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

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

Prospective evaluation of EUS versus CT scan for staging of ampullary cancer

Background: Malignancies of the biliary and pancreatic systems are associated with a poor prognosis. However, ampullary cancer carries a better prognosis and is often diagnosed when curative treatment is still possible. Accurate staging is important for the determination of the most appropriate treatment option. Objectives: (1) To determine the test performance characteristics of EUS and CT in loco-regional staging of ampullary neoplasms, and (2) to determine the impact of CT scan results on the test performance characteristics of EUS. Design and Setting: Prospective single-arm intervention study performed in 2 academic hospitals. Results and Main Outcome Measurements: Thirty-seven patients were screened and 33 staged with EUS and CT A total of 27 patients (13 men; mean age, 69.5 years; mean serum bilirubin level, 12.6 mg/dL) with locally advanced disease completed the protocol with EUS and CT and underwent surgical resection. Tumor classifications were as follows: 2 patients (7.4%), T1 tumors; 13 patients (48.1%), T2 tumors; and 12 patients (44.4%), T3 tumors, as per surgical pathology. Seventeen tumors (62.9%) were classified as NO and 10 (37.1%) as NI. The difference in proportion of correct tumor (74.1% vs 51.8%; P =.15, 95% CI, -0.06-0-50) and lymph node (81.4% vs; 55.5%; P =.07, 95% Cl, -0.01-0.53) staging by EUS and CT, respectively, was not statistically significantly different. However, the strength of tumor (kappa 0.51 vs 0.11) and nodal (kappa 0.59 vs 0.05) agreement with pathology was statistically significantly higher for EUS than for CT (P <.05). EUS was more sensitive and specific than CT for tumor and nodal staging, and the association of CT to EUS data did not improve the final test accuracy Limitation: Low number of T1 tumors. Conclusions: EUS is in accurate diagnostic test and exhibits a high level of agreement with surgical pathology. CT findings do not improve the test performance characteristics of EUS. Therefore, the evaluation for metastatic disease should not be compromised by CT protocols that aim to perform tumor and nodal staging. Further studies to determine the role of specialized CT protocols in patients with ampullary malignancies are needed. (Gastrointest Endosc 2009;70:290-6.

INITIAL EXPERIENCE WITH ENDOSCOPIC ULTRASOUND-GUIDED FINE NEEDLE ASPIRATION OF RENAL MASSES: indications, applications and limitations

Context Tissue sampling of renal masses is traditionally performed via the percutaneous approach or laparoscopicaly. The utility of endoscopic ultrasound to biopsy renal lesions it remains unclear and few cases have been reported. Objectives To evaluate the feasibility and outcome of endoscopic ultrasound fine needle aspiration of renal tumors. Methods Consecutive subjects undergoing attempted endoscopic ultrasound fine needle aspiration of a kidney mass after evaluation with computerized tomography or magnetic resonance. Results Ten procedures were performed in nine male patients (median age 54.7 years) on the right (n&#160;=&#160;4) and left kidney (n = 4) and bilaterally (n = 1). Kidney masses (median diameter 55 mm ; range 13-160 mm) were located in the upper pole (n = 3), the lower pole (n = 2) and the mesorenal region (n = 3). In two cases, the mass involved more than one kidney region. Surgical resection confirmed renal cell carcinoma in six patients in whom pre-operative endoscopic ultrasound fine needle aspiration demonstrated renal cell carcinoma. No complications were reported. Conclusions Endoscopic ultrasound fine needle aspiration appears as a safe and feasible procedure with good results and minimal morbidity