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Aim: To evaluate the efficacy and safety of undiluted N-butyl-2 cyanoacrylate plus methacryloxysulfolane (NBCM) as a prophylactic treatment for gastric varices (GV) bleeding., Methods: This prospective study was conducted at a single tertiary-care teaching hospital between October 2009 and March 2013. Patients with portal hypertension (PH) and GV, with no active gastrointestinal bleeding, were enrolled in primary prophylactic treatment with NBCM injection without lipiodol dilution. Initial diagnosis of GV was based on endoscopy and confirmed with endosonography (EUS); the same procedure was used after treatment to confirm eradication of GV. After puncturing the GV with a regular injection needle, 1 mL of undiluted NBCM was injected intranasally into GV. The injection was repeated as necessary to achieve eradication or until a maximum total volume of 3 mL of NBCM had been injected. Patients were followed clinically and evaluated with endoscopy at 3, 6 and 12 mo. Later follow-ups were performed yearly. The main outcome measures were efficacy (GV eradication), safety (adverse events related to cyanoacrylate injection), recurrence, bleeding from GV and mortality related to GV treatment., Results: A total of 20 patients (15 male) with PH and GV were enrolled in the study and treated with undiluted NBCM injection. Only 2 (10%) patients had no esophageal varices (EV); 18 (90%) patients were treated with endoscopic band ligation to eradicate EV before inclusion in the study. The patients were followed clinically and endoscopically for a median of 31 mo (range: 6-40 mo). Eradication of GV was observed in all patients (13 patients were treated with 1 session and 7 patients with 2 sessions), with a maximum injected volume of 2 mL NBCM. One patient had GV recurrence, confirmed by EUS, at 6-mo follow-up, and another had late recurrence with GV bleeding after 35 mo of follow-up; overall, GV recurrence was observed in 2 patients (10%), after 6 and 35 mo of follow-up, and GV bleeding rate was 5% (1 patient). Mild epigastric pain was reported by 3 patients (15%). No mortality or major complications, including embolism, or damage to equipment were observed., Conclusion: Endoscopic injection with NBCM, without lipiodol, may be a safe and effective treatment for primary prophylaxis of gastric variceal bleeding.

Context: Endoscopic mucosal resection is an established modality for excision of sessile lesions in the gastrointestinal tract. Submucosal fluid injection creates a cushion and may prevent thermal injury and perforation., Objectives: This blind study investigated the performance of three different solutions to create submucosal fluid cushions in porcine stomach., Methods: Three solutions were injected in the stomach of nine pigs BR1: normal saline solution, carboxymethylcellulose 0.5% and hydroxypropyl methylcellulose 0.25%. In each pig, submucosal injections with 6 mL per test-solution were performed. One drop of methylene blue was added to all injections for better visualization. The time for the bleb to disappear was recorded., Results: The overall median time of visible submucosal cushion was 37 minutes (range 12-60 min) for hydroxypropyl methylcellulose, 31 minutes for carboxymethylcellulose (range 10-43 min) and 19 minutes for normal saline solution (range 8-37 min). There was no statistically significant difference neither between normal saline solution and carboxymethylcellulose (P = 0.146) nor carboxymethylcellulose and hydroxypropyl methylcellulose (P = 0.119) but the median duration of hydroxypropyl methylcellulose was significantly longer than normal saline solution (P = 0.039)., Conclusions: The length of hydroxypropyl methylcellulose submucosal fluid cushion is longer in comparison with normal saline solution. The median time for carboxymethylcellulose was not longer than normal saline solution. Hydroxypropyl methylcellulose, in the concentration of 0.25%, may be a durable alternative for submucosal injection.

Background: ERCP has become widely available for the diagnosis and treatment of benign and malignant pancreaticobiliary diseases. In this prospective study, the overall complication rate and risk factors for diagnostic and therapeutic ERCP were identified., Methods: Data were collected prospectively on patient characteristics and endoscopic techniques from 1223 ERCPs performed at a single referral center and entered into a database. Univariate and multivariate analyses were used to identify risk factors for ERCP-associated complications., Results: Of 1223 ERCPs performed, 554 (45.3%) were diagnostic and 667 (54.7%) therapeutic. The overall complication rate was 11.2%. Post-ERCP pancreatitis was the most common (7.2%) and in 93% of cases was self-limiting, requiring only conservative treatment. Bleeding occurred in 10 patients (0.8%) and was related to a therapeutic procedure in all cases. Nine patients had cholangitis develop, most cases being secondary to incomplete drainage. There was one perforation (0.08%). All other complications totaled 1.5%. Variables derived from cannulation technique associated with an increased risk for post-ERCP pancreatitis were precut access papillotomy (20%), multiple cannulation attempts (14.9%), sphincterotome use to achieve cannulation (13.1%), pancreatic duct manipulation (13%), multiple pancreatic injections (12.3%), guidewire use to achieve cannulation (10.2%), and the extent of pancreatic duct opacification (10%). Patient characteristics associated with an increased risk of pancreatitis were sphincter of Oddi dysfunction (21.7%) documented by manometry, previous ERCP-related pancreatitis (19%), and recurrent pancreatitis (16.2%). Pain during the procedure was an important indicator of an increased risk of post-ERCP pancreatitis (27%). Independent risk factors for post-ERCP pancreatitis were identified as a history of recurrent pancreatitis, previous ERCP-related pancreatitis, multiple cannulation attempts, pancreatic brush cytology, and pain during the procedure., Conclusions: The most frequent ERCP-related complication was pancreatitis, which was mild in the majority of patients. The frequency of post-ERCP pancreatitis was similar for both diagnostic and therapeutic procedures. Bleeding was rare and mostly associated with sphincterotomy. Other complications such as cholangitis and perforation were rare. Specific patient- and technique-related characteristics that can increase the risk of post-ERCP complications were identified.

