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Barbosa EC, Espírito Santo PA, Baraldo S, Meine GC. Remimazolam versus propofol for sedation in gastrointestinal endoscopic procedures: a systematic review and meta-analysis. Br J Anaesth 2024; 132:1219-1229. [PMID: 38443286 DOI: 10.1016/j.bja.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/11/2024] [Accepted: 02/09/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Propofol has a favourable efficacy profile in gastrointestinal endoscopic procedures, however adverse events remain frequent. Emerging evidence supports remimazolam use in gastrointestinal endoscopy. This systematic review and meta-analysis compares remimazolam and propofol, both combined with a short-acting opioid, for sedation of adults in gastrointestinal endoscopy. METHODS We searched MEDLINE, Embase, and Cochrane databases for randomised controlled trials comparing efficacy-, safety-, and satisfaction-related outcomes between remimazolam and propofol, both combined with short-acting opioids, for sedation of adults undergoing gastrointestinal endoscopy. We performed sensitivity analyses, subgroup assessments by type of short-acting opioid used and age range, and meta-regression analysis using mean patient age as a covariate. We used R statistical software for statistical analyses. RESULTS We included 15 trials (4516 subjects). Remimazolam was associated with a significantly lower sedation success rate (risk ratio [RR] 0.991; 95% confidence interval [CI] 0.984-0.998; high-quality evidence) and a slightly longer induction time (mean difference [MD] 9 s; 95% CI 4-13; moderate-quality evidence), whereas there was no significant difference between the sedatives in other time-related outcomes. Remimazolam was associated with significantly lower rates of respiratory depression (RR 0.41; 95% CI 0.30-0.56; high-quality evidence), hypotension (RR 0.43; 95% CI 0.35-0.51; moderate-quality evidence), hypotension requiring treatment (RR 0.25; 95% CI 0.12-0.52; high-quality evidence), and bradycardia (RR 0.42; 95% CI 0.30-0.58; high-quality evidence). There was no difference in patient (MD 0.41; 95% CI -0.07 to 0.89; moderate-quality evidence) and endoscopist satisfaction (MD -0.31; 95% CI -0.65 to 0.04; high-quality evidence) between both drugs. CONCLUSIONS Remimazolam has clinically similar efficacy and greater safety when compared with propofol for sedation in gastrointestinal endoscopies.
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Affiliation(s)
| | - Paula Arruda Espírito Santo
- Diagnostic Imaging and Specialized Diagnosis Unit, University Hospital of Federal University of São Carlos, São Carlos, Brazil
| | - Stefano Baraldo
- Department of Endoscopy, Barretos Cancer Hospital, Barretos, Brazil
| | - Gilmara Coelho Meine
- Division of Gastroenterology, Internal Medicine Department, Feevale University, Novo Hamburgo, Brazil.
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de Oliveira FD, Costa RC, de Santana Sato EDB, Khalil SM, Meine GC. Efficacy and Safety of Monoclonal Antibodies for the Treatment of Eosinophilic Esophagitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Dig Dis Sci 2024:10.1007/s10620-024-08413-w. [PMID: 38709421 DOI: 10.1007/s10620-024-08413-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/27/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND AND AIMS Monoclonal antibodies (MAbs) have clinical benefits for treating several atopic diseases. However, consensus on its use for eosinophilic esophagitis (EoE) is lacking. The present meta-analysis aimed to compare the efficacy and safety of MAbs versus placebo for treating EoE. METHODS We searched PubMed, Embase, and Cochrane Library for randomized controlled trials (RCTs). The primary outcomes were changes in peak esophageal eosinophils count/high power field (HPF) and mean esophageal eosinophils count/HPF. The secondary outcomes were changes in the EoE-Histology Scoring System (EoE-HSS), Endoscopic Reference Score (EREFS), dysphagia score, and adverse events (AEs). We compared binary outcomes using risk ratio (RR) and continuous outcomes using mean difference (MD) or standardized mean difference (SMD), with 95% confidence interval (CI). Considering the diversity of mechanistic properties of MAbs, a pre-specified subgroup analysis by MAb mechanism of action was performed for all outcomes, provided that at least two studies were in each subgroup. Heterogeneity was assessed using Cochran's Q test and I2 statistics. RESULTS 6 RCTs were included (533 patients). Compared to placebo, MAbs led to a significant reduction in peak esophageal eosinophils count/HPF (MD -0.78; CI 95% -0.87, -0.6801) and mean esophageal eosinophils count/HPF (SMD -0.79; CI 95% -1.5, -0.08). Moreover, MAbs significantly reduced EoE-HSS scores (grade score: SMD -9.31; 95% CI -13.95, -4.6701; stage score: SMD -10.18; 95% CI -15.06, -5.31), EREFS (SMD -5.95; CI 95% -9.19, -2.71) and dysphagia score (SMD -1.79; CI 95% -3.36, -0.23) without increasing AEs compared to placebo. Among those MAbs whose mechanism of action includes the blockage of the receptor for IL-13 (Dupilumab, QAX576, and RPC4046), the scores of EoE-HSS grade, EoE-HSS stage, EREFS, and dysphagia were significantly reduced, and they presented a similar risk of overall and serious AEs compared to placebo. CONCLUSION MAbs seem effective and safe in reducing esophageal eosinophil infiltrate, EoE-HSS score, EREFS score, and dysphagia symptoms in patients with EoE. However, further evidence is needed to establish its place in EoE management.
