (two), virus B (one) and virus A (one). The time between the first bleeding and the examination at University of Campinas Hospital, in Campinas, SP, Brazil, varied from 0.23 months to 54 months with a median of 12 months. Only 11.5% of patients underwent the endoscopy with sclerotherapy before going to University of Campinas Hospital. Aminotransferases' activities were considered normal in 20 patients. We could conclude that: 1. The most frequent initial symptom was hematemesis. 2. The known risk factors for portal vein thrombosis were present in about 1/3 of the cases. 3. Laboratorial exams usually indicated absence of hepatocitic lesions. 4. The efforts towards sending the patient to a reference center were late with a delayed diagnostic and with delayed effective therapeutic conduct. 5. In about 50% of the cases there was PVT associated with other hepatic diseases.
 
Gastric polyps are small gastric lesions, asymptomatic in most cases and are generally discovered inadvertently during upper digestive endoscopy. To retrospectively review the characteristics and frequency of gastric polyps, derived from the gastric mucosal epithelium in a large series of endoscopies. 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. 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%). 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 pathologist's aid, once the conduct to be adopted will depend on the result of the biopsy.
 
The authors analyse the clinical features of 27 patients with non-coronary chest pain. They applied specific questionnaire and used esophageal function tests. The pain features were very similar to coronary patients, but there was a strict relationship with emotional stress. Esophageal symptoms were found in about 50% of patients. Eighty-five, one percent of the patients, presented with some abnormalities; 33.3% of the total group with esophagitis and 66.6% with motor disorders; some patients presented overlapping pictures. Three patients had duodenal ulcer. The patients were classified as having pain of proved (18.5%), or suspected (66.6%) esophageal origin. Twenty of these patients were followed and those with esophagitis and/or duodenal ulcer had a good response to specific treatment. The author stress the importance of showing the patients the benign nature of this disease. In the present group of patients, the actual diagnosis was more important in obtaining good therapeutic response than classifying the pain as above.
 
Twenty seven patients, inspected by endoscope, and diagnosed as having the Mallory-Weiss syndrome, have been studied taking into account their age, sex, background, clinic presentation, manifestations, number of lacerations, associated lesions and evolution. Twenty three of them were males and 4 females. The age average was 46.7 years. Only 8 patients had intra-abdominal increased pressure, suffering retching and vomiting 7 of them, while one had a cough access. Out of the 21 patients that we controlled, 9 were chronic alcoholism while 3 had ethanol intoxication previously. Immediate prior ingestion of salicylates had taken place in 6 patients. The clinical presentation of 22 of them was gastrointestinal bleeding, that is, 4.9% of all the upper endoscopies carried out within the bleeding patients. Single laceration was present in 22 cases, double one in 4, and triple in 1. We have frequently found endoscopy lesions associated, the most common one (37%), was hiatal hernia. They all were medically treated except one, who was operated because of gastric perforation was associated. Just one of the Mallory-Weiss syndrome patient died, due to an associated diffused bleeding gastritis.
 
Eosinophilic esophagitis is a recently described entity with esophageal symptoms like gastroesophageal reflux disease and significant esophageal eosinophilic infiltration. To present our clinical series of 29 children with eosinophilic esophagitis, describing the clinical and diagnostic features, treatment and outcome. We describe 29 patients (22 boys), 1-18 years-old, with 20 eosinophils per high-power field in esophageal biopsy specimens and absence of eosinophilic inflammation in the stomach and duodenum. Evaluation of the clinical, endoscopic and histologic findings, treatment and outcome was undertaken. The most common presenting symptoms included vomiting in 15 patients (52%) and abdominal pain in 11 patients (38%). Children under the age of 4 years presented with feeding disorder and failure to thrive. Patients between 5 and 8 years of age presented commonly with abdominal pain or symptoms that may be associated with reflux (heartburn and/or vomiting). Patients over the age of 8 presented most often with abdominal pain, dysphagia and occasional food impaction. Endoscopic features included vertical furrowing in 14 patients (48%), whitish papules in 12 (41%), corrugated rings in 2 patients (7%) and esophageal erosions in 3 patients (10%). In seven patients endoscopy was normal (24%). Treatment included swallowed fluticasone propionate in 19 patients and restriction diet in 7 patients. Patients who returned for follow-up had either improvement or remission of symptoms. After treatment, endoscopic biopsies were repeated in 11 patients, and a significant decrease in esophageal eosinophil counts was observed. The diagnosis of eosinophilic esophagitis must be considered when symptoms of reflux do not respond to conventional treatment. Upper gastrointestinal endoscopy must be complemented by a detailed analysis of histologic findings and eosinophil counts.
 
Top-cited authors
Angelo Alves de Mattos
  • Universidade Federal de Ciências da Saúde de Porto Alegre
Fagundes Neto Ulysses
  • Escola Paulista de Medicina, Universidade Federal de São Paulo, Brazil
Roberto Dantas
  • University of São Paulo
Joaquim Prado Moraes-Filho
  • University of São Paulo School of Medicine
Jaques Waisberg
  • Faculdade de Medicina do ABC