José Celso Ardengh | Universidade de São Paulo (original) (raw)

Papers by José Celso Ardengh

Arquivos de Gastroenterologia, 2007

relator do consenso Agradecimentos Ao Dr. Thiago F. Souza pela ajuda prestada para a compilação d... more relator do consenso Agradecimentos Ao Dr. Thiago F. Souza pela ajuda prestada para a compilação das referências bibliográficas Ao Prof. Dr. Desiderio Kiss pela participação nas votações dos temas de ecoendoscopia em doenças colorretais Autor para Correspondência Fauze Maluf-Filho R. Olegário Mariano, 488 CEP 05616-090 São Paulo -SP fauze.maluf@terra.com.br 2 Resumo Introdução: Ainda que se reconheça a eficiência da ecoendoscopia para o diagnóstico e até mesmo para o tratamento de várias doenças do aparelho digestivo, a sua inclusão nos algoritmos de decisão clínica em gastroenterologia tem sofrido restrições. Este fato é comprovado indiretamente através da existência de vários estudos que se preocuparam em demonstrar o impacto do exame ecoendoscópio na mudança de condutas e na redução de custos. Outra evidência, esta direta e identificável em nosso meio, é a disponibilidade bastante limitada da ecoendoscopia no Brasil. Neste sentido, quiseram-se identificar as situações clínicas em que o exame ecoendoscópico é eficiente, através de revisões sistemáticas, graduando-se o grau da evidência e a força da recomendação, realizadas pelo grupo envolvido com o método em nosso país, apresentadas e votadas na forma de consenso. Material e Método: o grupo de médicos que realiza ecoendoscopia foi formado a partir de informações obtidas junto às Sociedades de Especialidades e aos fabricantes de equipamentos. A lista de tópicos e perguntas relevantes foi formulada por dois membros do consenso, discutida com e distribuída aos consensualistas cinco meses antes da reunião de consenso. Foi solicitado que se realizassem, na medida do possível, revisões sistemáticas e que as respostas fossem apresentadas para a votação com o grau de evidência e a força da recomendação. Nos dois dias da reunião de consenso, as respostas foram apresentadas, debatidas e votadas. Quando, no mínimo, 70% dos votantes concordaram com o texto da resposta, houve consenso. O relatório final foi submetido à apreciação de e aprovado por todos os consensualistas Resultados: 79 questões foram debatidas na pré-reunião do consenso, resultando 85 questões que foram então distribuídas. Nos dois dias da reunião do consenso, 22 participantes debateram e votaram as 85 respostas. O 3 impacto causado pelo exame ecoendoscópico foi comprovado por evidências do nível 1, gerando recomendações grau A e consenso entre os participantes nas seguintes situações: diagnóstico diferencial da lesão subepitelial do tubo digestivo e do espessamento de pregas gástricas, estadiamento e identificação de lesão irressecável no câncer do esôfago, sinais indiretos de carcinomatose peritoneal no câncer gástrico avançado, estadiamento de linfoma gástrico tipo Malt e estadiamento do câncer de reto, diagnóstico da litíase da vesícula biliar e do colédoco, diagnóstico da pancreatite crônica, diagnóstico diferencial do nódulo sólido da pancreatite crônica, diagnóstico diferencial do cisto pancreático, resultados do tratamento endoscópico das varizes esofágicas, diagnóstico e estadiamento do câncer de pulmão nãopequenas células. Conclusão: já há evidências do melhor nível na literatura médica justificando a utilização do exame ecoendoscópico em várias doenças do aparelho digestivo e, até mesmo, no câncer do pulmão. Palavras-chave: reunião de consenso, revisão, ecoendoscopia, endossonografia 4 Summary Background: In the last 20 years, several papers have focused on

In the majority of cases, duodenal papillary tumors are adenomas or adenocarcinomas, but the endo... more In the majority of cases, duodenal papillary tumors
are adenomas or adenocarcinomas, but the endoscopy
biopsy shows low accuracy to make the correct differentiation.
Endoscopic ultrasonography and endoscopic
retrograde cholangiopancreatography are important
tools for the diagnosis, staging and management
of
ampullary lesions. Although the endoscopic papillectomy
(EP) represent higher risk endoscopic interventions, it
has successfully replaced surgical treatment for benign
or malignant papillary tumors. The authors review the
epidemiology and discuss the current evidence for
the use of endoscopic procedures for resection, the
selection of the patient and the preventive maneuvers
that can minimize the probability of persistent or
recurrent lesions and to avoid complications after the
procedure. The accurate staging of ampullary tumors
is important for selecting patients to EP or surgical
treatment. Compared to surgery, EP is associated
with lower morbidity and mortality, and seems to be
a preferable modality of treatment for small benign
ampullary tumors with no intraductal extension. The
EP procedure, when performed by an experienced
endoscopist, leads to successful eradication in up to
85% of patients with ampullary adenomas. EP is a safe
and effective therapy and should be established as the
first-line therapy for ampullary adenomas.