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Affiliation(s)
| | | | | | | | - Gilmara Coelho Meine
- Division of Gastroenterology, Internal Medicine Department, Instituto de Ciências da Saúde - ICS, Universidade Feevale, Novo Hamburgo, Brazil.
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Barbosa EC, Santo PADE, Baraldo S, Nau AL, Meine GC. EUS- versus ERCP-guided biliary drainage for malignant biliary obstruction: A systematic review and meta-analysis of randomized controlled trials. Gastrointest Endosc 2024:S0016-5107(24)00239-6. [PMID: 38648989 DOI: 10.1016/j.gie.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/05/2024] [Accepted: 04/15/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND AND AIMS Increasing evidence support endoscopic ultrasound-guided biliary drainage (EUS-BD) as a potential alternative to endoscopic retrograde cholangiopancreatography-guided biliary drainage (ERCP-BD) in the primary treatment of malignant biliary obstruction (MBO). This systematic review and meta-analysis aimed to compare the efficacy and safety of both techniques as the initial approach for MBO. METHODS We searched MEDLINE, Embase, and Cochrane databases for randomized controlled trials (RCTs) comparing both techniques and reporting at least one of the outcomes of interest. The pooled estimates were calculated using the random-effects model and I2 statistics were used to evaluate heterogeneity. RESULTS We included six RCTs (577 patients). There were no significant differences between groups in stent patency (MD 8.18 days; 95% CI -22.55, 38.91), procedure time (MD -6.31 minutes; 95% CI -12.68, 0.06), and survival (MD 4.59 days; 95% CI -34.23, 43.40). Technical success (RR 1.04; 95% CI 0.96, 1.13), clinical success (RR 1.02; 95% CI 0.96, 1.08), overall adverse events (RR 0.58; 95% CI 0.24, 1.43), and cholangitis (RR 1.19; 95% CI 0.39, 3.61) were also similar between groups. However, hospital stay was significantly shorter (MD -1.03 days; 95% CI -1.53, -0.53), and risk of reintervention (RR 0.57; 95% CI 0.37, 0.88), post-procedure pancreatitis (RR 0.15; 95% CI 0.03, 0.66), and tumor in/overgrowth (RR 0.28; 95% CI 0.11, 0.70) were significantly lower with EUS-BD. CONCLUSIONS EUS-BD and ERCP-BD had similar efficacy and safety as the initial approach for MBO. However, EUS-BD had a significantly lower risk of reintervention, post-procedure pancreatitis, tumor in/overgrowth, and reduced hospital stay.