Background: Magnification colonoscopy and contrast chromoscopy with indigo carmine dye solution have been used to differentiate neoplastic polyps (adenomas and adenocarcinomas) from non-neoplastic (hyperplastic, inflammatory, juvenile) in an attempt to obviate endoscopic polypectomy. On the other hand, little published information exists concerning conventional video colonoscopes and chromoscopy for polyp histology prediction. Aim - To assess usefullness of conventional video colonoscopes and contrast chromoscopy with indigo carmine solution for differential diagnosis of colon polyps., Methods: In a routine colonoscopy series, we performed chromoscopy with conventional video colonoscopes before endoscopic excision of detected polyps. If a sulcus pattern was observed on the surface of the lesion, it was classified as neoplastic. Polyps were classified as non-neoplastic if no sulcus was detected on its surface. These observations were then compared with histology., Results: In the study period (18 months), we detected 133 polyps in 53 patients. We were able to compare results of histology and chromoscopy in 126 lesions. The sensitivity, specificity, diagnostic accuracy, negative predictive value, and positive predictive value were 56,4%, 79,2%, 65,1%, 52,8%, and 81,5%, respectively., Conclusion: On the base of the presented data, we concluded that conventional video colonoscopes and contrast chromoscopy with indigo carmine solution is not a good technique for differential diagnosis of colon polyps.

Background: Colorectal cancer is an important cause of death in western countries. Screening methods are based on flexible sigmoidoscopy, a cheap, effective, and less painful procedure, but some important lesions on the right colon can be missed., Aim: Evaluate how many important lesions would be missed if colonoscopy indicated only for patients with distal lesions identified during flexible sigmoidoscopy., Material and Methods: All consecutive colonoscopy performed in the Endoscopy Unit of the Gastroenterology Division of Federal University of São Paulo, SP, Brazil, with polyps and cancer suspicious lesions were reviewed. Patients with a second procedure, inflammatory bowel disease or colonic surgery were excluded., Results: We reviewed 101 patients with 38 possible cancer lesions and 70 polyps. The mean age was 62 years (SD 13.7 years) and 45 were male. Forty five lesions were in the right colon, namely 23 adenomas, 10 adenocarcinomas, 1 lymphoma and 11 benign lesion. Among such lesions, 28 were isolated in the right colon (16 adenomas and 7 adenocarcinomas)., Conclusion: In our study 23 patients (22.77%) had adenomas or adenocarcinomas isolated in the right colon, that would be missed if flexible sigmoidoscopy was used alone.

Helicobacter pylori (HP) infection is endemic worldwide. The proposed treatment is expensive and there are few reports regarding reinfection rates in Brazil. The aim of this study was to compare the eradication rates obtained with two therapeutic options and to evaluate reinfection one year after treatment. This was a prospective randomized trial with 55 patients. Thirty-nine patients had active duodenal ulcer (DU) and 16 non-ulcer dyspepsia (NUD), and all tested positive for HP. Diagnosis was based on at least two positive tests: ultrarapid urease test, histology and/or culture. Patients were randomized to two groups: group OMC treated with 40 mg omeprazole (once a day), 500 mg metronidazole and 250 mg clarithromycin (twice daily) for 7 days, or group NA treated with 300 mg nizatidine (once a day) and 1000 mg amoxicillin (twice daily) for 14 days. Those patients in whom HP was eradicated were followed up for one year to evaluate reinfection. Twenty-five patients were randomized for OMC and 30 for NA. HP eradication occurred in 20/25 patients (80%) treated with OMC and 13/30 (43%) treated with NA (P = 0.01). After reallocation because of initial treatment failure, the overall eradication rate was 44/51 patients (86%). After an average follow-up of one year, we evaluated 34 patients (23 with DU and 11 with NUD). Reinfection occurred in 3/34 patients (7.6%). We conclude that OMC is effective for HP eradication, and that NA should not be used. Reinfection occurs in 7.6% of the patients in the first year after eradication.

