Intensidade e velocidade da recuperação do relaxamento esfincteriano induzido pelo reflexo inibitorio retoanal e sua correlação com constipação por evacuação obstruida

Orientador: Juvenal Ricardo Navarro GoesTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasResumo: A constipação intestinal é uma queixa muito freqüente, sendo o motivo de um grande número de consultas médicas. No entanto, apesar dos avanços na compreensão da fisiologia anorretocólica, ainda representa um problema clínico nem sempre resolvido. O objetivo deste trabalho é identificar possível correlação entre dados fisiológicos presentes no RIRA e a constipação intestinal por evacuação obstruída. Para isso foram selecionados 69 exames de pacientes, que tinham sido submetidos, previamente, à manometria anorretal no Laboratório de Fisiologia Anorretal no Gastrocentro da FCM ¿ UNICAMP. Destes, após serem aplicados os critérios de exclusão e inclusão, foram selecionados 29 pacientes com constipação intestinal por evacuação obstruída, sendo 27 do sexo feminino e média de idade de 42,3 (19-73) anos. Da mesma forma, foram selecionados 13 indivíduos sem queixas funcionais anorretais, sendo oito do sexo feminino, com média de idade de 52,5 (28-73) anos. No RIRA foi analisada a pressão anal de repouso média (PARM), o ponto de máximo relaxamento (PMR) e a velocidade de recuperação (VR) até atingir a pressão basal, todos nos níveis proximal e distal do canal anal. A seguir foi realizado o estudo comparativo entre esses dados. Os resultados mostraram que o valor médio da PARM pré-indução do RIRA no nível proximal foi, nos pacientes constipados, de 61,8 mmHg e no nível distal, 81,7 mmHg, enquanto que nos assintomáticos encontrou-se 46,0 mmHg e 64,5 mmHg, respectivamente, para os níveis proximal e distal. A média da pressão no PMR nos pacientes constipados foi 29,0 mmHg no nível proximal do canal anal e 52,1 mmHg no nível distal, enquanto que no grupo de assintomáticos foi 17,8 mmHg e 36,3 mmHg respectivamente, no canal anal proximal e no distal. A média da diferença percentual entre a PARM e a pressão no PMR no nível proximal foi 54,1 % nos constipados e 54,3% nos assintomáticos. No nível distal, a média da diferença foi 35,6% nos constipados e 38,5% no grupo-controle. A média da VR no nível proximal foi 4,06 mm/seg. nos constipados e 2,98mm/seg nos assintomáticos, sendo a diferença entre as duas estatisticamente significativa. A média da velocidade de recuperação no grupo de constipados no nível distal do canal anal foi 3,9 mm/seg. e 2,98 mm/seg. nos normais, sendo a diferença entre as duas também significativa do ponto de vista estatístico. A análise dos resultados, obtidos da avaliação dos parâmetros do RIRA, mostrou que o relaxamento esfincteriano em pacientes constipados foi mais acentuado no canal anal proximal do que no distal, da mesma forma como o observado nos controles normais. A velocidade de recuperação da pressão anal de repouso em canal anal proximal e distal foi maior nos pacientes constipadosAbstract: Intestinal constipation is a very common complaint and is thus a common reason for consultations with physicians. The prevalence in the United State of America varies from 2 to 14.7% of the population. In Brazil there are no epidemiological studies on this subject, however it is known that there is a high incidence. Intestinal constipation occurs due to organic and functional factors. Functional constipation may either be associated with a functional alteration of the colon, which in this case is called colonic inertia, or an involvement of the voiding mechanism in the anorectal region, which is denominated constipation by obstructive evacuation. The latter, which is of interest in this study, can by diagnosed and evaluated through several tests, among which are the defecography and anorectal manometry. In anorectal manometry, the rectoanal inhibitory reflex (RAIR) is evaluated. The morphologic alterations detected in the various phases of RAIR have been associated with the genesis of constipation by obstructive evacuation. The aim of this work is to identify a possible correlation between the physiological data present in RAIR and constipation by obstructive evacuation. A total of 69 patients with intestinal constipation, who had previously been submitted to anorectal manometry in the Physiological Anorectal Laboratory in the Gastrocentro of FCM ¿ Unicamp, Brazil were investigated. After the inclusion and exclusion criteria were applied, 29 patients suffering from constipation by obstructive evacuation were selected. Of these 27 were female and the mean age was 42.3 (19-73) years. In the same way a control group of a total of thirteen individuals without anorretal symptoms were evaluated, eight of whom were male and the mean age was 52.5 (28-73) years. The Average Resting Anal Pressure (ARAP), the Maximum Relaxation Point (MRP) and the Recovery Velocity until reaching the base pressure, both at the proximal and distal regions of the anal tract were analyzed during RAIR. After this a comparative study of the results was performed. The results demonstrated that the pre-induced ARAP at RAIR at the proximal level was 61.8 mmHg and at the distal level it was 81.7 mmHg in constipated patients. In asymptomatic individuals, however, the ARAP was 46.0 mmHg and 64.5 mmHg at the proximal and distal levels respectively. The mean MRP in constipated patients was 29 mmHg at the proximal level of the anal tract and 52.1 mmHg at the distal level, when in the control group it was 17.8 mmHg and 36.3 mmHg respectively at the proximal and distal levels. The differences between the ARAP and MRP at the proximal level in constipated patients was 54.1% and in asymptomatic individuals it was 54.3%. At the distal level the difference was 35.6% and 38.5% in the experimental and control groups respectively. The recovery velocity at the proximal level was 4.06 mm/second in constipated patients and 2.98 mm/second in the asymptomatic group with a statistically significant difference. At the distal level the recovery velocity of constipated individuals was 3.9 mm/second whilst for the control group the rate was 2.98 mm/second again giving a statistically significant difference. An analysis of the results obtained from the analysis of the RAIR showed that sphincter relaxation in constipated individuals was more stressed at the proximal level of the anal canal than at the distal level which was also observed in controls. The recovery velocity of the resting anal pressure at both the proximal and distal levels was greater in constipated patients than in controlsDoutoradoCirurgiaDoutor em Cirurgi

