Clinical factors associated with severity in patients with inflammatory bowel disease in Brazil based on 2-year national registry data from GEDIIB

The Brazilian Organization for Crohn's Disease and Colitis (GEDIIB) established a national registry of inflammatory bowel disease (IBD). The aim of the study was to identify clinical factors associated with disease severity in IBD patients in Brazil. A population-based risk model aimed at stratifying the severity of IBD based on previous hospitalization, use of biologics, and need for surgery for ulcerative colitis (UC) and Crohn's Disease (CD) and on previous complications for CD. A total of 1179 patients (34.4 ± 14.7y; females 59%) were included: 46.6% with UC, 44.2% with CD, and 0.9% with unclassified IBD (IBD-U). The time from the beginning of the symptoms to diagnosis was 3.85y. In CD, 41.2% of patients presented with ileocolic disease, 32% inflammatory behavior, and 15.5% perianal disease. In UC, 46.3% presented with extensive colitis. Regarding treatment, 68.1%, 67%, and 47.6% received biological therapy, salicylates and immunosuppressors, respectively. Severe disease was associated with the presence of extensive colitis, EIM, male, comorbidities, and familial history of colorectal cancer in patients with UC. The presence of Montreal B2 and B3 behaviors, colonic location, and EIM were associated with CD severity. In conclusion, disease severity was associated with younger age, greater disease extent, and the presence of rheumatic EIM.

Thiols as a marker of inflammatory bowel disease activity: a systematic review

BACKGROUND

Evidence indicates that inflammation in Inflammatory Bowel Disease (IBD) is associated with increased systemic levels of reactive oxygen species. Systemic oxidative stress has been associated with reduced levels of plasma thiols. Less invasive tests capable of reflecting and predicting IBD activity are increasingly sought after. We sought to systematically review the evidence inherent in serum thiol levels as a marker of Crohn's Disease and Ulcerative Colitis activity (PROSPERO: CRD42021255521).

METHODS

The highest quality documents for systematic reviews standards were used as reference. Articles were searched on Medline via PubMed, VHL, LILACS, WOS, EMBASE, SCOPUS, COCHRANE, CINAHL, OVID, CTGOV, WHO/ICTRP, OPENGREY, BDTD and CAPES, between August, 03 and September, 03 on 2021. Descriptors were defined according to the Medical Subject Heading. Of the 11 articles selected for full reading, 8 were included in the review. It was not possible to perform a pooled analysis of the studies, as there were no combinable studies between subjects with active IBD and controls/inactive disease.

RESULTS

Findings from the individual studies included in this review suggest an association between disease activity and systemic oxidation, as measured by serum thiol levels, however, there are limitations that preclude weighting the study results in a meta-analysis.

CONCLUSIONS

We recommend conducting better-designed and controlled studies, that include individuals of both phenotypes and at different stages of IBD, involving a larger number of participants, using the standardization of the technique for measuring serum thiols, to confirm whether thiols can be a good parameter for monitoring the clinical course of these intestinal diseases and the degree of clinical applicability.

SECOND BRAZILIAN CONSENSUS ON THE MANAGEMENT OF CROHN'S DISEASE IN ADULTS: A CONSENSUS OF THE BRAZILIAN ORGANIZATION FOR CROHN'S DISEASE AND COLITIS (GEDIIB)

BACKGROUND

Inflammatory bowel disease (IBD) is an immune-mediated disorder that includes Crohn's disease (CD) and ulcerative colitis. CD is characterized by a transmural intestinal involvement from the mouth to the anus with recurrent and remitting symptoms that can lead to progressive bowel damage and disability over time.

OBJECTIVE

To guide the safest and effective medical treatments of adults with CD.

METHODS

This consensus was developed by stakeholders representing Brazilian gastroenterologists and colorectal surgeons (Brazilian Organization for Crohn's disease and Colitis (GEDIIB)). A systematic review of the most recent evidence was conducted to support the recommendations/statements. All included recommendations and statements were endorsed in a modified Delphi panel by the stakeholders and experts in IBD with an agreement of at least 80% or greater consensus rate.

RESULTS AND CONCLUSION

The medical recommendations (pharmacological and non-pharmacological interventions) were mapped according to the stage of treatment and severity of the disease in three domains: management and treatment (drug and surgical interventions), criteria for evaluating the effectiveness of medical treatment, and follow-up/patient monitoring after initial treatment. The consensus is targeted towards general practitioners, gastroenterologists, and surgeons interested in treating and managing adults with CD and supports the decision-making of health insurance companies, regulatory agencies, and health institutional leaders or administrators.

SECOND BRAZILIAN CONSENSUS ON THE MANAGEMENT OF ULCERATIVE COLITIS IN ADULTS: A CONSENSUS OF THE BRAZILIAN ORGANIZATION FOR CROHN'S DISEASE AND COLITIS (GEDIIB)

BACKGROUND

Inflammatory bowel diseases are immune-mediated disorders that include Crohn's disease (CD) and ulcerative colitis (UC). UC is a progressive disease that affects the colorectal mucosa causing debilitating symptoms leading to high morbidity and work disability. As a consequence of chronic colonic inflammation, UC is also associated with an increased risk of colorectal cancer.

OBJECTIVE

This consensus aims to provide guidance on the most effective medical management of adult patients with UC.

METHODS

A consensus statement was developed by stakeholders representing Brazilian gastroenterologists and colorectal surgeons (Brazilian Organization for Crohn's Disease and Colitis [GEDIIB]). A systematic review including the most recent evidence was conducted to support the recommendations and statements. All recommendations/statements were endorsed using a modified Delphi Panel by the stakeholders/experts in inflammatory bowel disease with at least 80% or greater consensus.

RESULTS AND CONCLUSION

The medical recommendations (pharmacological and non-pharmacological) were mapped according to the stage of treatment and severity of the disease onto three domains: management and treatment (drug and surgical interventions), criteria for evaluating the effectiveness of medical treatment, and follow-up/patient monitoring after initial treatment. The consensus targeted general practitioners, gastroenterologists and surgeons who manage patients with UC, and supports decision-making processes by health insurance companies, regulatory agencies, health institutional leaders, and administrators.

COMPLEMENTARY AND ALTERNATIVE MEDICINE USE IN BRAZILIAN PATIENTS WITH INFLAMMATORY BOWEL DISEASE

BACKGROUND

The conventional treatment of inflammatory bowel disease (IBD) is based on drug therapy, but different studies have shown a progressive increase in the use of complementary and alternative medicine (CAM). The most used CAM comprises of acupuncture, traditional Chinese medicine, Ayurvedic medicine, homeopathy, and herbal medicine, as well as more modern practices, including aromatherapy and reflexology. Data from CAM use in Brazil has previously been scarce and there are no studies among Brazilian patients with IBD.