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Affiliation(s)
| | - Paula Arruda do Espírito Santo
- Diagnostic Imaging and Specialized Diagnosis Unit, University Hospital of Federal University of São Carlos, São Carlos, Brazil
| | - Stefano Baraldo
- Department of Endoscopy, Barretos Cancer Hospital, Barretos, Brazil
| | - Angélica Luciana Nau
- Department of Pediatric Gastroenterology, Jaraguá Hospital, Jaraguá do Sul, Brazil
| | - Gilmara Coelho Meine
- Division of Gastroenterology, Department of Internal Medicine, Feevale University, Novo Hamburgo, Brazil
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Arruda do Espirito Santo P, Meine GC, Baraldo S, Barbosa EC. Cold endoscopic mucosal resection versus cold snare polypectomy for colorectal lesions: a systematic review and meta-analysis of randomized controlled trials. Endoscopy 2024. [PMID: 38503302 DOI: 10.1055/a-2275-5349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
BACKGROUND Cold resection of colorectal lesions is widely performed because of its safety and effectiveness; however, it remains uncertain whether adding submucosal injection could improve the efficacy and safety. We aimed to compare cold endoscopic mucosal resection (C-EMR) versus cold snare polypectomy (CSP) for colorectal lesions. METHODS We performed a systematic review of randomized controlled trials (RCTs) identified from PubMed, Cochrane Library, and Embase. The primary outcome was complete resection. Secondary outcomes were procedure time, en bloc resection, and adverse events (AEs). Prespecified subgroup analyses based on the size and morphology of the polyps were performed. The random-effects model was used to calculate the pooled risk ratio (RR) and mean difference, with corresponding 95%CIs, for dichotomous and continuous variables, respectively. Heterogeneity was assessed using the Cochran Q test and I 2 statistics. RESULTS 7 RCTs were included, comprising 1556 patients, with 2287 polyps analyzed. C-EMR and CSP had similar risk ratios for complete resection (RR 1.02, 95%CI 0.98-1.07), en bloc resection (RR 1.08, 95%CI 0.82-1.41), and AEs (RR 0.74, 95%CI 0.41-1.32). C-EMR had a longer procedure time (mean difference 42.1 seconds, 95%CI 14.5-69.7 seconds). In stratified subgroup analyses, the risk was not statistically different between C-EMR and CSP for complete resection in polyps<10 mm or ≥10 mm, or for complete resection, en bloc resection, and AEs in the two groups among nonpedunculated polyps. CONCLUSIONS The findings of this meta-analysis suggest that C-EMR has similar efficacy and safety to CSP, but significantly increases the procedure time. PROSPERO CRD42023439605.
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Affiliation(s)
- Paula Arruda do Espirito Santo
- Diagnostic Imaging and Specialized Diagnosis Unit, University Hospital of Federal University of São Carlos, São Carlos, Brazil
| | - Gilmara Coelho Meine
- Department of Internal Medicine (Division of Gastroenterology), FEEVALE University, Novo Hamburgo, Brazil
| | - Stefano Baraldo
- Department of Endoscopy, Barretos Cancer Hospital, Barretos, Brazil
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Meine GC, Sander GB. PREVALENCE OF SERRATED POLYPS AND THEIR ASSOCIATION WITH SYNCHRONOUS COLORECTAL ADVANCED ADENOMAS. Arq Gastroenterol 2023; 60:224-229. [PMID: 37556749 DOI: 10.1590/s0004-2803.20230223-020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 04/18/2023] [Indexed: 08/11/2023]
Abstract
•This study revealed a similar prevalence of clinically significant serrated polyps and advanced adenomas among patients who underwent colonoscopy. •Multivariate analysis demonstrated an association between clinically significant serrated polyps and synchronous advanced adenomas, though the strength of this association was stronger for proximal advanced adenomas. •Large serrated polyps and sessile serrated adenomas were associated with proximal advanced adenomas. Background - Serrated lesions are the precursors of up to one-third of colorectal cancer (CRC) cases and share molecular and epidemiological features with interval CRC. Previous studies have reported wide variation in serrated polyp prevalence and diverse magnitude of its relationship with synchronous advanced adenomas.Objective - Describe the prevalence of serrated polyps and evaluate their association with synchronous advanced adenomas. Methods - The study is a retrospective analysis of 1208 colonoscopies performed in patients aged 45 to 75, predominantly for CRC screening. Data on the prevalence of serrated polyps subsets and advanced adenomas were collected, and multivariate analysis were performed to identify the association between serrated polyps and synchronous advanced adenomas. Results - The prevalence of clinically significant serrated polyps (CSSP), large serrated polyps (LSP), and sessile serrated adenomas (SSA) were 11.3%, 6%, and 3.7%. CSSP were associated with synchronous advanced adenomas (OR 2.121, 95%CI 1.321-3.406), regardless of proximal (OR 2.966, 95%CI 1.701-5.170) or distal (OR 1.945, 95%CI 1.081-3.499) location, while LSP (OR 2.872, 95%CI 1.425-5.787) and SSA (OR 5.032, 95%CI 2.395-10.576) were associated with proximal advanced adenomas. Conclusion - The prevalence of CSSP and advanced adenomas were alike. CSSP is a risk factor for advanced adenomas, and the strength of this association is stronger for proximal advanced adenomas. LSP and SSA are associated with proximal advanced adenomas.
