Helicobacter pylori eradication does not influence gastroesophageal reflux disease: a prospective, parallel, randomized, open-label, controlled trial

CONTEXT

Helicobacter pylori has been associated with worsening of gastroesophageal reflux disease (GERD).

OBJECTIVE

To evaluate the effect of H. pylori eradication in GERD patients.

METHODS

We conducted a prospective, randomized, controlled trial performing symptom evaluation, endoscopy, histology, manometry and esophageal pH testing on GERD patients. Patients infected with H. pylori were randomized to: 1) eradication treatment plus proton pump inhibitors treatment, or 2) proton pump inhibitors alone. Patients not infected constituted a negative control group. After 3 months, patients were re-evaluated by symptom assessment, endoscopy, histology and manometry.

RESULTS

GERD treatment resulted in significantly higher lower esophageal sphincter pressure, as measured by mean expiratory pressure, in H. pylori negative patients. There was significantly lower proportion of hypotensive waves and significantly higher proportion of normotensive waves in non-eradicated patients. All symptom scores were significantly reduced in the post-treatment period compared to baseline, to values that were similar among the three groups, in the post-treatment period. In the post-treatment period, erosive esophagitis was significantly less frequent on those not eradicated.

CONCLUSION

Manometric, clinical and endoscopic data showed no benefit in eradicating H. pylori in GERD. Our data supports the hypothesis that H. pylori eradication does not influence GERD.

Endoscopic ultrasound guided fine-needle aspiration core biopsy: comparison between an automatic biopsy device and two conventional needle systems

BACKGROUND

endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) allows cytologic and/or histologic diagnosis of lesions within or adjacent to the gastrointestinal tract. However, the amount of tissue obtained with a regular 22 gauge needle is not always satisfactory. With the development of a needle XNA-10J-KB (Shot-Gun) that resembles the automatic liver biopsy needle, it is expected that significant samples be obtained more frequently (core biopsy), optimizing histological analysis.

OBJECTIVE

to compare samples obtained with EUS-FNA using 3 different needle systems: GIP, NA-10J-1 and Shot-Gun.

METHODS

19 patients underwent EUS-FNA for diagnosis (5) or tumor staging (14). Mean age was 58.9 years (range 27-82), being 50% men. All patients were submitted to EUS-FNA with the 3 needle models. The Shot-Gun model was "shot" when its tip was near the target inside the lesion, followed by aspiration. Samples were submitted for cytologic and histologic examination.

RESULTS

mean lesion size was 3.0 cm (range 0.8-5.5 cm). Final diagnoses were made after surgery or intra-operative biopsy: 13 pancreatic tumors (12 adenocarcinomas and 1 neuroendocrine tumor), 4 chronic pancreatitis, 1 acute pancreatitis, and 1 cholangiocarcinoma. Specimens adequate for cytologic diagnosis were obtained in 13/19 (68. 4%) patients using GIP model, in 14/19 (73.7%) with NA10J-1 model, and in 17/19 (89.5%) with ShotGun, model (p=0.039). Histologic analysis was possible in 10/19 (52.6%) patients using the GIP model, in 14/19 (73.7%) with NA10J-1, and in 17/19 (89.5%) with Shot-Gun, model (p=0.005). Adequate samples for cytologic or histologic assessment in 16/19 (84.2%) patients using the GIP model, in 17/19 (89.5%) with NA10J-1, and in 18/19 (94.7%) with Shot-Gun, model (p=0.223). In two cases biopsies were negative due to very hard tumors.

CONCLUSION

the Shot-Gun needle obtained better samples for histological diagnosis than NA10J-1 needle and GIP.

