Gastroesophageal reflux disease (GERD) is probably one of the most prevalent diseases in the world that also compromises the quality of life of the affected significantly. Its incidence in Brazil is 12%, corresponding to 20 million individuals.
To update the GERD management and the new trends on diagnosis and treatment, reviewing the international and Brazilian experience on it.
The literature review was based on papers published on Medline/Pubmed, SciELO, Lilacs, Embase and Cochrane crossing the following headings: gastroesophageal reflux disease, diagnosis, clinical treatment, surgery, fundoplication.
Various factors are involved on GERD physiopathology, the most important being the transient lower esophageal sphincter relaxation. Clinical manifestations are heartburn, regurgitation (typical symptoms), cough, chest pain, asthma, hoarseness and throat clearing (atypical symptoms), which may be followed or not by typical symptoms. GERD patients may present complications such as peptic stenosis, hemorrhage, and Barrett's esophagus, which is the most important predisposing factor to adenocarcinoma. The GERD diagnosis must be based on the anamnesis and the symptoms must be evaluated in terms of duration, intensity, frequency, triggering and relief factors, pattern of evolution and impact on the patient's quality of life. The diagnosis requires confirmation with different exams. The goal of the clinical treatment is to relieve the symptoms and surgical treatment is indicated for patients who require continued drug use, with intolerance to prolonged clinical treatment and with GERD complications.
GERD is a major digestive health problem and affect 12% of Brazilian people. The anamnesis is fundamental for the diagnosis of GERD, with special analysis of the typical and atypical symptoms (duration, intensity, frequency, triggering and relief factors, evolution and impact on the life quality). High digestive endoscopy and esophageal pHmetry are the most sensitive diagnosctic methods. The clinical treatment is useful in controlling the symptoms; however, the great problem is keeping the patients asymptomatic over time. Surgical treatment is indicated for patients who required continued drug use, intolerant to the drugs and with complicated forms of GERD.
The field of medicine has always been at the forefront of technological innovation, constantly seeking new strategies to diagnose, treat, and prevent diseases. Guidelines for clinical practice to orientate medical teams regarding diagnosis, treatment, and prevention measures have increased over the years. The purpose is to gather the most medical knowledge to construct an orientation for practice. Evidence-based guidelines follow several main characteristics of a systematic review, including systematic and unbiased search, selection, and extraction of the source of evidence. In recent years, the rapid advancement of artificial intelligence has provided clinicians and patients with access to personalized, data-driven insights, support and new opportunities for healthcare professionals to improve patient outcomes, increase efficiency, and reduce costs. One of the most exciting developments in Artificial Intelligence has been the emergence of chatbots. A chatbot is a computer program used to simulate conversations with human users. Recently, OpenAI, a research organization focused on machine learning, developed ChatGPT, a large language model that generates human-like text. ChatGPT uses a type of AI known as a deep learning model. ChatGPT can quickly search and select pieces of evidence through numerous databases to provide answers to complex questions, reducing the time and effort required to research a particular topic manually. Consequently, language models can accelerate the creation of clinical practice guidelines. While there is no doubt that ChatGPT has the potential to revolutionize the way healthcare is delivered, it is essential to note that it should not be used as a substitute for human healthcare professionals. Instead, ChatGPT should be considered a tool that can be used to augment and support the work of healthcare professionals, helping them to provide better care to their patients.
Malignant anal melanoma is a rare disorder, corresponding to 0.05-1.0% of all anorectal tumors, and 0.4-1.6% of all other melanomas7,8,9. Its rarity can be confirmed by the fact that for every anal melanoma, there are eight squamous cell carcinomas and 250 anal adenocarcinomas8,9.
The article´s aim is to present a case of a malignant anal melanoma coexisting with colon adenocarcinoma, in addition to a discussion on how to speed up the diagnosis with simple routine measures, and report an objective treatment.
A 57-year-old patient was admitted with weakness, pale skin and a lump in the inguinal region. According to his medical history, one year prior to admittance the patient was treated for anemia. At the time, he presented positive fecal occult blood test. Endoscopy and contrast exams were normal and no weight loss or changes in bowel movements were noticed.
In the six months prior to admittance, the patient felt sporadic pain in the anal canal that ceased with the use of NSAID suppositories. After 30 days, he sought medical attendance and underwent proctosigmoidoscopy and colonoscopy, along with biopsy of lesions in the anal canal and cecum. The patient was then diagnosed with poorly differentiated carcinoma of the canal and well differentiated tubular adenocarcinoma of the cecum. At the time, a lump began forming in the root of the thigh, just below the inguinal fold.
The patient was refered to Sírio-Libanês Hospital in São Paulo, Brazil, for surgical treatment of the colon lesion and clinical treatment of the anal canal lesion (Figure 1), as he refused to operate the anal lesion. Abdominal ultrasonography and thorax tomography did not reveal any findings. Surgery was then performed with right ileocecal colectomy, intra-operatory biopsy of lesion in the anal canal and of the right inguinal lymph node.
Hepatocellular carcinoma is an aggressive malignant tumor with high lethality.