OBJECTIVE

The aim of the study was to evaluate the frequency of, and factors associated with the use of CAM among IBD patients in Brazil, in addition to estimating the satisfaction with CAM use.

METHODS

A cross-sectional study was performed in adult IBD outpatients from two Southeastern Brazilian referral centers, with a total a sample of 227 individuals. A semi-structured questionnaire was used containing CAM products - tea, probiotics, omega 3 or glutamine, homeopathy, and herbal therapy, and factors associated with CAM use and patient satisfaction. We used descriptive statistics, association tests (P<0.05) and logistic regression for statistical analyses.

RESULTS

In total, 126 patients with Crohn's disease and 101 with ulcerative colitis were included. The mean age was 41.19±14.49 years and 57.27% were female. The time since diagnosis was 10.58±7.5 years, and most patients were in clinical remission. Twenty-nine patients (12.8%) reported having used CAM for IBD treatment, such as tea (5.29%), probiotics (5.29%), omega-3 or glutamine (1.76%), homeopathy (0.88%), and herbal therapies (0.44%). Despite the low frequency, patients were satisfied (>50%). There was no difference between CAM use in Crohn's disease as compared to ulcerative colitis patients (P=0.1171). The factors associated with the use of CAM were regular or poor quality of life (odds ratio 2.084; 95% confidence interval 1.147-3.786, P=0.0159) and a shorter time since diagnosis (odds ratio 0.956; 95% confidence interval 0.918-0.995; P=0.0260).

CONCLUSION

The prevalence of CAM use was low, but satisfactory among Brazilian IBD patients. The application of CAM has been associated with poor quality of life and shorter disease duration compared to patients with no use of CAM.

Update of the PANCCO clinical practice guidelines for the treatment of ulcerative colitis in the adult population

Ulcerative colitis (US) is a chronic disease of unknown etiology. It is incurable and its clinical course is intermittent, characterized by periods of remission and relapse. The prevalence and incidence of the disease has been increasing worldwide. The update presented herein includes the participation of healthcare professionals, decision-makers, and a representative of the patients, all of whom declared their conflicts of interest. Answerable clinical questions were formulated, and the outcomes were graded. The information search was conducted on the Medline/PubMed, Embase, Epistemonikos, and LILACS databases, and covered grey literature sources, as well. The search was updated on November 30, 2020, with no restrictions regarding date or language. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification system was implemented to establish the strength of the recommendation and quality of evidence. A formal consensus was developed, based on the RAND/UCLA methodology and the document was peer reviewed. The short version of the Clinical Practice Guidelines for the Treatment of Ulcerative Colitis in the Adult Population is presented herein, together with the supporting evidence and respective recommendations. In mild-to-moderate UC, budesonide MMX is an option when treatment with 5-ASA fails, and before using systemic steroids. In moderate-to-severe UC, infliximab, adalimumab, vedolizumab, ustekinumab, and tofacitinib can be used as first-line therapy. If there is anti-TNF therapy failure, ustekinumab and tofacitinib provide the best results. In patients with antibiotic-refractory pouchitis, anti-TNFs are the treatment of choice.

Real-world treatment patterns and disease control over one year in patients with inflammatory bowel disease in Brazil

BACKGROUND

Crohn’s disease (CD) and ulcerative colitis (UC) are inflammatory bowel diseases (IBDs) with a remission-relapsing presentation and symptomatic exacerbations that have detrimental impacts on patient quality of life and are associated with a high cost burden, especially in patients with moderate-to-severe disease. The Real-world Data of Moderate-to-Severe Inflammatory Bowel Disease in Brazil (RISE BR) study was a noninterventional study designed to evaluate disease control, treatment patterns, disease burden and health-related quality of life in patients with moderate-to-severe active IBD. We report findings from the prospective follow-up phase of the RISE BR study in patients with active UC or CD.

AIM

To describe the 12-mo disease evolution and treatment patterns among patients with active moderate-to-severe IBD in Brazil.

METHODS

This was a prospective, noninterventional study of adult patients with active Crohn’s disease (CD: Harvey-Bradshaw Index ≥ 8, CD Activity Index ≥ 220), inadequate CD control (i.e., calprotectin > 200 µg/g or colonoscopy previous results), or active ulcerative colitis (UC: Partial Mayo score ≥ 5). Enrollment occurred in 14 centers from October 2016 to February 2017. The proportion of active IBD patients after 9-12 mo of follow-up, Kaplan-Meier estimates of the time to mild or no activity and a summary of treatment initiation, discontinuation and dose changes were examined.

RESULTS

The study included 118 CD and 36 UC patients, with mean ± SD ages of 43.3 ± 12.6 and 44.9 ± 16.5 years, respectively. The most frequent drug classes at index were biologics for CD (62.7%) and 5-aminosalicylate derivates for UC patients (91.7%). During follow-up, 65.3% of CD and 86.1% of UC patients initiated a new treatment at least once. Discontinuations/dose changes occurred in 68.1% of CD patients [median 2.0 (IQR: 2-5)] and 94.3% of UC patients [median 4.0 (IQR: 3-7)]. On average, CD and UC patients had 4.4 ± 2.6 and 5.0 ± 3.3 outpatient visits, respectively. The median time to first mild or no activity was 319 (IQR: 239-358) d for CD and 320 (IQR: 288-358) d for UC patients. At 9-12 mo, 22.0% of CD and 20.0% of UC patients had active disease.

CONCLUSION

Although a marked proportion of active IBD patients achieved disease control within one year, the considerable time to achieve this outcome represents an unmet medical need of the current standard of care in a Brazilian real-world setting.

Hospitalization and surgery rates in patients with inflammatory bowel disease in Brazil: a time-trend analysis

Background

The prevalence of inflammatory bowel disease (IBD) is increasing globally, and the disease is frequently managed surgically. The aim of this study was to investigate the time trends and geographic distribution of IBD hospitalizations, surgeries and surgical-associated lethality.

Methods

Data from the Brazilian Health Public System were retrospectively collected regarding hospitalizations, in-hospital deaths, IBD-related surgical procedures and lethality from 2005 to 2015.

Results

This eleven-year period revealed decreases in the rates of hospitalization (24%), IBD-related surgeries (35%), and IBD-related surgical lethality (46%). Most surgeries were performed in Crohn’s disease patients, and the predominant procedure was small bowel resection, mostly in young adults. A higher prevalence of ulcerative was observed throughout the country. The highest hospitalization and surgical rates were observed in the more industrialized regions of the South and the Southeast and in the municipalities integrated with metropolitan regions (MRs). The highest surgical-related lethality rates were seen in the less-developed regions and in municipalities not integrated with MRs. The length of hospital stay showed a slight increase throughout the period.

