Is there still a role for intraoperative enteroscopy in patients with obscure gastrointestinal bleeding?

BACKGROUND: in 21st century, endoscopic study of the small intestine has undergone a revolution with capsule endoscopy and balloon-assisted enteroscopy. The difficulties and morbidity associated with intraoperative enteroscopy, the gold-standard in the 20th century, made this technique to be relegated to a second level. AIMS: evaluate the actual role and assess the diagnostic and therapeutic value of intraoperative enteroscopy in patients with obscure gastrointestinal bleeding. PATIENTS AND METHODS: we conducted a retrospective study of 19 patients (11 males; mean age: 66.5 ± 15.3 years) submitted to 21 IOE procedures for obscure GI bleeding. Capsule endoscopy and double balloon enteroscopy had been performed in 10 and 5 patients, respectively. RESULTS: with intraoperative enteroscopy a small bowel bleeding lesion was identified in 79% of patients and a gastrointestinal bleeding lesion in 94%. Small bowel findings included: angiodysplasia (n = 6), ulcers (n = 4), small bowel Dieulafoy´s lesion (n = 2), bleeding from anastomotic vessels (n = 1), multiple cavernous hemangiomas (n = 1) and bleeding ectopic jejunal varices (n = 1). Agreement between capsule endoscopy and intraoperative enteroscopy was 70%. Endoscopic and/or surgical treatment was used in 77.8% of the patients with a positive finding on intraoperative enteroscopy, with a rebleeding rate of 21.4% in a mean 21-month follow-up period. Procedure-related mortality and postoperative complications have been 5 and 21%, respectively. CONCLUSIONS: intraoperative enteroscopy remains a valuable tool in selected patients with obscure GI bleeding, achieving a high diagnostic yield and allowing an endoscopic and/or surgical treatment in most of them. However, as an invasive procedure with relevant mortality and morbidity, a precise indication for its use is indispensable

Small-Bowel Capsule Endoscopy in Patients with Suspected Crohn's Disease—Diagnostic Value and Complications

Background. The aim of this work was to assess the value of capsule enteroscopy in the diagnosis of patients with suspected Crohn's Disease (CD). Methods. This was a retrospective study in a single tertiary care centre involving patients undergoing capsule enteroscopy for suspected CD. Patients taking nonsteroidal anti inflammatory drugs during the thirty preceding days or with a follow-up period of less than six months were excluded. Results. Seventy eight patients were included. The endoscopic findings included mucosal breaks in 50%, ulcerated stenosis in 5%, and villous atrophy in 4%. The diagnosis of CD was established in 31 patients. The sensitivity, specificity, positive and negative predictive value of the endoscopic findings were 93%, 80%, 77%, and 94%, respectively. Capsule retention occurred in four patients (5%). The presence of ulcerated stenosis was significantly more frequent in patients with positive inflammatory markers. The diagnostic yield of capsule enteroscopy in patients with negative ileoscopy was 56%, with a diagnostic acuity of 93%. Conclusions. Small bowel capsule endoscopy is a safe and valid technique for assessing patients with suspected CD. Capsule retention is more frequent in patients with positive inflammatory markers. Patients with negative ileoscopy and suspected CD should be submitted to capsule enteroscopy

Endoscopic treatment of bleeding gastric varices with histoacryl (N-butyl-2-cyanoacrylate): a South European single center experience

BACKGROUND: Endoscopic injection of N-butyl-2-cyanoacrylate is the current recommended treatment for gastric variceal bleeding. Despite the extensive worldwide use, there are still differences related to the technique, safety, and long term-results. We retrospectively evaluated the efficacy and safety of cyanoacrylate in patients with gastric variceal bleeding. PATIENTS AND METHODS: Between January 1998 and January 2010, 97 patients with gastric variceal bleeding underwent endoscopic treatment with a mixture of N-butyl-2-cyanoacrylate and Lipiodol(TM). Ninety-one patients had cirrhosis and 6 had non-cirrhotic portal hypertension. Child-Pugh score at presentation for cirrhotic patients was A-12.1 %; B-53.8 %; C-34.1 % and median MELD score at admission was 13 (3-26). Successful hemostasis, rebleeding rate and complications were reviewed. Median time of follow up was 19 months (0.5-126). RESULTS: A median mixture volume of 1.5 mL (0.6 to 5 mL), in 1 to 8 injections, was used, with immediate hemostasis rate of 95.9 % and early rebleeding rate of 14.4 %. One or more complications occurred in 17.5 % and were associated with the use of Sengstaken-Blakemore tube before cyanoacrylate and very early rebleeding (p < 0.05). Hospital mortality rate during initial bleeding episode was 9.3 %. Very early rebleeding was a strong and independent predictor for in-hospital mortality (p < 0.001). Long-term mortality rate was 58.8 %, in most of the cases secondary to hepatic failure. CONCLUSION: N-butyl-2-cyanoacrylate is a rapid, easy and highly effective modality for immediate hemostasis of gastric variceal bleeding with an acceptable rebleeding rate. Patients with very early rebleeding are at higher risk of death