Neuroendocrine tumor of the anal canal

AbstractWe report a rare case of neuroendocrine tumor of the anal canal and its poor prognosis, plus discuss the need of immunohistochemical for an acurate diagnosis and to guide treatment

Associação dos fatores sociodemográficos e clínicos à qualidade de vida dos estomizados

This study identifies the socio-demographic and clinical factors of patients with irreversible colostomy secondary to colorectal cancer and correlates them with quality of life (QOL). It is a cross-sectional study. Socio-demographic and clinical data were collected through interviews and the WHOQOL-bref to assess QOL. The sample comprised 60 patients. Most of the patients were male, elderly individuals, half were married and half did not have a sexual partner, with complete primary education, receiving up to two times the minimum wage, carried a stoma for three months on average, were instructed they would carry a stoma, but did not have their stoma marked prior to surgery. The average QOL score was 75.500, while the psychological, social and physical domains were the most affected. No statistically significant differences were found in QOL in relation to the following socio-demographic and clinical factors: female gender, low income, no sexual partners, and lack of instruction. The patients with an intestinal stoma presented a satisfactory QOL.El artículo tuvo por objetivo identificar los factores sociodemográficos y clínicos de pacientes con estoma intestinal definitivo secundario al cáncer colorrectal y correlacionarlos a la calidad de vida (CV). Se trata de un estudio transversal, que utilizó, para recolectar datos sociodemográficos y clínicos, la entrevista y para evaluar la CV el cuestionario WHOQOL-bref. La muestra abarcó 60 pacientes. La mayoría de los pacientes era del sexo masculino, anciano, casado, sin pareja sexual, con educación fundamental completa, recibía hasta dos salarios mínimos, con tiempo promedio de estoma de tres meses, informado que portaría una estoma, pero no programado para la cirugía. El promedio de CV fue 75,00, siendo que los dominios psicológico, social y físico fueron los más afectados. Los factores sociodemográficos y clínicos: sexo femenino, baja renta, no tener pareja sexual y falta de orientación, mostraron diferencias estadísticas significativas en la CV. Se concluye que los pacientes portadores de estoma intestinal demostraron una CV satisfactoria.Os objetivos deste estudo foram identificar os fatores sociodemográficos e clínicos dos pacientes com estoma intestinal definitivo, secundário ao câncer colorretal, e correlacioná-los à qualidade de vida (QV). Como métodos usaram-se o estudo transversal, utilizando a entrevista como instrumento de coleta de dados sociodemográficos e clínicos, e, para avaliação da QV, o WHOQOL-bref. A amostra foi composta por 60 pacientes. Como resultados tem-se que a maioria dos pacientes era do sexo masculino, idoso, casado, sem parceiro sexual, com ensino fundamental completo, recebia até dois salários-mínimos, tempo médio de estoma de três meses, foram orientados que portariam um estoma, mas não foi demarcado para a cirurgia. A média da QV foi de 75,00, sendo que os domínios psicológico, social e físico foram os mais afetados. Os fatores sociodemográficos e clínicos: sexo feminino, baixa renda, não ter parceiros sexuais e falta de orientação apresentaram diferenças estatísticas significantes na QV. Conclui-s que os pacientes portadores de estoma intestinal demonstraram QV satisfatória