Conclusions

Brazil follows the global trend of decreases in hospitalizations, lethality, surgeries, and surgical lethality associated with IBD. The unequal distribution of hospitalizations and surgeries, concentrated in the industrialized areas, but with a shift towards the Northeast and from urbanized to rural areas, indicates ongoing changes within the country. Reductions in the rates of IBD-related hospitalizations, surgeries and lethality suggest the effectiveness of decentralization and improvements in the quality of public health services and the advances in medical therapy during the study period.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-021-01781-x.

Real-world disease activity and sociodemographic, clinical and treatment characteristics of moderate-to-severe inflammatory bowel disease in Brazil

BACKGROUND

Understanding the treatment landscape of inflammatory bowel diseases (IBD) is essential for improving disease management and patient outcomes. Brazil is the largest Latin American country, and it presents socioeconomic and health care differences across its geographical regions. This country has the highest increase in IBD incidence and prevalence in Latin America, but information about the clinical and treatment characteristics of IBD is scarce.

AIM

To describe the sociodemographic, clinical, and treatment characteristics of IBD outpatients in Brazil overall and in the Southeast, South and Northeast/Midwest regions.

METHODS

Multicenter, cross-sectional study with a 3-year retrospective chart review component. Patients with moderate-to-severe Crohn's disease (CD) or ulcerative colitis (UC) were consecutively enrolled between October 2016 and February 2017. Active CD at enrollment was defined as a Harvey Bradshaw Index ≥ 8 or a CD Activity Index ≥ 220 or a calprotectin level > 200 μg/g or an active result based on colonoscopy suggestive of inadequate control during the previous year; active UC was defined as a partial Mayo score ≥ 5. Descriptive statistics were used to analyze all variables.

RESULTS

In a total of 407 included patients, CD was more frequent than UC, both overall (264 CD/143 UC patients) and by region (CD:UC ratios of 2.1 in the Southeast, 1.6 in the South and 1.2 in the Northeast/Midwest). The majority of patients were female (54.2% of CD; 56.6% of UC), and the mean ages were 45.9 ± 13.8 years (CD) and 42.9 ± 13.0 years (UC). The median disease duration was 10.0 (range: 0.5-45) years for both IBD types. At enrollment, 44.7% [95% confidence interval (CI): 38.7-50.7] of CD patients and 25.2% (95%CI: 18.1-32.3) of UC patients presented with active disease. More than 95% of IBD patients were receiving treatment at enrollment; CD patients were commonly treated with biologics (71.6%) and immunosuppressors (67.4%), and UC patients were commonly treated with mesalazine [5-Aminosalicylic acid (5-ASA)] derivates (69.9%) and immunosuppressors (44.1%). More than 50% of the CD patients had ileocolonic disease, and 41.7% presented with stricturing disease. One-quarter of CD patients had undergone CD-related surgery in the past 3 years, and this proportion was lower in the Northeast/Midwest region (2.9%).

CONCLUSION

In Brazil, there are regional variations in IBD management. CD outweighs UC in both frequency and disease activity. However, one-quarter of UC patients have active disease, and most are receiving 5-ASA treatment.

The Use of Curcumin as a Complementary Therapy in Ulcerative Colitis: A Systematic Review of Randomized Controlled Clinical Trials

The objective of this study was to systematically review the literature to verify the efficacy and safety of curcumin as a complementary therapy for the maintenance or induction of remission in patients with inflammatory bowel disease (IBD). A comprehensive search was conducted by two independent authors in MEDLINE (PubMed), Scopus, Web of Science, the Cochrane Library, Lilacs, Food Science and Technology Abstracts, and ScienceDirect. The search terms “curcumin”, “curcuma”, “inflammatory bowel disease”, “proctocolitis”, “crohn disease”, and “inflammation” were combined to create search protocols. This study considered randomized controlled trials (RCTs) published in any language before March 2020 that evaluated the effects of curcumin on inflammatory activity and the maintenance or remission of IBD patients. After duplicates were removed, 989 trials were identified, but only 11 met the eligibility criteria. Five of these were considered to be biased and were excluded. Therefore, six trials were considered in this review. All the studies included in the systematic review were placebo-controlled RCTs conducted on individuals with ulcerative colitis (UC). All the RCTs reported that curcumin was well tolerated and was not associated with any serious side effects. Studies show that curcumin may be a safe, effective therapy for maintaining remission in UC when administered with standard treatments. However, the same cannot be stated for Crohn’s disease due to the lack of low bias risk studies. Further studies with larger sample sizes are needed before curcumin can be recommended as a complementary therapy for UC.

Review of the epidemiology and burden of ulcerative colitis in Latin America

The incidence and prevalence of ulcerative colitis (UC) has been reported to be rising in newly industrialised regions, such as Latin America. Here, we review data from published studies reporting demographics and clinical aspects of UC in Latin America to further understand epidemiology and disease burden. The incidence and prevalence of UC in Latin America varied between regions and studies, ranging between 0.04 to 8.00/100,000 and 0.23 to 76.1/100,000, respectively, and generally increased over the period from 1986 to 2015. The majority of patients with UC were female (53.6-72.6%) and urban residents (77.8-97.4%). Extraintestinal manifestations were reported in approximately 26-89.4% of patients. Use of biologic therapies was generally low (0.8-16.2%), with the exception of Mato Grosso do Sul, Brazil, with a greater proportion of patients tending to receive 5-aminosalicylates, immunosuppressants or corticosteroids; colectomy rates varied between studies (1.5-22%). A high proportion of patients had moderate to severe UC (45.9-73.0%) and, in 11 of 19 studies, the greatest proportion of patients had extensive disease (pancolitis). Colorectal cancer (0-1.7%) and mortality rates (0-7.6%) were low. This evaluation of published studies may influence therapeutic approaches and the development of strategies to improve healthcare access and patient outcomes, although further high-quality studies are required in patients with UC in Latin America.

Risk factors associated with inflammatory bowel disease: A multicenter case-control study in Brazil

BACKGROUND

The etiology of inflammatory bowel disease (IBD) is unknown, but it is believed to be multifactorial. The hygiene hypothesis proposes that better hygiene conditions would lead to less infectious disease during childhood and favor the development of immune-mediated diseases.

AIM

To test the hygiene hypothesis in IBD by assessing the environmental risk factors associated with IBD development in different regions of Brazil with diverse socioeconomic development indices.

METHODS

A multicenter case-control study was carried out with 548 Crohn’s disease (CD) and 492 ulcerative colitis (UC) outpatients and 416 healthy controls, from six IBD centers within different Brazilian states at diverse socioeconomic development stages. A semi-structured questionnaire with 87 socioeconomic and environmental questions was applied. Logistic regression model was created to assess the odds ratio (OR) with P value and 95% confidence intervals (CI).