Objective. Widespread use of imaging procedures has promoted a higher identification of incidenta... more Objective. Widespread use of imaging procedures has promoted a higher identification of incidental pancreatic cysts (IPCs). However, little is known as to whether endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) could change the management strategy of patients having IPCs. This study has aimed to evaluate the management impact of EUS-FNA on IPCs.
Material and methods. Patients with pancreatic cysts (PCs) who were referred to EUS-FNA were recruited prospectively.
The referring physicians were questioned about the management strategy for these patients before and after EUS-FNA. The impact of EUS-FNA on management was then evaluated. Results. A total of 302 PC patients were recruited. Of these, 159 (52.6%) patients had asymptomatic IPCs. The average size was 2.3 cm (range: 0.2–7.1 cm), and 110 patients having smaller than 3 cm sized cysts. Lesions were located in the pancreatic head in 96 (61%) cases, and most patients (94%) had only a single cyst. The final diagnoses, obtained by EUS-FNA (91) and surgery (68), were 93 (58%) benign lesions, 36 (23%) cysts with malignant potential, 14 (9%) noninvasive malignancies, 10 (6%) malignant precursor lesions (PanIN), and 6 (4%) invasive malignancies. Management strategy changed significantly after EUS-FNA in 114 (71.7%) patients: 43% of the cases were referred to surgery, 44% of the patients were discharged from surveillance, and 13% of the cases were given further periodical imaging tests. Conclusion. EUS-FNA has a management impact in almost 72% of IPCs, with a major influence on the management strategy, either discharge rather than surgical resection or surgery rather than additional follow up.

A really different adverse event after endoscopic papillectomy!

This paper analyzes the performance of endoscopic ultrasound in the diagnosis and treatment of co... more This paper analyzes the performance of endoscopic ultrasound in the diagnosis and treatment of complications of acute pancreatitis

Context Pseudotumoral chronic pancreatitis can be difficult to differentiate from pancreatic carc... more Context Pseudotumoral chronic pancreatitis can be difficult to differentiate from pancreatic carcinoma.

A 75-year-old diabetic woman was referred to our Endoscopy Unit with a 2 months history of recurr... more A 75-year-old diabetic woman was referred to our Endoscopy Unit with a 2 months history of recurrent stomatitis and gastric fullness sensation. She had undergone laparoscopic fundoplication 4 years earlier with no recorded adverse events. Her physical examination was unrevealing. Endoscopy revealed a round elevation (5 centimeters in diameter) at the anterior gastric wall, with 2 small ulcerations with fibrin on its top (figure 1).

-Ainda que se reconheça a eficiência da ecoendoscopia para o diagnóstico e até mesmo para o trata... more -Ainda que se reconheça a eficiência da ecoendoscopia para o diagnóstico e até mesmo para o tratamento de várias doenças do aparelho digestivo, a sua inclusão nos algoritmos de decisão clínica em gastroenterologia tem sofrido restrições. Este fato é comprovado indiretamente através da existência de vários estudos que se preocuparam em demonstrar o impacto do exame ecoendoscópio na mudança de condutas e na redução de custos. Outra evidência, esta direta e identificável em nosso meio, é a disponibilidade bastante limitada da ecoendoscopia no Brasil. Neste sentido, quiseram-se identificar as situações clínicas em que o exame ecoendoscópico é eficiente, através de revisões sistemáticas, graduando-se o grau da evidência e a força da recomendação, realizadas pelo grupo envolvido com o método em nosso país, apresentadas e votadas na forma de consenso. Método -O grupo de médicos que realiza ecoendoscopia foi formado a partir de informações obtidas junto às sociedades de especialidades e aos fabricantes de equipamentos. A lista de tópicos e perguntas relevantes foi formulada por dois membros do consenso (FMF, CMD), discutida com e distribuída aos consensualistas 5 meses antes da reunião de consenso. Foi solicitado que se realizassem, na medida do possível, revisões sistemáticas e que as respostas fossem apresentadas para a votação com o grau de evidência e a força da recomendação. Nos 2 dias da reunião de consenso, as respostas foram apresentadas, debatidas e votadas. Quando, no mínimo, 70% dos votantes concordaram com o texto da resposta, houve consenso. O relatório final foi submetido a apreciação e aprovado por todos os consensualistas. Resultados -Setenta e nove questões foram debatidas na pré-reunião do consenso, resultando 85 questões que foram então distribuídas. Nos 2 dias da reunião do consenso, 22 participantes debateram e votaram as 85 respostas. O impacto causado pelo exame ecoendoscópico foi comprovado por evidências do nível 1, gerando recomendações grau A e consenso entre os participantes nas seguintes situações: diagnóstico diferencial da lesão subepitelial do tubo digestivo e do espessamento de pregas gástricas, estádio e identificação de lesão irressecável no câncer do esôfago, sinais indiretos de carcinomatose peritonial no câncer gástrico avançado, estádio de linfoma gástrico tipo Malt e estádio do câncer de reto, diagnóstico da litíase da vesícula biliar e do colédoco, diagnóstico da pancreatite crônica, diagnóstico diferencial do nódulo sólido da pancreatite crônica, diagnóstico diferencial do cisto pancreático, resultados do tratamento endoscópico das varizes esofágicas, diagnóstico e estádio do câncer de pulmão não-pequenas células. Conclusão -Já há evidências do melhor nível na literatura médica justificando a utilização do exame ecoendoscópico em várias doenças do sistema digestório e, até mesmo, no câncer do pulmão. DESCRITORES -Endossonografia. Consenso. Brasil *apoio da SOBED -Sociedade Brasileira de Endoscopia Digestiva **relator do consenso Correspondência: Dr. Fauze Maluf-Filho -R. Olegário Mariano, 488 -05616-090 -São Paulo, SP.