To review diagnosis and management of hepatocellular carcinoma.
Literature review using web databases Medline/PubMed.
Hepatocellular carcinoma is a common complication of hepatic cirrhosis. Chronic viral hepatitis B and C also constitute as risk factors for its development. In patients with cirrhosis, hepatocelular carcinoma usually rises upon malignant transformation of a dysplastic regenerative nodule. Differential diagnosis with other liver tumors is obtained through computed tomography scan with intravenous contrast. Magnetic resonance may be helpful in some instances. The only potentially curative treatment for hepatocellular carcinoma is tumor resection, which may be performed through partial liver resection or liver transplantation. Only 15% of all hepatocellular carcinomas are amenable to operative treatment. Patients with Child C liver cirrhosis are not amenable to partial liver resections. The only curative treatment for hepatocellular carcinomas in patients with Child C cirrhosis is liver transplantation. In most countries, only patients with hepatocellular carcinoma under Milan Criteria are considered candidates to a liver transplant.
Hepatocellular carcinoma is potentially curable if discovered in its initial stages. Medical staff should be familiar with strategies for early diagnosis and treatment of hepatocellular carcinoma as a way to decrease mortality associated with this malignant neoplasm.
The hypervascular liver lesions represent a diagnostic challenge.
To identify risk factors for cancer in patients with non-hemangiomatous hypervascular hepatic lesions in radiologically normal liver.
This prospective study included patients with hypervascular liver lesions in radiologically normal liver. The diagnosis was made by biopsy or was presumed on the basis of radiologic stability in follow-up period of one year. Cirrhosis or patients with typical imaging characteristics of haemangioma were excluded.
Eighty-eight patients were included. The average age was 42.4. The lesions were unique and were between 2-5 cm in size in most cases. Liver biopsy was performed in approximately 1/3 of cases. The lesions were benign or most likely benign in 81.8%, while cancer was diagnosed in 12.5% of cases. Univariate analysis showed that age >45 years (p< 0.001), personal history of cancer (p=0.020), presence of >3 nodules (p=0.003) and elevated alkaline phosphatase (p=0.013) were significant risk factors for cancer.
It is safe to observe hypervascular liver lesions in normal liver in patients up to 45 years, normal alanine aminotransaminase, up to three nodules and no personal history of cancer. Lesion biopsies are safe in patients with atypical lesions and define the treatment to be established for most of these patients.
Tissue diagnosis is required for gastric subepithelial lesions for differential diagnosis of GISTs. However, there has not been consensus about the best needle for EUS-guided sampling of these lesions.
To evaluate the diagnostic yield of EUS-FNA for gastric subepithelial lesions of the proper muscle layer with large-bore 19 gauge needles.
A prospectively maintained database was retrospectively reviewed to identify consecutive patients who underwent EUS-FNA with 19 and 22 gauge needles for gastric subepithelial lesions of the fourth endosonographic layer in a tertiary care referral center. EUS-FNA was performed by the same endosonographer, using the fanning technique, without on-site cytopathologist. Specimens were analysed through cell blocks by the same pathologist. Procedure results were categorized into diagnostic, defined as enough material for histopathology and immunohistochemistry, or nondiagnostic.
Eighty-nine patients (mean age: 59 years, 77% women) underwent 92 EUS-FNA with 19 (75) or 22 (17) gauge needles. Mean lesion size was 22.6 mm. Overall diagnostic yield was 88%. The diagnostic yield of 19 gauge was higher than that of 22 gauge needle (92%x70.6%; p=0.0410), and similar for lesions >2 cm and <2 cm (93.7%x90.7%; p=0.9563). The best performance for 19 gauge needles was obtained performing <3 needle passes. Complication rate was 2.8%.
Diagnostic yield of EUS-FNA with 19 gauge needles is 92% for gastric subepithelial lesions of the proper muscle layer. It is safe and highly valuable for differentiation between GIST and leiomyoma, no matter the size of the lesion.
It is important to obtain representative histological samples of solid biliopancreatic lesions without a clear indication for resection. The role of new needles in such task is yet to be determined.
To compare performance assessment between 20G double fine needle biopsy (FNB) and conventional 22G fine needle aspiration (FNA) needles for endoscopic ultrasound (EUS)-guided biopsy.
This prospective study examined 20 patients who underwent the random puncture of solid pancreatic lesions with both needles and the analysis of tissue samples by a single pathologist.
The ProCore 20G FNB needle provided more adequate tissue samples (16 vs. 9, p=0.039) with better cellularity quantitative scores (11 vs. 5, p=0.002) and larger diameter of the histological sample (1.51±1.3 mm vs. 0.94±0.55 mm, p=0.032) than the 22G needle. The technical success, puncture difficulty, and sample bleeding were similar between groups. The sensitivity, specificity, and diagnostic accuracy were 88.9%, 100%, and 90% and 77.8%, 100%, and 78.9% for the 20G and 22G needles, respectively.
The samples obtained with the ProCore 20G FNB showed better histological parameters; although there was no difference in the diagnostic performance between the two needles, these findings may improve pathologist performance.
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