RESULTS

Predictive variables for both diseases (CD and UC) were women [odd ratios (OR) = 1.31; OR = 1.69], low monthly family income (OR = 1.78; OR = 1.57), lower number of cohabitants (OR = 1.70; OR = 1.60), absence of vaccination (OR = 3.11; OR = 2.51), previous history of bowel infections (OR = 1.78; OR = 1.49), and family history of IBD (OR = 5.26; OR = 3.33). Associated risk factors for CD were age (18-39 years) (OR = 1.73), higher educational level (OR = 2.22), absence of infectious childhood diseases (OR = 1.99). The UC predictive variables were living in an urban area (OR = 1.62), inadequate living conditions (OR = 1.48) and former smokers (OR = 3.36). Appendectomy was a risk factor for CD (OR = 1.58) with inverse association with UC (OR = 4.79). Consumption of treated and untreated water was associated with risk of CD (OR = 1.38) and UC (OR = 1.53), respectively.

CONCLUSION

This is the first examining environmental exposures as risk factors for inflammatory bowel disease in Brazil. Most of the variables associated with disease risk support the role of the hygiene hypothesis in IBD development.

Quality of life, work productivity impairment and healthcare resources in inflammatory bowel diseases in Brazil

BACKGROUND

Inflammatory bowel diseases (IBD) have been associated with a low quality of life (QoL) and a negative impact on work productivity compared to the general population. Information about disease control, patient-reported outcomes (PROs), treatment patterns and use of healthcare resources is relevant to optimizing IBD management.

AIM

To describe QoL and work productivity and activity impairment (WPAI), treatment patterns and use of healthcare resources among IBD patients in Brazil.

METHODS

A multicenter cross-sectional study included adult outpatients who were previously diagnosed with moderate to severe Crohn’s disease (CD) or ulcerative colitis (UC). At enrolment, active CD and UC were defined as having a Harvey Bradshaw Index ≥ 8 or a CD Activity Index ≥ 220 or calprotectin > 200 µg/g or previous colonoscopy results suggestive of inadequate control (per investigator criteria) and a 9-point partial Mayo score ≥ 5, respectively. The PRO assessment included the QoL questionnaires SF-36 and EQ-5D-5L, the Inflammatory Bowel Disease Questionnaire (IBDQ), and the WPAI questionnaire. Information about healthcare resources and treatment during the previous 3 years was collected from medical records. Chi-square, Fisher’s exact and Student’s t-/Mann-Whitney U tests were used to compare PROs, treatment patterns and the use of healthcare resources by disease activity (α = 0.05).

RESULTS

Of the 407 patients in this study (CD/UC: 64.9%/35.1%, mean age 42.9/45.9 years, 54.2%/56.6% female, 38.3%/37.1% employed), 44.7%/25.2% presented moderate-to-severe CD/UC activity, respectively, at baseline. Expressed in median values for CD/UC, respectively, the SF-36 physical component was 46.6/44.7 and the mental component was 45.2/44.2, the EQ-visual analog scale score was 80.0/70.0, and the IBDQ overall score was 164.0/165.0. Moderate to severe activity, female gender, being unemployed, a lower educational level and lower income were associated with lower QoL (P < 0.05). Median work productivity impairment was 20% and 5% for CD and UC patients, respectively, and activity impairment was 30%, the latter being higher among patients with moderate to severe disease activity compared to patients with mild or no disease activity (75.0% vs 10.0%, P < 0.001). For CD/UC patients, respectively, 25.4%/2.8% had at least one surgery, 38.3%/19.6% were hospitalized, and 70.7%/77.6% changed IBD treatment at least once during the last 3 years. The most common treatments at baseline were biologics (75.3%) and immunosuppressants (70.9%) for CD patients and 5-ASA compounds (77.5%) for UC patients.

CONCLUSION

Moderate to severe IBD activity, especially among CD patients, is associated with a substantial impact on QoL, work productivity impairment and an increased number of IBD surgeries and hospitalizations in Brazil.

Crohn's disease - treatment with biological medication

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Brazilian recommendations on the safety and effectiveness of the yellow fever vaccination in patients with chronic immune-mediated inflammatory diseases

BACKGROUND

In Brazil, we are facing an alarming epidemic scenario of Yellow fever (YF), which is reaching the most populous areas of the country in unvaccinated people. Vaccination is the only effective tool to prevent YF. In special situations, such as patients with chronic immune-mediated inflammatory diseases (CIMID), undergoing immunosuppressive therapy, as a higher risk of severe adverse events may occur, assessment of the risk-benefit ratio of the yellow fever vaccine (YFV) should be performed on an individual level. Faced with the scarcity of specific orientation on YFV for this special group of patients, the Brazilian Rheumatology Society (BRS) endorsed a project aiming the development of individualized YFV recommendations for patients with CIMID, guided by questions addressed by both medical professionals and patients, followed an internationally validated methodology (GIN-McMaster Guideline Development). Firstly, a systematic review was carried out and an expert panel formed to take part of the decision process, comprising BRS clinical practitioners, as well as individuals from the Brazilian Dermatology Society (BDS), Brazilian Inflammatory Bowel Diseases Study Group (GEDIIB), and specialists on infectious diseases and vaccination (from Tropical Medicine, Infectious Diseases and Immunizations National Societies); in addition, two representatives of patient groups were included as members of the panel. When the quality of the evidence was low or there was a lack of evidence to determine the recommendations, the decisions were based on the expert opinion panel and a Delphi approach was performed. A recommendation was accepted upon achieving ≥80% agreement among the panel, including the patient representatives. As a result, eight recommendations were developed regarding the safety of YFV in patients with CIMID, considering the immunosuppression degree conferred by the treatment used. It was not possible to establish recommendations on the effectiveness of YFV in these patients as there is no consistent evidence to support these recommendations.

CONCLUSION

This paper approaches a real need, assessed by clinicians and patient care groups, to address specific questions on the management of YFV in patients with CIMID living or traveling to YF endemic areas, involving specialists from many areas together with patients, and might have global applicability, contributing to and supporting vaccination practices. We recommended a shared decision-making approach on taking or not the YFV.