Microbiologic profile of flexible endoscope disinfection in two Brazilian hospitals

BACKGROUND

[corrected] Endoscopes are routinely used in hospitals and clinics of the world and they can be potential sources of cross-infection when the decontamination process is unsuitable

AIM

The routines of flexible endoscope (bronchoscopes, esophagogastroduodenoscopes and colonoscopes) disinfection procedures used in two Brazilian university hospitals were evaluated during a 3-year period

METHODS

Aleatory samples from internal channels of endoscopes were collected after patient examination and after cleaning/disinfection procedures

RESULTS

A contamination >3 log10 was achieved in samples recovered from endoscopes after patient examination. These samples yielded gram-negative bacilli (n = 142: 56%), gram-positive cocci (n = 43: 17%), yeast cells (n = 43: 17%), and gram-positive bacilli (n = 26: 10%). Approximately, 72 out of 149 samples (48.32%) collected after undergoing the cleaning and disinfection procedures disclosed gram-negative bacilli (n = 55: 61%), gram-positive cocci (n = 21: 23%), gram-positive bacilli (n = 8: 9%) and yeast cells (n = 6: 7%). Esophagogastroduodenoscopes and colonoscopes were the most frequently contaminated devices. Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, Enterobacter spp, Serratia marcescens, Proteus mirabilis, Citrobacter freundii, Staphylococcus aureus, Staphylococcus coagulase negative, Micrococcus luteus, Candida albicans, C. tropicalis, C. glabrata, C. guilliermondii, Bacillus spp and Corynebacterium spp were predominantly identified

CONCLUSION

Inappropriate cleaning and low times of disinfection were respectively the major factors associated with the presence of microorganisms in colonoscopes and esophagogastroduodenoscopes. By analyzing the identified germs, hospital disinfection was considered of either intermediate or poor level. After this investigation, both university centers improved their previous protocols for disinfection and conditions for reprocessing endoscopes.

Prevalence of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography

BACKGROUND: Sphincter of Oddi manometry is the gold-standard method for sphincter of Oddi dysfunction. The prevalence of sphincter of Oddi dysfunction among patients referred to endoscopic retrograde cholangiopancreatography is largely unknown. AIM: To evaluate prospectively the prevalence of biliary sphincter of Oddi dysfunction (B-SOD) among Brazilian patients referred to endoscopic retrograde cholangiopancreatography and to study the safety of sphincter of Oddi manometry in this setting. METHODS: Biliary sphincter of Oddi manometry was intended in 110 patients referred to endoscopic retrograde cholangiopancreatography. The number of attempts to obtain deep cannulation with the manometry catheter was recorded and patients were divided into two groups: up to 5 (easy cannulation) and >5 attempts (difficult cannulation). RESULTS: Sphincter of Oddi manometry was successful in 71/110 patients (64.5%). Sphincter of Oddi dysfunction was found in 18/71 patients (25%). Endoscopic retrograde cholangiopancreatography findings were: normal in 16, biliary stones in 39, malignant biliary strictures in 9 and benign biliary strictures in 7. There was no statistical difference in sphincter of Oddi dysfunction prevalence regarding disease, gender or difficulty of cannulation. Only 2/71 patients developed post-procedure mild pancreatitis. CONCLUSIONS: We have found a high prevalence of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography. Gender, nature of disease or difficulty of cannulation did not influence the prevalence of sphincter of Oddi dysfunction among these patients. Sphincter of Oddi manometry is a safe procedure for the evaluation of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography.

Análise microbiológica de gastroscópios descontaminados em aparelho Cleantop WM-1 por uso de água eletrolítica ácida

RACIONAL: O método com utilização manual de glutaraldeído é amplamente empregado para desinfecção de endoscópios. A elevada rotina nos serviços de gastroscopia, pequena quantidade de equipamentos e a falta de conhecimento técnico sobre os processos de descontaminação contribuem para desinfecção inadequada dos endoscópios, intensificando o risco de transmissão de microrganismos. A água eletrolítica ácida tem apresentado eficácia na inativação e destruição de microrganismos e vem sendo usada na descontaminação de endoscópios. OBJETIVO: Verificar a eficiência microbicida da água eletrolítica ácida, produzida pelo aparelho Cleantop WM-1, em 20 gastroscópios contaminados após uso em pacientes. MATERIAL E MÉTODOS: Amostras coletadas do canal de biopsia dos endoscópios, após uso em pacientes (n = 20) e depois da desinfecção (n = 20), foram cultivadas em ágar tripticaseína de soja, MacConkey e Sabouraud dextrose. RESULTADOS: Dezessete das 20 amostras coletadas após o uso do aparelho em pacientes revelaram a presença de bacilos gram-negativos, cocos gram-positivos e leveduras em taxas de 10³ a 10(5) ufc/mL. Nenhuma amostra, das 20 coletadas após a descontaminação, apresentou contaminação microbiana. CONCLUSÃO: Nesse estudo preliminar, a desinfecção mecânica realizada pelo aparelho Cleantop com água eletrolítica ácida revelou resultados satisfatórios pela eliminação de microrganismos e otimização no tempo de processamento dos gastroscópios