P16 and hpv genotype significance in hpv-associated cervical cancer-a large cohort of two tertiary referral centers

The expression of p16 is a good surrogate of human papillomavirus (HPV) infection in HPV-associated cancers. The significance of p16 expression, HPV genotype and genera in the outcome of patients with HPV-associated cervical cancer (CC) is unclear. Our aim is to ascertain the prognostic significance of these factors. Data from 348 patients (median age: 47.5 years old) with CC, diagnosed in two referral centers, were retrospectively collected. Advanced disease (FIGO2018 IB2-IV) was present in 68% of patients. A single HPV genotype was identified in 82.8% of patients. The most common HPVs were HPV16 (69%) and HPV18 (14%). HPV genera reflected this distribution. HPV16 tumors presented at an earlier stage. P16 was negative in 18 cases (5.2%), 83.3% of which were squamous cell carcinomas. These cases occurred in older patients who tended to have advanced disease. In the univariate analysis, HPV16 (HR: 0.58; p = 0.0198), α-9 genera (HR: 0.37; p = 0.0106) and p16 overexpression (HR: 0.54; p = 0.032) were associated with better survival. HPV16 (HR: 0.63; p = 0.0174) and α-9 genera (HR: 0.57; p = 0.0286) were associated with less relapse. In the multivariate analysis, only the International Federation of Gynecology and Obstetrics (FIGO) stage retained an independent prognostic value. HPV16, α-9 genera and p16 overexpression were associated with better survival, although not as independent prognostic factors. Patients with p16-nega-tive HPV-associated CC were older, presented with advanced disease and had worse prognosis.publishersversionpublishe

Efeito do fator neurotrófico derivado do cérebro na libertação de ácido γ-amino butírico em terminações nervosas de hipocampo de rato incubadas com o péptido β-amilóide

Relatório de projeto no âmbito do Programa de Bolsas Universidade de Lisboa/Fundação Amadeu Dias (2011/2012). Universidade de Lisboa. Faculdade de Medicin

Amyloid-β peptide impairs BDNF effects upon GABA release from rat synaptosomes in a calpain dependent way

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014Alzheimer's disease (AD) affects neural networks, which involves multiple changes in hippocampal GABAergic transmission. While the cause of AD is uncertain, several lines of evidence suggest amyloid-β (Aβ) peptides as having a causal role in this pathogenesis. It has been shown that brain-derived neurotrophic factor (BDNF) inhibits K+-evoked gamma-aminobutyric acid (GABA) release, but the effect of the exposure to Aβ peptides on BDNF-induced GABA release inhibition has not yet been elucidated. On the other hand, it is known that BDNF levels are decreased in AD, and Aβ peptide decreases BDNF receptor, tyrosine kinase B receptor (TrkB), levels by a calpain-dependent mechanism. In this work it was evaluated the role of Aβ peptide upon BDNF effects on K+-evoked GABA release from rat hippocampal synaptosomes prepared from hippocampal slices incubated with Aβ25-35 (25μM) or Aβ1-42 (20μM) or without Aβ. It was also studied the involvement of calpains inhibition on the Aβ peptide impairment of the BDNF effect upon GABA release by incubating hippocampal slices with Aβ and MDL28170 (20μM), an inhibitor of calpains.The results showed that the incubation of hippocampal slices with Aβ25-35 (25M) or Aβ1-42 (20μM) does not alter S2/S1 ratio for GABA K+-evoked release. In hippocampal slices incubated with Aβ25-35 (25 M) or Aβ1-42 (20μM) the inhibitory effect of BDNF upon GABA release was totally abolished. Calpain inhibition with MDL28170 (20μM) allowed the completely recovery of the BDNF inhibitory effect in Aβ25-35 (25 M) presence.With this work we describe for the first time the impairment of BDNF inhibitory effect, on the evoked-GABA release, mediated by Aβ peptides. This impairment involves a mechanism dependent on calpain activation, since the inhibition of calpains completely recover the BDNF effect in presence of Aβ peptides. Thus the present work highlights a new mechanism involved in the Aβ-induced TrkB dysregulation, and supports the use of calpain inhibitors as a therapeutic tool in AD.A doença de Alzheimer (DA), é uma patologia de redes neuronais envolvendo várias alterações na transmissão GABAérgica do hipocampo. Apesar da etiologia da DA não ser totalmente conhecida, diversos estudos apontam para um papel causal do péptido β-amiloide (Aβ) na sua patogénese. Embora o fator neurotrófico derivado do cérebro (BDNF) iniba a libertação de ácido γ-amino butírico (GABA), o efeito do Aβ na modulação do BDNF sobre a libertação de GABA é desconhecido. Por outro lado na DA o BDNF encontra-se reduzido, e o péptido Aβ diminui os níveis de recetores do BDNF, recetores tirosina cinase B (TrkB), através de um mecanismo dependente de calpaínas. Neste trabalho avaliou-se o papel do peptido Aβ sobre o efeito do BDNF sobre a libertação de GABA evocada por K+ de sinaptossomas do hipocampo de rato preparados de fatias de hipocampo incubadas com Aβ25-35 (25μM) ou Aβ1-42 (20μM) ou sem Aβ. Igualmente foi também estudado o envolvimento da inibição das calpainas sobre o efeito do peptido Aβ no efeito modulatório do BDNF na libertação de GABA através da incubação de fatias de hipocampo com Aβ e MDL28170 (20μM), inibidor das calpaínas. Os resultados demonstram que a incubação de fatias de hipocampo com Aβ25-35 (25μM) ou Aβ1-42 (20μM) não alterou o racio S2/S1 de libertação de GABA evocada por K+. Em fatias de hipocampo incubadas com Aβ25-35 (25μM) ou Aβ1-42 (20μM) o efeito inibitório do BDNF sobre a libertação de GABA foi totalmente abolido. A inibição das calpaínas com MDL28170 (20μM) permitiu a recuperação completa do efeito inibitório do BDNF na presença de Aβ25-35 (25M). Com este trabalho descrevemos pela primeira vez o efeito deletério do péptido Aβ sobre o efeito inibitório do BDNF na libertação de GABA. Este efeito deletério envolve um mecanismo mediado por calpaínas, dado que a inibição das calpaínas permite a total recuperação do efeito do BDNF na presença de Aβ. Assim o presente trabalho destaca um novo mecanismo envolvendo uma desregulação do TrkB induzida pelo Aβ, bem como suporta o uso de inibidores de calpaínas na terapêutica na DA