Ophthalmic manifestations in patients with inflammatory bowel disease: A review

Clinical manifestations of inflammatory bowel disease (IBD) are not locally restricted to the gastrointestinal tract, and a significant portion of patients have involvement of other organs and systems. The visual system is one of the most frequently affected, mainly by inflammatory disorders such as episcleritis, uveitis and scleritis. A critical review of available literature concerning ocular involvement in IBD, as it appears in PubMed, was performed. Episcleritis, the most common ocular extraintestinal manifestation (EIM), seems to be more associated with IBD activity when compared with other ocular EIMs. In IBD patients, anterior uveitis has an insidious onset, it is longstanding and bilateral, and not related to the intestinal disease activity. Systemic steroids or immunosuppressants may be necessary in severe ocular inflammation cases, and control of the underlying bowel disease is important to prevent recurrence. Our review revealed that ocular involvement is more prevalent in Crohn’s disease than ulcerative colitis, in active IBD, mainly in the presence of other EIMs. The ophthalmic symptoms in IBD are mainly non-specific and their relevance may not be recognized by the clinician; most ophthalmic manifestations are treatable, and resolve without sequel upon prompt treatment. A collaborative clinical care team for management of IBD that includes ophthalmologists is central for improvement of quality care for these patients, and it is also cost-effective.

Crohn’s disease environmental factors in the developing world: A case-control study in a statewide catchment area in Brazil

AIM

To identify environmental risk factors associated with the development of Crohn’s disease (CD) in order to re-assess the hygiene hypothesis.

METHODS

A hospital-based, case-control study was carried out with CD patients (n = 145) and controls (n = 163) representing a socioeconomically diverse statewide catchment area in Brazil. Controls were recruited from caregivers of patients seen in different outpatient clinics at the same hospital. A multi-item survey with 94 questions regarding family history of CD, perinatal and childhood circumstances, living conditions, tobacco use and familial socioeconomic status was carried out by interviewers.

RESULTS

On the univariate analysis, predictive variables for CD included being male, under age of 40, a high education level, urban dweller, smaller family size, exposure to enteric pathogens and user of treated water (P < 0.005). On the multivariate analysis, variables significantly associated with CD were male gender (OR = 2.09), under age 40 (OR = 3.10), white (OR = 2.32), from a small family in childhood (OR = 2.34) and adulthood (OR = 3.02), absence of viral infections in childhood (OR = 2.23), exposure to enteric pathogens (OR = 2.41), having had an appendectomy (OR = 2.47) and prior or current smoker (OR = 2.83/1.12).

CONCLUSION

Most variables supporting the “hygiene hypothesis” are associated with the development of CD but are not independent predictors of the diagnosis.

Special situations in inflammatory bowel disease: First Latin American consensus of the Pan American Crohn's and Colitis Organisation (PANCCO) (Second part)

This is the first Latin American Consensus of the Pan American Crohn's and Colitis Organisation (PANCCO) regarding special situations in patients with inflammatory bowel disease (IBD). The aim of this consensus is to raise awareness in the medical community in all Latin American countries with respect to pregnancy, vaccinations, infections, neoplasms, including colorectal cancer, and pediatric issues in patients with IBD.

High prevalence of vitamin A deficiency in Crohn's disease patients according to serum retinol levels and the relative dose-response test

AIM: To assess the vitamin A status of patients with Crohn’s disease (CD) by evaluating serum retinol levels and the relative dose response (RDR) test (liver retinol stores).

METHODS: Vitamin A nutritional status was measured by serum retinol obtained by high performance liquid chromatography and the RDR test for evaluation of the hepatic stores. Body composition was performed by densitometry by dual-energy X-ray absorptiometry. Vitamin A dietary intake was assessed from a semi-quantitative food frequency questionnaire.

RESULTS: This study included 38 CD patients and 33 controls. Low serum retinol concentrations were detected in 29% of CD patients vs 15% in controls (P < 0.005). The RDR test was positive in 37% of CD patients vs 12% in controls, which indicated inadequate hepatic vitamin A stores (P < 0.005). Individuals with hypovitaminosis A had lower BMI and body fat compared with those without this deficiency. There was no association between vitamin A deficiency and its dietary intake, ileal location, presence of disease activity and prior bowel resections.

CONCLUSION: Patients with CD have higher prevalence of vitamin A deficiency, as assessed by two independent methods.

Focal enhanced gastritis and macrophage microaggregates in the gastric mucosa: potential role in the differential diagnosis between Crohn's disease and ulcerative colitis

CONTEXT AND OBJECTIVES

Focally enhanced gastritis and macrophage microaggregates are found in the upper gastrointestinal involvement of Crohn's disease, and may reflect an underlying defective innate immunity. These features, however, are also described in patients with Helicobacter pylori infection. The role of these gastric abnormalities in the diagnosis of Crohn's disease was assessed in a population with high prevalence of H. pylori infection.

METHODS

Thirty-seven Crohn's disease, 26 ulcerative colitis, and 30 control patients were included. The H. pylori status was evaluated by the rapid urease test and histology. The presence of focally enhanced gastritis and macrophage microaggregates was recorded.

RESULTS

Focally enhanced gastritis was present in 24% of Crohn's disease patients, 4% of ulcerative colitis patients and 11.5% of controls, presenting an overall sensitivity and specificity for Crohn's disease of 24% and 88%, respectively. Macrophage microaggregates were found in all groups, but were only detected in ulcerative colitis and controls in association with H. pylori infection, with an overall sensitivity and specificity for Crohn's disease of 61% and 69%, respectively. In the absence of H. pylori infection, focally enhanced gastritis and macrophage microaggregates were significantly associated with Crohn's disease (P<0.02 and P = 0.001 respectively).

CONCLUSIONS

Focally gastritis and macrophage microaggregates are suggestive of Crohn's disease only in H. pylori-negative specimens.

Lower extremity mobility limitation and impaired muscle function in women with ulcerative colitis

BACKGROUND AND AIM

Fatigue, weakness and musculoskeletal manifestations are associated with IBD. An impaired nutritional status and a reduced physical activity can contribute to these clinical outcomes, impacting quality of life and increasing disability. This study aims to assess muscle strength and lower limb physical performance in female UC patients, taking into consideration disease activity, body composition and habitual physical activity.

METHODS

A case-control study was performed including 23 UC female outpatients and 23 age- and BMI-matched healthy women as controls. Quadriceps strength (QS), handgrip strength (HGS), physical performance based measures (five repetitions sit-up test and 4meter gait speed test), body composition (bioelectrical impedance analysis, anthropometry), and habitual physical activity (HPA) levels were assessed.

RESULTS

UC group had decreased QS (-6%; P=0.012), slower sit-up test (-32%; P=0.000), slower gait speed (-17% P=0.002) and decreased HPA level (-30%, P=0.001) compared with controls. No difference in HGS was observed between groups. Logistic regression showed that UC was an independent factor for decreased QS and slower sit-up test, while HPA was a protective factor for impaired gait speed. Multivariate linear regression showed that BMI was independently associated with an improved QS and slower sit-up test in the UC group.