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Affiliation(s)
- Gilmara Coelho Meine
- Universidade Federal do Rio Grande do Sul, Escola de Medicina, Programa de Pós-graduação: Ciências em Gastroenterologia e Hepatologia, Porto Alegre, RS, Brasil
- Universidade Feevale, Faculdade de Medicina, Hospital Regina, Novo Hamburgo, RS, Brasil
| | - Guilherme Becker Sander
- Universidade Federal do Rio Grande do Sul, Escola de Medicina, Programa de Pós-graduação: Ciências em Gastroenterologia e Hepatologia, Porto Alegre, RS, Brasil
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Chaves DM, Meine GC, Moura DTHD, Matuguma SE, Lera ME, Artifon ELDA, Moura EGHD, Sakai P. ENDOSCOPIC ULTRASOUND IN THE EVALUATION OF UPPER SUBEPITHELIAL LESIONS. Arq Gastroenterol 2016; 52:186-9. [PMID: 26486284 DOI: 10.1590/s0004-28032015000300006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Accepted: 03/24/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic ultrasound is considered the best imaging test for the diagnosis and evaluation of subepithelial lesions of the gastrointestinal tract. OBJECTIVE The present study aims to describe the endosonographic characteristics of upper gastric subepithelial lesions and our experience using endoscopic ultrasound for evaluation of such lesions. METHODS Retrospective data study of 342 patients who underwent endoscopic ultrasound evaluation of subepithelial lesions. RESULTS Lesions of the fourth layer were more common in the stomach (63.72%) than in the esophagus (44.68%) and duodenum (29.03%). In stomach, 81.1% of the lesions ≥2 cm, and 96.5% ≥3 cm, were from the fourth layer. Endosonographic signs that could be related to malignant behavior, such as irregular borders, echogenic foci, cystic spaces and/or size greater than 3 cm were identified in 34 (15.81%) lesions at the first endoscopic ultrasound evaluation. Endoscopic ultrasound-fine needle aspiration did the diagnosis in 21 (61.76%) patients who were submitted a puncture. Three (12.0%) lesions of 25 who were submitted to regular endoscopic ultrasound surveillance increased the size. CONCLUSION Stomach is the organ most affected with subepithelial lesions of the gastrointestinal tract and the fourth layer was the most common layer of origin. More than 80% of gastric subepithelial lesions from the fourth layer are ≥2 cm. Endoscopic ultrasound evaluation of subepithelial lesions has been very important for stratification into risk groups and to determine the best management.
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Affiliation(s)
- Dalton Marques Chaves
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, BR
| | - Gilmara Coelho Meine
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, BR
| | | | - Sergio Eiji Matuguma
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, BR
| | - Marcos Eduardo Lera
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, BR
| | | | | | - Paulo Sakai
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, BR
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Meine GC, Baron TH. Endoscopic papillary large-balloon dilation combined with endoscopic biliary sphincterotomy for the removal of bile duct stones (with video). Gastrointest Endosc 2011; 74:1119-26; quiz 1115.e1-5. [PMID: 21944309 DOI: 10.1016/j.gie.2011.06.042] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 06/28/2011] [Indexed: 02/08/2023]
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Meine GC, Rota C, Dietz J, Sekine S, Prolla JC. Relationship between cagA-positive Helicobacter pylori infection and risk of gastric cancer: a case control study in Porto Alegre, RS, Brazil. Arq Gastroenterol 2011; 48:41-5. [PMID: 21537541 DOI: 10.1590/s0004-28032011000100009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Accepted: 08/06/2010] [Indexed: 02/07/2023]
Abstract
CONTEXT Gastric cancer is the second most common cause of cancer related death worldwide. Although Helicobacter pylori has been classified as a class I carcinogen, the presence of infection is not a factor that alone is able to lead to gastric cancer, and one of the possible explanations for this is the existence of different strains of H. pylori with different degrees of virulence. OBJECTIVES To investigate the association between cagA-positive H. pylori and gastric cancer, using polymerase chain reaction (PCR) for the detection of this bacterial strain. METHODS Twenty-nine patients with gastric cancer were matched by sex and age (± 5 years) with 58 patients without gastric cancer, submitted to upper gastrointestinal endoscopy. All patients were evaluated for the status of infection by H. pylori (through urease test, histological analysis and PCR for the genes ureA and 16SrRNA) and by cagA-positive strain (through PCR for cagA gene). RESULTS Evaluating the presence of infection by cagA-positive H. pylori, it was verified that the rate of infection was significantly higher in the group with gastric cancer when compared with the matched controls, occurring in 62.1% and 29.3%, respectively (OR = 3.95; CI 95% 1.543-10.096). CONCLUSIONS There is an association between cagA-positive H. pylori strain and risk of gastric cancer.
