Diagnóstico de trauma pancreático associado à trombose da veia mesentérica feito através da ultrassonografia endoscópica

BACKGROUND: Blunt pancreatic injuries occur when a high-energy crushing force is applied to the upper abdomen. In adults, the majority of blunt pancreatic injuries result from motor vehicle accidents. CASE REPORT: Male with 32 years old had a high-energy crushing history in witch he was pressured by the chest on the front car area. His life signs demonstrated to be regular. Ct scan demonstrated body pancreatic edema. All routine laboratorial exams were normal, EUS revealed pancreatic lesion grade II without involvement of the pancreatic duct and an impressive superior mesenteric vein thrombosis. He was sustained by means of anti- coagulation for about two months and after that time the multislice CT scan showed a mesenteric vein recanalization and a normal pancreatic parenchyma. The patient had an uneventfull follow-up. CONCLUSION: Patients presenting possible pancreatic trauma associated to superior mesenteric vein thrombosis, EUS must be used firstly.INTRODUÇÃO: Traumas pancreáticos fechados ocorrem em acidentes que promovem força intensa no abdome superior, principalmente em acidentes automobilísticos. RELATO DO CASO: Homem de 32 anos foi jogado contra a área frontal de seu automóvel. Seus sinais vitais eram normais. CT mostrou edema pancreático. EUS mostrou lesão pancreática grau II sem envolvimento do ducto pancreático, mas com impressionante trombose da veia mesentérica superior. Ele foi mantido com anticoagulants por dois meses e após este period novo scan mostrou recanalização e pâncreas normal. Teve seguimento favorável. CONCLUSÃO: Paciente apresentando edema pancreático associado a possível trombose de veia mesentérica superior deve ser submetido à EUS para monitorização e acompanhamento

Cost-Effectiveness of Palliation of Unresectable Esophageal Cancer

Introduction Different modalities of palliation for obstructive symptoms in patients with unresectable esophageal cancer (EC) exist. However, these therapeutic alternatives have significant differences in costs and effectiveness. Methods A Markov model was designed to compare the cost-effectiveness (CE) of self-expandable stent (SES), brachytherapy and laser in the palliation of unresectable EC. Patients were assigned to one of the strategies, and the improvement in swallowing function was compared given the treatment efficacy, probability of survival, and risks of complications associated to each strategy. Probabilities and parameters for distribution were based on a 9-month time frame. Results Under the base-case scenario, laser has the lowest CE ratio, followed by brachytherapy at an incremental cost-effectiveness ratio (ICER) of $4,400.00, and SES is a dominated strategy. In the probabilistic analysis, laser is the strategy with the highest probability of cost-effectiveness for willingness to pay (WTP) values lower than$3,201 and brachytherapy for all WTP yielding a positive net health benefit (NHB) (threshold $4,440). The highest probability of cost-effectiveness for brachytherapy is 96$ 4.32 to US$ 38.09 million dollars over the next 5-20 years. Conclusion Conditional to the WTP and current US Medicare costs, palliation of unresectable esophageal cancers with brachytherapy provides the largest amount of NHB and is the strategy with the highest probability of CE. However, some level of uncertainly remains, and wrong decisions will be made until further knowledge is acquired

Suprapapillary needle puncture for common bile duct access: laboratory profile

BACKGROUD: Biliary cannulation to perform endoscopic retrograde cholangiopancreatography may be difficult due to technical reasons and often is necessary to perform papillotomy, where complications as pancreatitis and perforation may occur AIM: To show minimal complications by a new model of biliary access by means of the suprapapillary needle puncture and its laboratory profile. PATIENTS AND METHODS: After the approval of the protocol by the Scientific Ethics Committee of the institution a free and informed consent was signed by all patients participating in the study. From July 2003 to August 2004, fulfilling the inclusion and exclusion criteria, 30 patients were selected for endoscopic retrograde cholangiopancreatography, using the suprapapillary puncture technique. All patients remained hospitalized, fasting and with basal hydroelectrolytic replacement, were clinically followed up and samples for the determination of serum amylase, lipase and C-RP (C-reactive protein) were collected before and 4 h, 12 h and 24 h after the procedure and reevaluated 60 days after the procedure. Laboratory parameters were submitted to statistical study using analysis of variance for repeated measurements. Multiple comparisons were made based on Wald's statistics RESULTS: The technique was successful in 93.4% (28/30) of the patients. No statistically significant difference regarding to the laboratory profile were observed. Complications related to the technique of papillary puncture occurred in 1/28 patients by not using the guide wire and in 1/28 where mild hemorrhage after dilation of the papillary fistula occurred. Regarding complications related to therapeutic procedures, there were 2/28 retroduodenal perforations, with one (1/30) following unsuccessful puncture and another due to the passage of Dormia's basket through the dilated fistula path. All patients submitted to diagnostic puncture and evaluated 60 days after the procedure presented with the major duodenal papilla of normal aspect. The patients with dilation of the suprapapillary fistula showed the fistula continuing to drain clear bile CONCLUSION: Suprapapillary puncture allows investigative and therapeutic procedures without significant increases in amylase, lipase and C-RP. Patients submitted to diagnostic puncture present complete recovery of the papilla, while dilation of the fistula maintains it pervious later on, but without complications

High prevalence of duodenal ulcer in a tertiary care hospital in the city of São Paulo, SP, Brazil

CONTEXT: In spite of Helicobacter pylori infection being the etiological cause of peptic ulcer and its high prevalence in Brazil, the prevalence of peptic ulcer disease has been poorly studied. OBJECTIVES: To verify the peptic ulcer disease prevalence in patients of a tertiary care hospital. METHODS: Diagnostic findings from 1,478 consecutive endoscopies were correlated with the urease test results for H. pylori infection diagnosis and demographic data in a total of 3,779 endoscopies performed in 2005. The mean age of the patients was 51.14 ± 16.46, being 613 (41.5%) men. RESULTS: Peptic ulcer was diagnosed in 494 (33.4%) patients with a mean age of 54.86 ± 14.53, 205 (52%) were men, being 391 (26.5%) duodenal ulcer and 103 (7%) gastric ulcer. Normal endoscopy was found in 272 (18.4%) patients with a mean age of 38.4 ± 15.22, being 49 (18%) men. The comparison of peptic ulcer group with the patients that had normal endoscopy revealed that H. pylori infection [P = 0.005; OR = 1.70; 95% CI = 1.17-2.47][ign], male gender [P<0.0001; OR = 5.53; 95%CI = 3.67-8.34][ign] and older age [P<0.0001; OR = 1.08; 95%CI = 1.06-1.09] increased the risk of peptic ulcers. The overall H. pylori prevalence was 53% (786). CONCLUSIONS: Prevalence of duodenal ulcer is high in a Brazilian population that had H. pylori infection associated with older age and male gender as important determinants to gastrointestinal diseases outcome. Future prospective studies should confirm these findings