CONCLUSION

Women with UC had decreased lower limb strength and mobility limitations, which were associated with BMI and the level of physical activity. Early evaluation of nutritional status and performance of the lower limbs could identify UC patients with pre-clinical disability who may benefit from earlier health lifestyle modifications.

Does active Crohn's disease have decreased intestinal antioxidant capacity?

BACKGROUND AND AIMS

Oxidative stress is presumed to play an important role in Crohn's disease (CD) pathogenesis. Nevertheless, the evaluation of the intestinal antioxidant capacity through the analysis of glutathione peroxidase activity in CD remains to be determined.

METHODS

20 CD outpatients and 16 volunteers going through colonic cancer screening were enrolled. Colonoscopy with biopsies was performed in all individuals. Samples from inflamed and non-inflamed mucosa were taken when there was CD endoscopic activity. Spectrophotometric assays were performed to measure tissue glutathione peroxidase (GPx) activity, and total (GSHT) and oxidized (GSSG) glutathione in all samples. Demographics and clinical characteristics were collected from clinical charts.

RESULTS

Inflamed CD mucosa presented reduced GPx activity compared to non-inflamed CD mucosa (42.94mU/mg protein vs 79.62mU/mg protein, P<0.05) and control mucosa (42.94mU/mg protein vs 95.08mU/mg protein, P<0.001). GSHT concentration was reduced in inflamed mucosa when compared to non-inflamed CD mucosa (0.78μmol/g vs 1.98μmol/g, P<0.01) and the control group (0.78μmol/g vs 2.11μmol/g, P<0.001). A significant correlation was detected between GPx activity and GSSG (r=-0.599), disease duration (r=0.546), and thiopurine treatment (r=-0.480) in non-inflamed CD mucosa.

CONCLUSION

Our findings suggest that reduced GPx activity is present in inflamed CD mucosa. In addition, endoscopic activity, disease duration and thiopurine therapy could be associated with mucosal decreased antioxidant activity.

Pseudomelanosis duodeni associated with chronic renal failure

Pseudomelanosis duodeni (PD) is a rare dark speckled appearance of the duodenum associated with gastrointestinal bleeding, hypertension, chronic heart failure, chronic renal failure and consumption of different drugs. We report four cases of PD associated with chronic renal failure admitted to the gastroenterology outpatient unit due to epigastric pain, nausea, melena and progressive reduction of hemoglobin index. Gastroduodenal endoscopy revealed erosions in the esophagus and stomach, with no active bleeding at the moment. In addition, the duodenal mucosa presented marked signs of melanosis; later confirmed by histopathological study. Even though PD is usually regarded as a benign condition, its pathogenesis and clinical significance is yet to be defined.

In vitro ultrasound biomicroscopic imaging of colitis in rats

OBJECTIVE

The purpose of this study was to show the feasibility of 50-MHz ultrasound biomicroscopy (UBM) to image the rat colon.

METHODS

B-mode images were obtained from ex vivo colon samples (n = 4) collected from Rattus norvegicus (Berkenhout, 1769) rats, with 2,4,6-trinitrobenzene sulfonic acid-induced colitis in 3 of them. Left colon rectangular fragments (5 x 5 mm) were obtained after necropsy, and UBM images were acquired with the samples immersed in saline at 37 degrees C. All layers of the normal intestinal wall were analyzed according to their thickness and the presence of uneven bowel mucosa (ulcers). The folds and layers detected by UBM were correlated with histopathologic analysis.

RESULTS

The 4 layers of the normal colon were identified on the UBM images: the mucosa (hyperechoic), muscularis mucosae (hypoechoic), submucosa (hyperechoic), and muscularis externa (hypoechoic). On 2 UBM images, superficial ulcers were detected, approximately 0.5 mm in size, with intestinal involvement limited to the mucosa. The histopathologic analysis verified enlargement of submucosa layers due to an edema associated with sub-mucosa leukocyte infiltration. On 1 UBM image, it was possible to detect a deep ulcer, which was confirmed by the light microscopic analysis.

CONCLUSIONS

An ultrasound imaging system was scaled and optimized to visualize the rat colon. Ultrasound biomicroscopy provided axial and lateral resolutions close to 25 and 45 mum, respectively, and adequate penetration depth to visualize the whole thickness of an inflamed colon. The system identified the colon layers and was able to detect mural changes and superficial ulcers on the order of 500 mum.

[Descriptive analysis of the social, clinical, laboratorial and anthropometric profiles of inflammatory bowel disease inwards patients from the "Clementino Fraga Filho" University Hospital, Rio de Janeiro, RJ, Brazil]

BACKGROUND

The epidemiologic survey in Brazil is limited probably due to a diagnosis deficiency and a small number of population-based studies performed. The majority of the prevalence studies available have evaluated inflammatory bowel diseases outpatients, but the knowledge of the profile of inflammatory bowel diseases inpatients is important in order to detect predictive markers of disease severity that will allow earlier medical intervention decreasing the rate of hospitalization and reducing the Health System costs.

AIM

To determine social, clinical, laboratorial and anthropometric profiles of hospitalized adults inflammatory bowel diseases patients of a tertiary university hospital.

METHODS

Prospective study was performed with 43 inflammatory bowel diseases inpatients from clinical and surgical wards and emergency section of university hospital. We characterized demographic data, presence of comorbidities, disease location and behavior, surgical past-history, extra intestinal manifestations using standardized definitions. Laboratory results were abstracted from medical records and anthropometric measures were performed during our visit.

RESULTS

The vast majority of the inflammatory bowel diseases patients had Crohn's disease (72.1%), with ileocolic involvement (60%), with a penetrating disease behavior (77.4%) while ulcerative colitis group presented mostly pancolitis (50%). Articular pain was the most common (44.2%) extra intestinal manifestation of inflammatory bowel diseases patients and 97.7% of them had at least one type of complication related to disease. Although, the previous use of specific medical therapies to inflammatory bowel diseases before the hospitalization (more frequently corticosteroids) was done (79%), the majority of the patients were hospitalized because of inflammatory bowel diseases activity. Disease activity was present in 80.7% of Crohn's disease and 50% ulcerative colitis patients. Inflammatory bowel diseases mortality rate was 5.5% (2/36). Comorbidities presence occurred only in 30.2% of inflammatory bowel diseases patients. The predominant surgery performed was intestinal resection. The interval between the symptoms appearance and the definitive diagnosis was less than 1 year in more than 70% of inflammatory bowel diseases patients. Laboratory findings detected were a decreased serum albumin (85.7%) and anemia (69.8%). The majority of the patients had at least one anthropometric alteration. The social stratification of the inflammatory bowel diseases group was similar to the Brazilian population.