Bupivacaína a 0,15% hipobárica para raquianestesia posterior (dorsal) versus bupivacaína a 0,5% hiperbárica para procedimentos cirúrgicos anorretais em regime ambulatorial Bupivacaína a 0,15% hipobárica para raquianestesia posterior (dorsal) versus bupivacaína a 0,5% hiperbara para procedimientos quirúrgicos anorrectales en régimen ambulatorial Hypobaric 0.15% bupivacaine versus hyperbaric 0.5% bupivacaine for posterior (dorsal) spinal block in outpatient anorectal surgery

JUSTIFICATIVA E OBJETIVOS: Estudar baixa dose de bupivacaína hipobárica a 0,15% e hiperbárica a 0,5% em pacientes ambulatoriais para procedimentos cirúrgicos anorretais. MÉTODO: Dois grupos de 50 pacientes, estado físico ASA I e II, submetidos a intervenções cirúrgicas anorretais, em posição de canivete, receberam 6 mg de bupivacaína a 0,15% hipobárica na posição cirúrgica (Grupo 1) ou 6 mg de bupivacaína a 0,5% hiperbárica na posição sentada por cinco minutos, e depois colocados em posição de canivete (Grupo 2). Avaliou-se bloqueio sensitivo e motor, primeira micção, deambulação, complicações e necessidade de analgésico. Foram acompanhados até o terceiro dia de pós-operatório e questionados sobre cefaléia pós-punção ou sintomas neurológicos transitórios, e até 30 dias sobre complicação neurológica permanente. Para análise estatística foram utilizados os testes t de Student, mediana de Mood e Exato de Fisher, sendo p < 0,05 significativo. RESULTADOS: O bloqueio seletivo das raízes sacrais posteriores foi obtido em todos os pacientes do Grupo 1 e bloqueio das raízes anteriores e posteriores foi observado nos pacientes do Grupo 2. O bloqueio foi significativamente mais alto no Grupo 1. O bloqueio motor foi muito menos intenso no Grupo 1. Quarenta e nove pacientes do Grupo 1 passaram para a maca sem ajuda enquanto apenas 40 pacientes do Grupo 2 conseguiram fazê-lo. A recuperação ocorreu em 105 &plusmn; 25 minutos no Grupo 1 e de 95 &plusmn; 15 minutos no Grupo 2, sem diferença significativa. Não ocorreu alteração hemodinâmica, náusea ou vômito, retenção urinária ou cefaléia pós-punção. CONCLUSÕES: A intervenção cirúrgica anorretal sob raquianestesia com baixas doses de bupivacaína, hiperbárica ou hipobárica, pode ser conduzida com segurança.<br>JUSTIFICATIVA Y OBJETIVOS: Estudiar baja dosis de bupivacaína hipobárica a 0,15% e hiperbara a 0,5% en pacientes ambulatoriales para procedimientos quirúrgicos anorrectales. MÉTODO: Dos grupos de 50 pacientes, estado físico ASA I y II, sometidos a intervenciones quirúrgicas anorrectales, en posición de cuchilla, recibieron 6 mg de bupivacaína a 0,15% hipobárica en la posición quirúrgica (Grupo 1) o 6 mg de bupivacaína a 0,5% hiperbara en la posición sentada por cinco minutos, y después colocados en posición de cuchilla (Grupo 2). Se evaluaron los bloqueos sensitivo y motor, primera micción, deambulación, complicaciones y necesidad de analgésico. Se monitorearon hasta el tercer día de postoperatorio y preguntados sobre cefalea pospunción o síntomas neurológicos temporales, y hasta 30 días sobre complicación neurológica permanente. Para análisis estadística fueron utilizadas las pruebas t de Student, mediana de Mood y Exacto de Fisher, siendo p < 0,05 significativo. RESULTADOS: El bloqueo selectivo de las raíces sacrales posteriores se obtuvo en todos los pacientes del Grupo 1 y bloqueo de las raíces anteriores y posteriores se observó en los pacientes del Grupo 2. El bloqueo fue significativamente más alto en el Grupo 1. El bloqueo motor fue significativamente menos intenso en el Grupo 1. Cuarenta y nueve pacientes del Grupo 1 pasaron para la cama sin ayuda mientras que solamente 40 pacientes del Grupo 2 lograron hacerlo. La recuperación se dio en 105 &plusmn; 25 minutos en el Grupo 1 y de 95 &plusmn; 15 minutos en el Grupo 2, sin diferencia significativa. No se dio alteración hemodinámica, náusea o vómito, retención urinaria o cefalea pospunción. CONCLUSIONES: La intervención quirúrgica anorrectal bajo raquianestesia con bajas dosis de bupivacaína, hiperbara o hipobárica, puede ser hecha con seguridad.<br>BACKGROUND AND OBJECTIVES: The aim of this study was to study low dose hypobaric 0.15% bupivacaine and hyperbaric 0.5% bupivacaine in outpatient anorectal surgical procedures. METHODS: Two groups of 50 patients, physical status ASA I and II, undergoing anorectal surgical procedures in a jackknife position, received 6 mg of hypobaric 0.15% bupivacaine in the surgical position (Group 1) or 6 mg of hyperbaric 0.5% bupivacaine in the sitting position for 5 minutes, after which they were placed in a jackknife position (Group 2). Sensitive and motor blockade, time of first urination, ambulation, complications, and the need for analgesics were evaluated. Patients were followed until the third postoperative day and questioned whether they experienced post-puncture headache or temporary neurological symptoms, and until the 30th day and questioned about permanent neurological complications. The test t Student, Mood's median, and Fisher Exact test were used for statistical analysis, and a p < 0.05 was considered significant. RESULTS: Every patient in Group 1 presented selective blockade of the posterior sacral nerve roots, while patients in Group 2 experienced blockade of the anterior and posterior nerve roots. Blockade was significantly higher in Group 1. Motor blockade was significantly less severe in Group 1. Forty-nine patients in Group 1 transferred to the stretcher unassisted while only 40 patients in Group 2 were able to do so. Recovery in Group 1 occurred in 105 &plusmn; 25 minutes and in 95 &plusmn; 15 minutes in Group 2, and this difference was not statistically significant. There were no hemodynamic changes, nausea or vomiting, urine retention, or post-puncture headache. CONCLUSIONS: Anorectal surgical procedures under spinal block with low dose bupivacaine, hyperbaric or hypobaric, can be safely done