Background: Enteral feeding by percutaneous endoscopic gastrostomy is indicated as long-term nutritional support for children with neurologic impairment and dysphagia. We report our experience with percutaneous endoscopic gastrostomy and evaluate the age range of children with cerebral palsy who benefit most with weight and height gain., Methods: In a prospective study, from August 1996 to August 1997, 20 endoscopic gastrostomies were performed in 20 children diagnosed with cerebral palsy (16), myopathy (2), and brain trauma (2). The mean age was 6.5 years and the mean follow-up 5.9 months. All patients had severe mental impairment and oropharyngeal dysphagia. They were followed up monthly on an outpatient basis by both the gastroenterologist and the dietitian, who assessed gastrostomy complications and performed anthropometric measurements., Results: All 20 patients benefited from enteral nutrition with a statistically significant gain in weight (p < 0.01), and there was a trend toward improved weight/height ratio in children under 4 years of age according to Z-score and mid-arm muscle area (p < 0.01). Triceps skinfold thickness failed to reach statistical significance. There were no immediate complications related to the procedure. Perforations occurred with three (15%) tubes, and the plugs for introduction of food had to be replaced after 4 months of use. All complications, namely formation of granulation tissue at the stoma (7), stoma infection (4), gastroesophageal reflux pneumonia (3), and pneumoperitoneum (1) were managed clinically., Conclusions: Endoscopic gastrostomy is a safe procedure for children. Enteral feeding resulted in a trend toward a normalized weight/height ratio for children with cerebral palsy younger than 4 years and significant weight gain in those older than 12 years.

Botulinum toxin (BT) has recently been indicated as an alternative treatment of idiopathic achalasia with a success rate of 60-70%. One-third of BT-treated cases either fail to respond or fail to sustain the response beyond 6 months. An explanation for BT therapeutic failure would be that the lower esophageal sphincter muscular layer (LES) may be missed as injection is delivered 'blindly'. We aimed to evaluate the percentage of exact endoscopically 'blind' LES punctures using echoendoscopy after the injection of BT for the treatment of Chagas' achalasia (CA). Five patients with CA (mean age 53 years) were randomized to receive 1.2 ml of BT or the same amount of saline injected endoscopically. Echoendoscopy was performed immediately after puncture. Patients were evaluated by the clinical score of dysphagia, radiological examination, upper endoscopy and esophageal manometry and followed up for 6 months. All puncture sites were identified: 17 out of 20 (85%) in the muscle layer and 3 out of 20 (15%) in the submucosa. The three patients in the treatment group showed clinical improvement (average clinical score fell from 14 to 2 after 7 days, and remained at 4 after 6 months of follow-up). The mean pressure of the LES dropped by 29%. Neither patient in the placebo group showed clinical improvement, and the mean pressure of the LES increased by 35%. Endoscopic 'blind' injection of BT into the LES through endoscopy for the management of achalasia is a safe and reproducible technique and has a high percentage of exactness.

Botulinum toxin (BT) has been used in neurology, ophthalmology, otorhinolaryngology and gastroenterology. Twenty-four patients with oropharyngeal dysphagia treated with BT injection into the cricopharyngeal muscle were reported, with good results in up to 79% of the patients. Different techniques were used to inject BT: percutaneous (guided by electromyography, computed tomography or videofluoroscopy) or direct injection during esophagoscopy (with a rigid esophagoscope). We report the first case of oropharyngeal dysphagia treated by BT injection into the cricopharyngeal muscle using a flexible scope, with clinical, radiological and manometric improvement. A reduction in the disability score 4 to 2 and sustained capacity to maintain adequate oral caloric intake were observed. The patient was also able to have the tracheotomy orifice closed and the gastrostomy tube removed after 3 months. Manometry showed a 38% reduction in the upper esophageal sphincter pressure with the presence of pharyngeal waves that were previously absent. After 1 year of follow-up, the patient was in good condition with mild dysphagia for solid foods. This is another case of complex dysphagia and relative hyperfunction of the cricopharyngeal muscle successfully treated with BT injection.

Endoscopy therapy of pancreatic pseudocyst has been described as an efficient method. We report six cases of pancreatic pseudocyst treated by pancreatic stenting (three cases), cystogastrostomy (three cases) and cystoduodenostomy (one case). Rapid symptomatic improvement and pseudocyst regression were noted in all cases, except one. Such patient needed pancreatic stenting even after cystogastrostomy due to main pancreatic duct stenosis. There were three complications: hemorrhage (one case) and pseudocyst infection (two cases), and all were treated clinically. Two patients had pseudocyst infection previous to endoscopic manipulation, and they were treated only with antibiotics and endoscopic drainage, without surgery (treatment suggested by most of the authors). We concluded that endoscopic therapy of pancreatic pseudocyst is efficient and safe, being responsible for rapid relief of symptoms in most of patients.

Gastric duplication cysts are rare and generally asymptomatic in adults. They are usually discovered incidentally at upper gastrointestinal endoscopy or barium contrast radiography. We report here the case of a 41-year-old woman with a gastric submucosal mass, initially diagnosed as a leiomyoma that proved to be a gastric cyst. The cyst was aspirated under direct endoscopic vision using a standard sclerotherapy needle. To our knowledge, this is the first description of such a procedure.