CONCLUSION

The inflammatory bowel diseases inpatients from the university hospital wards had more severe evolution of these illnesses with an active and extensive disease with complications and frequent extra intestinal manifestations, despite the prolonged use of corticosteroids. The higher prevalence of Crohn's disease inpatients than ulcerative colitis could reflect a higher aggressive behavior of this disease. The reduced serum albumin, anemia and anthropometric alterations are common inflammatory bowel diseases inpatients and could be related to a major severity of inflammatory bowel diseases evolution.

Hepatitis B virus prevalence and transmission risk factors in inflammatory bowel disease patients at Clementino Fraga Filho university hospital

AIM: To evaluate the prevalence of hepatitis B virus (HBV) infection in inflammatory bowel disease (IBD) patients that followed up in our hospital and try to identify the possible risk factors involved in this infection transmission.

METHODS: This was a cross-sectional study for which 176 patients were selected according to their arrival for the medical interview. All these patients had already IBD diagnosis. The patient was interviewed and a questionnaire was filled out.

RESULTS: In the group of 176 patients whom we examined, we found that 17% (30) were anti-HBc positive. Out of 30 patients with positive anti-HBc, 2.3% (4) had positive HBsAg and negative HBV-DNA. In an attempt to identify the possible HBV infection transmission risk factors in IBD patients, it was observed that 117 patients had been submitted to some kind of surgical procedure, but only 24 patients had positive anti-HBc (P = 0.085). It was also observed that surgery to treat IBD complications was not a risk factor for HBV infection transmission, since we did not get a statically significant P value. However, IBD patients that have been submitted to surgery to treat IBD complications received more blood transfusions then patients submitted to other surgical interventions (P = 0.015).

CONCLUSION: There was a high incidence of positive anti-HBc (17%) and positive HBsAg (2.3%) in IBD patient when compared with the overall population (7.9%).

Prevalence of periodontitis and DMFT index in patients with Crohn's disease and ulcerative colitis

AIM

To compare the prevalence of periodontal disease and the decayed, missing and filled teeth (DMFT) index in patients with Crohn's disease (CD) and ulcerative colitis (UC) with those without these diseases.

MATERIAL AND METHODS

Ninety-nine CD (39.0 SD+/-12.9 years), 80 UC (43.3 SD+/-13.2) and 74 healthy controls (40.3 SD+/-12.9) were compared for DMFT index and presence of periodontitis. Probing pocket depth (PPD), clinical attachment loss (CAL), bleeding on probing (BOP), plaque and DMFT index were measured on all subjects. The presence of periodontitis was defined as having CAL > or =3 mm in at least four sites in different teeth.

RESULTS

Significantly more patients with UC (90.0%; p<0.001) and CD (81.8%; p=0.03) had periodontitis than controls (67.6%). Among smokers, UC patients had significantly more periodontitis. CD had a greater mean DMFT score (18.7 versus 13.9; p=0.031) compared with controls and UC had greater median PPD (2.2 versus 1.7 mm; p<0.0001) than controls. Among non-smokers, CD (2.4 mm; p<0.0001) and UC showed deeper pockets (2.3 mm; p<0.0001) compared with controls (1.5 mm). UC had a greater mean DMFT score (15.3 versus 12.1; p=0.037) compared with controls.

CONCLUSIONS

CD and UC patients had higher DMFT and prevalence of periodontitis than controls, but smoking was an effect modifier.

Quality-of-life measurement in patients with inflammatory bowel disease receiving social support

BACKGROUND

Crohn's disease and ulcerative colitis, referred to as inflammatory bowel diseases, affect mainly young adults and have an elevated morbidity and a negative effect on quality of life. This study aimed to compare the health-related quality of life between 2 randomized groups of patients with inflammatory bowel disease: (1) the supported group (SG), patients receiving social support for an 18-month period, and (2) the control group (CG), patients receiving no social support.

METHODS

Health-related quality of life was assessed at 4 moments with the Portuguese versions of the Medical Outcomes Study Short Form 36 and the Inflammatory Bowel Disease Questionnaire (IBDQ), both validated in Brazil.

RESULTS

In the SG, using analysis of variance for repeated measures complemented by the Bonferroni test positive variations were observed (1) in the Social Aspects domain, between the first and third evaluations (P = 0.044), and (2) in the Emotional Aspects domain, between the first and second and the third and fourth evaluations (P = 0.029).

CONCLUSIONS

In the sample studied, social support, measured by use of the Inflammatory Bowel Disease Questionnaire, had a positive impact on the social and emotional aspects of quality of life.

Bronchial hyperresponsiveness and analysis of induced sputum cells in Crohn's disease

With the aim of investigating the presence of latent inflammatory process in the lungs of patients with Crohn's disease, 15 patients with Crohn's disease were evaluated by spirometry, the methacholine challenge test, induced sputum, and skin tests for inhaled antigens. Serum IgE, erythrocyte sedimentation rate and hematocrit were also determined. The patients were compared with 20 healthy controls by the Mann-Whitney and Fisher exact tests. Their respiratory physical examination was normal. None had a personal or family history of clinical atopy. None had a previous history of pulmonary disease, smoking or toxic bronchopulmonary exposure. None had sinusitis, migraine, diabetes mellitus, or cardiac failure. Four (26.6%) of the patients with Crohn's disease had a positive methacholine challenge test whereas none of the 20 controls had a positive methacholine test (P = 0.026, Fisher exact test). Patients with Crohn's disease had a higher level of lymphocytes in induced sputum than controls (mean 14.59%, range 3.2-50 vs 5.46%, 0-26.92%, respectively; P = 0.011, Mann-Whitney test). Patients with Crohn's disease and a positive methacholine challenge test had an even higher percentage of lymphocytes in induced sputum compared with patients with Crohn's disease and a negative methacholine test (mean 24.88%, range 12.87-50 vs 10.48%, 3.2-21.69%; P = 0.047, Mann-Whitney test). The simultaneous findings of bronchopulmonary lymphocytosis and bronchial hyperresponsiveness in patients with Crohn's disease were not reported up to now. These results suggest that patients with Crohn's disease present a subclinical inflammatory process despite the absence of pulmonary symptoms.