Is there still a role for intraoperative enteroscopy in patients with obscure gastrointestinal bleeding?

Background: in 21st century, endoscopic study of the small intestine has undergone a revolution with capsule endoscopy and balloon-assisted enteroscopy. The difficulties and morbidity associated with intraoperative enteroscopy, the gold-standard in the 20th century, made this technique to be relegated to a second level. Aims: evaluate the actual role and assess the diagnostic and therapeutic value of intraoperative enteroscopy in patients with obscure gastrointestinal bleeding. Patients and methods: we conducted a retrospective study of 19 patients (11 males; mean age: 66.5 ± 15.3 years) submitted to 21 IOE procedures for obscure GI bleeding. Capsule endoscopy and double balloon enteroscopy had been performed in 10 and 5 patients, respectively. Results: with intraoperative enteroscopy a small bowel bleeding lesion was identified in 79% of patients and a gastrointestinal bleed-ing lesion in 94%. Small bowel findings included: angiodysplasia (n = 6), ulcers (n = 4), small bowel Dieulafoy's lesion (n = 2), bleed-ing from anastomotic vessels (n = 1), multiple cavernous hemangiomas (n = 1) and bleeding ectopic jejunal varices (n = 1). Agreement between capsule endoscopy and intraoperative enteroscopy was 70%. Endoscopic and/or surgical treatment was used in 77.8% of the patients with a positive finding on intraoperative enteroscopy, with a rebleeding rate of 21.4% in a mean 21-month follow-up period. Procedure-related mortality and postoperative complications have been 5 and 21%, respectively. Conclusions: intraoperative enteroscopy remains a valuable tool in selected patients with obscure GI bleeding, achieving a high diagnostic yield and allowing an endoscopic and/or surgical treatment in most of them. However, as an invasive procedure with relevant mortality and morbidity, a precise indication for its use is indispensable

Association between the location of colon polyps at baseline and surveillance colonoscopy: a retrospective study

Introduction: Several factors are used to stratify the probability of polyp recurrence. However, there are no studies correlating the location of the initial polyps and the recurrent ones. The aim of this study was to verify whether the polyp location at the surveillance colonoscopy was correlated with the location of the previously excised polyps at the baseline colonoscopy. Methods: A retrospective study of patients submitted to colonoscopy with presence and excision of all polyps, followed by a surveillance colonoscopy. Polyp location was divided into proximal/distal to splenic flexure and rectum. Characteristics and recurrent rates at the same colon location were also evaluated. Results: Out of the 346 patients who underwent repeated colonoscopy, 268 (77.4%) had at least 1 polyp detected. For all the segments there was an increased risk of recurrent polyps in the same location and it was about four times higher in proximal (OR 3.5; CI 2.1-6.0) and distal colon segments (OR 3.8; CI 2.1-6.8), followed by three times higher in the rectum (OR 2.6; CI 1.5-4.6). No difference was found between the rates of recurrence at the same segment, taking into consideration the polyp morphology, size, polypectomy technique employed and histological classification. Conclusion: There seems to be a significant association between polyp location at baseline and surveillance colonoscopy