RESUMO -Racional -O câncer gástrico é a maior causa de morte por câncer no Brasil. Na avaliação d... more RESUMO -Racional -O câncer gástrico é a maior causa de morte por câncer no Brasil. Na avaliação do prognóstico e no planejamento da terapêutica, é importante determinar o estádio e classificá-lo em TNM. Objetivo -Estudar os resultados da ecoendoscopia na determinação pré-operatória das categorias T e N. Métodos -Foram examinados prospectivamente e de forma consecutiva 30 pacientes com adenocarcinoma gástrico no período de 1 ano. Utilizou-se o aparelho Olympus GIF-UM-20. Após seu posicionamento na terceira porção duodenal, estudaram-se as estações linfonodais , 1 e 2, usando a freqüência de 7,5 MHz. Os resultados T e N foram comparados com os achados cirúrgicos e/ou histopatológicos. Nos casos irressecáveis, a correlação foi feita com os achados macroscópicos. Para a análise estatística utilizou-se o teste de correlação coeficiente kappa. Resultados -Foram realizadas 16 gastrectomias totais, 7 subtotais, 5 laparotomias exploradoras e 2 videolaparoscopias. Para a categoria T a ecoendoscopia acertou em 25/30 casos (83,3%). Todos os restantes 16,7% foram superestimados. A precisão variou de 90% a 96,7%, de acordo com as subdivisões T1 a T4. Para a categoria N, a ecoendoscopia foi correta em 23/30 casos (76,7%), sendo 16,6% subestimados e 6,7% superestimados. A precisão variou de 76,7% a 90%, de acordo com as subdivisões N0 a N2. Conclusão -Houve nítida correlação entre a ecoendoscopia pré-operatória e os achados cirúrgicos e/ou histopatológicos em pacientes com adenocarcinoma gástrico. Malheiros CA, Ardengh JC, Santo GC, Barata RCB, Rahal F. Endoscopic ultrasound in the preoperative staging of gastric cancer: correlation with the surgical and/or pathological findings. Arq Gastroenterol. 2008;45 :22-7. ABSTRACT -Background -Gastric adenocarcinoma is the major cause of death by cancer in Brazil. For the planning of the treatment and evaluation of the prognosis, the preoperative staging according to the TNM classification is very important. Aim -To evaluate the results of endoscopic ultrasound for the T and N categories. Methods -We examined 30 patients with gastric adenocarcinoma in the period of 1 year. We used a Olympus GIF UM-20. After positioning in the third portion of the duodenum, we started to evaluate the lymph node stations , 1 and 2, using the frequency of 7.5 MHz. The depth of the tumor in the gastric wall was evaluated with the frequencies of 7.5 and 12 MHz. The results T and N were compared with the conclusive findings. In the unresectable cases, the correlation was made by the macroscopic findings. Results -We performed 16 total gastrectomies, 7 subtotal gastrectomies, 5 exploratory laparotomies and 2 laparoscopies. For T category, endoscopic ultrasound results were correct in 25/30 cases (83.3%). All the other 16.7% were overestimated. The accuracy varied from 90% to 96.7% according to the subcategories T1 to T4. For the N category, endoscopic ultrasound results were correct in 23/30 cases (76.7%). Sixteen point six percent were underestimated and 6.7% overestimated. The accuracy varied from 76.7% to 90%, in agreement with the subcategories N1 to N3. Conclusion -There was a clear correlation between endoscopic ultrasound and the surgical and pathological findings in the evaluation of T and N categories in patients with gastric adenocarcinoma. HEADINGS -Stomach neoplasms. Adenocarcinoma Endosonography. Recebido em 16/2/2007. Aprovado em 20/8/2007.