Small bowel of patients with asthma and allergic rhinitis: absence of inflammation despite the presence of major cellular components of allergic inflammation

Eosinophils participate in the pathogenesis of inflammatory diseases of the respiratory tract and the gut. We investigated the constitutive presence of eosinophils and mononuclear cells in the macroscopically normal duodenal mucosa of patients with asthma and allergic rhinitis. Macroscopically normal duodenal specimens were obtained at routine endoscopy for upper gastrointestinal symptoms from 16 patients with asthma and 13 patients with allergic rhinitis. Twelve nonatopic patients with irritable bowel syndrome were studied as controls. Specimens were analyzed by immunohistochemistry using a panel of antibodies to human eosinophil cationic protein clone EG1 (EG1) and clone EG2 (EG2), anti-human interleukin (anti-hIL)-5, anti-hIL-4, anti-CD4, and anti-CD68. Significantly increased numbers of eosinophils stained with EG1 and EG2 were found in the duodenum of patients with asthma and allergic rhinitis compared with controls. IL-5+ cells and IL-4+ cells were detected in significantly increased numbers in the duodenal mucosa of patients with asthma and rhinitis compared with controls. Mononuclear cells expressing CD4 (helper T cells) and CD68 (macrophages) also were significantly increased in the duodenal mucosa of asthma and rhinitis compared with controls. Accumulation of eosinophils in conjunction with IL-4+ cells and IL-5+ cells in the noninflamed duodenal mucosa may reflect a predominant T helper cell subset 2 systemic immune response in patients with asthma and allergic rhinitis. The absence of intestinal inflammation despite the marked presence of cells implicated in the allergic inflammation suggests that local mechanisms might determine the state of nonresponsiveness in the gut mucosa of patients with asthma and allergic rhinitis.

Long chain fatty acid uptake by human intestinal mucosa in vitro: mechanisms of transport

BACKGROUND/AIMS

The aim of this study was to investigate whether a carrier-mediated membrane transport for long chain fatty acid (LCFA) exists in the human intestinal mucosa.

METHODS

Biopsies obtained from the small intestine of patients, during routine endoscopies, were incubated for different periods in the presence of [(3)H]oleic acid complexed to albumin, and lipid fractions were separated and quantified. Biopsies were also incubated during 5 min in different oleic acid:albumin molar ratios. The effect of temperature on lipid transport was tested by incubating biopsies at 37 and 4 degrees C.

RESULTS

Maximum [(3)H]oleic acid uptake occurred at 15 min. With increasing unbound oleic acid concentrations in the medium, LCFA uptake during 5 min of incubation revealed a typical saturation kinetics profile, and exhibiting apparent K(m) values of 3.43 +/- 0.83 microM, and apparent V(max) values of 0.86 +/- 0.07 nmol x min(-1) x mg(-1). Within this period, nearly all intracellular fatty acid remained in the unesterified form. The system was also temperature-dependent, having shown a significant reduction of 78.03% in [(3)H]oleic acid uptake at 4 degrees C, in 5 min of incubation.

CONCLUSIONS

Our data confirm that LCFA uptake by human intestinal mucosa is likely to occur via a saturable carrier.

Upper gastrointestinal bleeding in a Brazilian hospital: a retrospective study of endoscopic records

BACKGROUND

Upper gastrointestinal bleeding is a frequent and potentially severe complication of most digestive diseases of the upper gastrointestinal tract. Upper endoscopy has a crucial role in the diagnosis and treatment of upper gastrointestinal bleeding, however epidemiological studies are still limited in our country. Aims - To assess the clinical characteristics, endoscopic accuracy, treatment efficiency and clinical outcome of patients admitted to the endoscopic unit with upper gastrointestinal bleeding.

METHODS

A retrospective study of consecutive records from patients who underwent emergency endoscopy for upper gastrointestinal bleeding was performed during a period of 2 years.

RESULTS

Most patients were male 68.7%, with a mean age of 54.5 +/- 17.5 years. A bleeding site could be detected in 75.6% of the patients. Diagnostic accuracy was greater within the first 24 hours of the bleeding onset, and in the presence of hematemesis. Peptic ulcer was the main cause of upper gastrointestinal bleeding (35%). The prevalence of variceal bleeding (20.45%) indicates a high rate of underlying liver disease. Endoscopic treatment was performed in 23.86% of the patients. Permanent hemostasis was achieved in 86% of the patients at the first endoscopic intervention, and in 62.5% of the patients after rebleeding. Emergency surgery was seldom necessary. The average number of blood units was 1.44 +/- 1.99 per patient. The average length of hospital stay was 7.71 +/- 12.2 days. Rebleeding was reported in 9.1% of the patients. The overall mortality rate of 15.34% was significantly correlated with previous liver disease.

CONCLUSIONS

Diagnostic accuracy was related to the time interval between the bleeding episode and endoscopy, and to clinical presentation. Endoscopic therapy was an effective tool for selected patients. The resulting increased duration of hospitalization and higher mortality rate in the patients submitted to therapeutic endoscopy were attributed to a higher prevalence of variceal bleeding and underlying liver disease.

Role of different methods for the detection of diarrhoeal pathogens in HIV-infected patients in Brazil

To evaluate the ability of different diagnostic methods for the detection of AIDS-related diarrhoeal pathogens in developing countries, we studied 40 HIV-infected patients with diarrhoea. All patients were subjected to stool examinations for parasites, stool culture and peroral jejunal biopsy. Jejunal specimens were processed for histological examination with several stains and for transmission electron microscopy (TEM). Jejunal juice and mucosa were cultured. An aetiologic agent was found in twenty patients. Eleven stool specimens were positive for parasites and stool culture was positive in three patients. The enteropathogens detected by these two methods included every microorganism amenable to treatment. Histological examination revealed four agents not previously identified. TEM added to diagnosis in only two patients. All cultures of jejunal mucosa and jejunal juice were negative, even when stool culture was positive. We conclude that a minimal investigation consisting of stool examination for parasites and stool culture is a cost-effective strategy in the management of AIDS-related diarrhoea in developing countries.

[Experience with peroral biopsy of the small intestine at the University Hospital--Federal University of Rio de Janeiro]

The experience with 103 jejunal biopsies in the Rio de Janeiro University Hospital--UFRJ, from January 1983 to June 1985 is presented. It is reported the effectiveness of the method and the low number of complications. The importance as a valuable complementary method of diagnosis and the usefulness in the small intestine disease's scientific investigation is emphasized.

[Selective splenorenal shunt and post-transfusional hepatitis. Short and medium-term follow-up]

Eighteen patients with protal hypertension were studied. Portal hypertension was due to schistosomiasis (N = 9), cirrhosis (N = 7) and congenital hepatic fibrosis (N = 2) diagnosed by surgical biopsy during the decompressive surgery (selective splenorenal shunt). All the patients have had at least one episode of digestive hemorrhage due to rupture of esophageal varices and received blood transfusion before or during surgery. The incidence of post-transfusion hepatitis was 44% (eight cases). The short and medium-term follow-up was good regardless the etiology of portal hypertension. The authors attributed these results mainly to good hepatic function at the time of surgery, younger patient population and good surgical technical conditions.