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Dietz J, Chaves-E-Silva S, Meurer L, Sekine S, de Souza AR, Meine GC. Short segment Barrett's esophagus and distal gastric intestinal metaplasia. Arq Gastroenterol 2006; 43:117-20. [PMID: 17119666 DOI: 10.1590/s0004-28032006000200011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2005] [Accepted: 01/04/2006] [Indexed: 11/22/2022]
Abstract
BACKGROUND Short segment Barrett's esophagus is defined by the presence of <3 cm of columnar-appearing mucosa in the distal esophagus with intestinal metaplasia on histophatological examination. Barrett's esophagus is a risk factor to develop adenocarcinoma of the esophagus. While Barrett's esophagus develops as a result of chronic gastroesophageal reflux disease, intestinal metaplasia in the gastric cardia is a consequence of chronic Helicobacter pylori infection and is associated with distal gastric intestinal metaplasia. It can be difficult to determine whether short-segment columnar epithelium with intestinal metaplasia are lining the esophagus (a condition called short segment Barrett's esophagus) or the proximal stomach (a condition called intestinal metaplasia of the gastric cardia). AIMS To study the association of short segment Barrett's esophagus (length <3 cm) with gastric intestinal metaplasia (antrum or body) and infection by H. pylori. PATIENTS AND METHODS Eight-nine patients with short segment columnar-appearing mucosa in the esophagus, length <3 cm, were studied. Symptoms of gastroesophageal reflux disease were recorded. Biopsies were obtained immediately below the squamous-columnar lining, from gastric antrum and gastric corpus for investigation of intestinal metaplasia and H. pylori. RESULTS Forty-two from 89 (47.2%) patients were diagnosed with esophageal intestinal metaplasia by histopathology. The mean-age was significantly higher in the group with esophageal intestinal metaplasia. The two groups were similar in terms of gender (male: female), gastroesophageal reflux disease symptoms and H. pylori infection. Gastric intestinal metaplasia (antrum or body) was diagnosed in 21 from 42 (50.0%) patients in the group with esophageal intestinal metaplasia and 7 from 47 (14.9%) patients in the group with esophageal columnar appearing mucosa but without intestinal metaplasia. CONCLUSION Intestinal metaplasia is a frequent finding in patients with <3 cm of columnar-appearing mucosa in the distal esophagus. In the present study, short segment intestinal metaplasia in the esophagus is associated with distal gastric intestinal metaplasia. Gastroesophageal reflux disease symptoms and H. pylori infection did not differ among the two groups studied.
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Affiliation(s)
- Judite Dietz
- Department of Endoscopy and Pathology, "Hospital Nossa Senhora da Conceição" and "Hospital de Clínicas", Porto Alegre, RS, Brazil
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Abstract
Strongyloides stercoralis is an intestinal helminth of systemic distribution, which, once in its host, has the ability to perpetuate itself through an autoinfection cycle, leading to chronic infection. In healthy hosts, the parasite usually does not cause any symptoms, or only mild symptoms that are limited mainly to the small intestine. However, in immunocompromised hosts, uncontrolled multiplication with massive infection may occur, causing hyperinfection syndrome or disseminated strongyloidiasis, which are both associated with high morbidity and mortality. There are few reports of gastric involvement, particularly presenting as ulcer in the stomach. We report a case of gastric ulcer caused by S. stercoralis in HIV-infected patient.
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Affiliation(s)
- G C Meine
- Endoscopy Department, N. Sra. Conceição Hospital, Porto Alegre, RS, Brazil
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