The Montreal classification for Crohn's disease: clinical application to a Brazilian single-center cohort of 90 consecutive patients

CONTEXT: Crohn's disease presents very heterogeneous features from a clinical point of view, and classifying Crohn's disease patients in homogeneous subgroups in the light of genetic, molecular and clinical aspects is challenging. The Montreal Classification for Crohn's disease was proposed in 2005 as an effort to characterize Crohn's disease patients according to recent clinical and research advances in the field of inflammatory bowel disease. Since its proposition, the Montreal Classification needs an ample validation and application among different populations around the world. To date, there are no known studies applying the Montreal Classification to a Brazilian cohort of Crohn's disease patients. OBJECTIVES: To apply the Montreal Classification to a Brazilian cohort of Crohn's disease patients at a referral center for inflammatory bowel disease in Northwestern São Paulo State, Brazil. METHODS: We selected 90 consecutive well-characterized Crohn's disease patients assisted at Inflammatory Bowel Disease Outpatient Clinic between January 1992 and January 2007, with a minimum follow-up of 2 years; data concerning demographic characteristics, clinical onset of disease, age at diagnosis, time of disease, location and behavior of disease, presence of extraintestinal manifestations, familial occurrence, perianal involvement, treatment with biological drugs, and history of surgical treatment were evaluated. RESULTS: Male patients were predominant (54%), with a mean age at diagnosis of 33 ± 14 years old, and a median followup of 5.5 years. Most of the patients were diagnosed between 17 and 40 years old (59%), and had disease located in terminal ileum 46%), with a nonstricturing, nonpenetrating behavior (71%). Time of disease was correlated with necessity of biological treatment, disease behavior, and surgical treatment (P<0.05). CONCLUSIONS: These study findings are consistent with results from other studies conducted among different populations, although a further multicentric study with a larger number of patients would be necessary to validate the Montreal Classification among Brazilian population