Identificação dos insulinomas pela ecoendoscopia

BACKGROUND

The aim of this study is to compare EUS and the others diagnostics tests in the correct localization of insulinomas.

METHODS

We prospectively investigated 30 patients with endoscopic ultrasound with a clinical diagnosis of insulinomas prior to surgical exploration. They were submitted to abdominal ultrasonography, spiral computed tomography and four patients were submitted to magnetic ressonance before EUS. Surgery was the gold standard for tumor localization.

RESULTS

Twenty-six tumors were benign (86.6%) and four were malign (13.4%). The median size tumors detected by EUS was 1.5 cm. The overall sensitivity of EUS in identifying insulinomas was 86.6% compared to 33% for CT, 40% to MRI and 90.9% to IUS. In 12 patients we were able to perform EUS-guided fine needle aspiration. Insulinoma was diagnosed in ten cytological specimens (83.3%). Tumors located in the head and body of the pancreas were seen by EUS in all patients, respectively but those located in the tail were diagnosed only in 55.5% of the cases.

CONCLUSIONS

EUS has a high sensibility in the identification and localization of pancreatic insulinomas and should replace traditional methods of image when clinical suspicion is high.

Morphological evaluation of ethylic damage on gastric mucosal repair after surgery

BACKGROUND/AIMS

The damage caused by either yeasted or distilled alcoholic beverages on repair of gastric mucosa is not totally clear. The aim of this work was to verify morphologically the effect of ethylic damage on the initial repair of gastric surgery.

METHODOLOGY

Eighteen albino rats equitably were divided into an experimental group receiving a placebo (EGpl), experimental group receiving fermented ethanol (EGfe) and experimental group receiving distilled ethanol (EGde). All of the rats were submitted to standardized gastric surgery of the fundic wall. During the first 6 post-operative days, 1 ml of distilled water to EGpl, 1 ml of ethanol 11.8% to EGfe and 1 ml of ethanol 43% to EGde were intragastrically administered on a daily basis. All of the animals were killed on the 7th post-operative day and fragments of fundic mucosa at the site of suture were adequately processed and a comparative observation was carried out through light and electron microscopies.

RESULTS

Both, low (wine) and high (whisky) concentrations of ethanol in the alcoholic beverage produced mild and severe erosion, respectively, on the gastric superficial lining epithelium.

CONCLUSIONS

The severe erosion of the epithelium was counterbalanced by an explosive secretion of gastric mucus caused by the high concentration of ethanol, but reepithelization of surgical repair, either of EGfe or EGde was slower than of EGpl.

Effects of cimetidine and pentagastrin on surgical repair of gastric mucosa

BACKGROUND/AIMS

The aim of this work is to evaluate the repair of mucosal epithelium at the critical time of the beginning of reepithelization of stomach wound.

METHODOLOGY

Structural and ultrastructural evaluation of rat gastric mucosa repair was carried out with administration of placebo, cimetidine and pentagastrin in different groups of rats (Rattus norvegicus albinus) during the first 7 post-operative days. Following 48 hours of starvation and anesthesia by ethyl ether inhalation, the animals were submitted to laparotomy exposing the stomach. A fusiform gastric resection measuring 5 mm in length was performed in the fundus stomach wall. The surgical wound was sutured in 2 plans: muscular tunic and visceral serosa. The abdominal wall was also sutured in 2 plans: parietal serosa-abdominal musculature and skin. During 6 consecutive post-operative days, the placebo group rats received 1 ml of distilled water intragastrically; those of the cimetidine group 10 mg/kg of cimetidine; and, animals of the pentagastrin group, 250 micrograms/kg of pentagastrin by intraperitoneal injection. On the 7th post-operative day, rats were killed and fragments of the stomach wall containing transverse section of surgical wound were collected and processed for light microscopy and electron microscopies.

RESULTS

At the beginning of gastric mucosal wound reepithelization cimetidine has better effect than that of pentagastrin.

CONCLUSIONS

Comparative mucosal morphology showed that cimetidine tends to accelerate the beginning of reepithelization of granulation tissue while pentagastrin delays reepithelization due to alteration of protective mucus and a provoking increase of granulation tissue.

[Peutz-Jeghers syndrome and adenocarcinoma. Report of a case]

Peutz-Jeghers syndrome is a rare disease, characterized by autosomic inheritance, presenting skin stain and hamartomatous polyps. We report one case of Peutz-Jeghers syndrome and duodenal adenocarcinoma in a young male who presented with liver metastasis and pancreatic invasion. Such association is reported to be presented in 5% of patients with the syndrome. The reasons of such association are unknown, being possible that: 1) there is malignant degeneration of a adenomatous polyp; 2) malignant degeneration of a hamartomatous polyp, or 3) adenomatous portion of a hamartomatous polyp could undergo malignant transformation.

Endoscopic study of the ileal papilla in a normal case and in patients under several pathological conditions

The ileal protrusion into the lumen of the large intestine was studied in 9 patients (8 adults and 1 girl), 6 females and 3 males, all Brazilians and Caucasians. One of the patients resulted to have no disease, whereas in the others was confirmed the suspected diverticulosis, non specific ulcerative colitis, polyposis, regional ileitis or tuberculosis. In all cases the papillary and bilabial types of the termination of the ileum was documented by endoscopic photography, justifying the change of the expression "Bauhin's ileocecal valve" to that of "eminentia ilealis". Even in cases (one with regional ileitis and the other with tuberculosis) in which the disease altered the eminentia ilealis, it was possible to recognize the ileal papilla. Endoscopy confirmed direct, in vivo observations of ileal papilla, excluding the influence of the surgical procedure (incision and exteriorization in cases of cecostomy) in the morphological aspect of the normal eminentia ilealis.

[Carcinosarcoma of the esophagus: diagnostic importance of partial endoscopic polypectomy]

The clinical and pathological manifestations of a case of carcinosarcoma of the esophagus are reported. Barium swallow and endoscopy revealed a polypoid mass in mid esophagus. The tumor was large, pedunculated, covered by smooth mucosa with some erosions. Histologically the tumor was composed of a mixture of invasion keratinizing cells and intermingled bundle of spindle shaped cells resembling fibrosarcoma. The tumor was removed with surgery and did not show submucosa infiltration. It was not detected any metastasis or local recurrence during the 12 months follow-up period. The diagnosis was made by an endoscopic partial polypectomy. We conclude that partial polypectomy may be of value in preoperative diagnosis of esophageal polypoid mass.

Successful endoscopic treatment of extensive recurrent papillary stenosis six years after endoscopic papillotomy

A case of recurrent almost complete papillary stenosis after endoscopic papillotomy is presented. The stenosis was treated successfully, again by renewed endoscopic papillotomy, prior to fistulotomy. The endoscopic findings, the therapeutic procedure and the results are documented.

Differences in sulfated glycosaminoglycans composition of the gastrointestinal mucosa

Sulfated glycosaminoglycan (SGAG) composition of normal mucosa of esophagus, gastric body, antrum, duodenum, jejunum and rectum is reported. Each region examined may be defined by specific sulfated glycosaminoglycan distributions showing variations in relative proportions and total amount of heparan sulfate, dermatan sulfate and chondroitin 4, 6-sulfate. The results are discussed in the light of a recent proposal regarding the role of these compounds in cell-cell recognition and stimulation of cell division. The methodology made it possible to detect sulfated glycosaminoglycans from small amounts of tissue obtained by endoscopic biopsies.