Digestive forms of Chagas disease and carcinogenesis: a study of association

The authors analyze the relation between gastrointestinal carcinogenesis and Chagas disease, based on detailed review of the literature. To this end, epidemiological, experimental and human material pathology description studies have been selected. The article discusses the possibility of protection being afforded by not fully known morphokinetic cellular, immune and neuroendocrine factors that would be secondary to plexus degeneration. Also aspects related to the parasite-host interaction from the viewpoint of epithelial modulation of colonic mucosa and its antitumor implications are presented. Finally, it exposes the pathophysiological mechanism of esophageal cancer development in patients with mega-organ. In conclusion, chagasic colopathy, especially the intrinsic neuronal damage, is a study model that can contribute to the understanding of colorectal carcinogenesis.Os autores analisam a relação entre carcinogênese gastrintestinal e doença de Chagas, com base em revisão pormenorizada da literatura. Para tal, foram selecionados estudos epidemiológicos, experimentais e de descrição anatomopatológica com material humano. O artigo discute a possibilidade de a proteção ser conferida por fatores celulares morfocinéticos, imunológicos e neuroendócrinos não totalmente conhecidos e que seriam secundários à degeneração plexular. Também são apresentados aspectos relacionados à interação parasito-hospedeiro, sob o ponto de vista da modulação epitelial da mucosa colônica, e suas implicações antitumorais. Por fim, expõe-se o mecanismo fisiopatológico de desenvolvimento da neoplasia de esôfago em pacientes com megaesôfago. Conclui-se que a colopatia chagásica, especialmente o dano neuronal intrínseco, constitui modelo de estudo que pode contribuir no entendimento da carcinogênese colorretal

MALNUTRITION AND CLINICAL OUTCOMES IN SURGICAL PATIENTS WITH COLORECTAL DISEASE

ABSTRACT BACKGROUND: Malnutrition is a frequent condition among hospitalized patients and a factor of increased risk of postoperative complication. OBJECTIVE: This study aimed to evaluate the impact of malnutrition on phase angle (PA), body water distribution and clinical outcomes in surgical patients with colorectal disease. METHODS: This retrospective study was performed in a tertiary hospital with 40 patients admitted electively. In the preoperative evaluation, global subjective assessment and bioelectrical impedance analysis were performed to determine nutritional status, PA, extracellular water (ECW), intracellular water (ICW) and total body water (TBW). In postoperative evaluation, the length of hospital stay and severe complications, according to Clavien-Dindo classification, were determined. The optimal PA cutoff for malnutrition screening was determined by ROC curve analysis. RESULTS: Seventeen (42.5%) patients were diagnosed as malnourished and 23 (57.5%) as well-nourished according to global subjective assessment. Twelve (30.0%) patients developed severe complications. The malnourished group presented lower values of serum albumin (P=0.012), hematocrit (P=0.026) and PA (P=0.002); meanwhile, ECW/ICW (P=0.019) and ECW/TBW (P=0.047) were higher. Furthermore, 58.8% of malnourished patients developed severe postoperative complications compared to 8.7% of well-nourished. Malnutrition was independent predictor of severe postoperative complications (OR=15.00, IC: 2.63-85.68, P=0.002). The optimal PA cutoff obtained was 6.0º (AUC=0.82, P=0.001), yielding sensitivity, specificity, positive predictive value and negative predictive value of 76.5%, 87.0%, 81.3% and 83.4%, respectively. CONCLUSION: Malnutrition was an independent predictive factor for severe complications in patients underwent to elective major coloproctological surgery. Besides that, malnutrition was associated with lower PA values and greater ratio of ECW. The PA provided great accuracy in nutritional screening, implying a useful marker of malnutrition

Non-Hodgkin lymphoma as a cause of acute intestinal obstruction/perforation in patients with adenocarcinoma of the sigmoidcolon: a case report

Report of a rare case of an 83-year-old patient with lymphoma of the terminal ileum causing obstructive/perforated acute abdomen synchronous with sigmoid colon adenocarcinoma and review of literature data about small bowel malignancies, particularly lymphomas. It seems to correspond to a rare disease (2% of all bowel cancers), more prevalent in elderly and immunocompromised patients, whose symptoms are vague and early diagnosis is difficult, often making it impossible to establish the correct therapy

Appendicular endometriosis as a cause of chronic abdominal pain alone in the right iliac fossa: case report and literature review

Endometriosis is a disease characterized by the presence of ectopic endometrial glands and stroma. Although its etiology is undefined, it is suggested to be a result of coelomic metaplasia, retrograde menstruation, to provide a genetic component, or to be one that occurs due to blood or lymphatic spread. The involvement of the gastrointestinal tract is common. However, appendicular endometriosis is a rare condition. It is usually asymptomatic. Recurrent pain in the right iliac fossa is an unusual clinical manifestation. There are no non-invasive complementary tests to confirm the diagnosis. Laparoscopy is the main option for research, due to its diagnostic and therapeutic features. A histopathological examination is necessary for the diagnosis. Although surgical and drug therapies have special indications, the combination therapy showed lower symptom recurrence. This study reports a case of appendicular endometriosis that was diagnosed and treated in the service of Coloproctology of the Base Hospital at Faculdade de Medicina of São Jose do Rio Preto. There is also a literature review about this situation