RESUMO -Objetivos -Chamar a atenção da classe médica em geral sobre os pacientes com alto risco d... more RESUMO -Objetivos -Chamar a atenção da classe médica em geral sobre os pacientes com alto risco de desenvolver câncer pancreático e se existem ou não formas de vigilância e prevenção dessa doença, que podem ser aplicadas à prática clínica diária. Levantamento de dados -Utilizou-se o banco de dados do PubMed (US National Library of Medicine), analisaram-se as publicações dos últimos anos, em relação haram aos grupos de risco, testes biológicos moleculares e exames de imagem empregados na identificação de pequenos tumores de pâncreas. Síntese dos dados -Mesmo após os significativos avanços no diagnóstico por imagem, tratamento e compreensão da biologia molecular do adenocarcinoma do pâncreas, a taxa de sobrevivência dessa doença permanece desprezível. Embora embrionárias, as estratégias de vigilância e prevenção para pessoas com risco elevado do câncer de pâncreas têm se desenvolvido. Conclusão -Este artigo de atualização enfoca, resumidamente, as estratégias para melhor identificação de pessoas com alto risco de desenvolver essa doença e qual é o estado da arte do aconselhamento genético e de rastreamento através dos exames de imagem disponíveis. DESCRITORES -Neoplasias pancreáticas, prevenção & controle. Diagnóstico por imagem. Diagnóstico precoce. Endossonografia. Recebido em 17/3/2008. Aprovado em 14/4/2008.

Background: endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) allows cytologic and/or... more Background: endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) allows cytologic and/or histologic diagnosis of lesions within or adjacent to the gastrointestinal tract. However, the amount of tissue obtained with a regular 22 gauge needle is not always satisfactory. With the development of a needle XNA-10J-KB (Shot-Gun ® ) that resembles the automatic liver biopsy needle, it is expected that significant samples be obtained more frequently (core biopsy), optimizing histological analysis. Objective: to compare samples obtained with EUS-FNA using 3 different needle systems: GIP ® , NA-10J-1 ® and Shot-Gun ® . Methods: 19 patients underwent EUS-FNA for diagnosis (5) or tumor staging (14). Mean age was 58.9 years (range 27-82), being 50% men. All patients were submitted to EUS-FNA with the 3 needle models. The Shot-Gun ® model was "shot" when its tip was near the target inside the lesion, followed by aspiration. Samples were submitted for cytologic and histologic examination. Results: mean lesion size was 3.0 cm (range 0.8-5.5 cm). Final diagnoses were made after surgery or intra-operative biopsy: 13 pancreatic tumors (12 adenocarcinomas and 1 neuroendocrine tumor), 4 chronic pancreatitis, 1 acute pancreatitis, and 1 cholangiocarcinoma. Biopsia tecidual con aguja fina guiada por ultrasonido endoscópico: comparación entre un dispositivo automático de la biopsia y dos sistemas de agujas convencionales Resumen Introducción: la ecografía endoscópica asociada a la punción guiada con aguja fina (EUS-FNA) permite el examen citológico y/o diagnóstico histológico de las lesiones dentro o junto al tracto gastrointestinal. Sin embargo, la cantidad de tejido obtenido con una aguja de calibre 22 G no es siempre satisfactoria. Con el desarrollo de una aguja XNA-10J-KB (Shot-Gun ® ) que se asemeja a la biopsia hepática automática como una aguja especial, se espera que se obtemgan muestras importantes con más frecuencia permitindo optimizar el mejor análisis histopatológico. Objetivo: comparar las muestras obtenidas con EUS-FNA con 3 diferentes sistemas de aguja: GIP ® , NA-10J-1 ® y Shot-Gun ® . Métodos: 19 pacientes fueron sometidos a EUS-FNA para el diagnóstico para el análisis de las etapas del Correspondence: José Celso Ardengh Alameda dos Arapanés, 881-cj 111.

Cytological smear is widely employed to analyse specimens obtained from endosonography-guided fin... more Cytological smear is widely employed to analyse specimens obtained from endosonography-guided fine-needle aspiration (EUS-FNA), but false-negative or inconclusive results may occur. A better diagnostic yield can be obtained from processing cell blocks. We compared the effectiveness of the cell block technique and cytological smear in the diagnosis of pancreatic neoplasms. From January 1997 to December 2006, 611 patients with pancreatic tumors were evaluated by EUS-FNA. Surgery was performed in 356 cases, and the other 255 patients were followed clinically for an average of 12.8 months. In total, 282 (46.2%) patients were evaluated with cytological smears, and 329 (53.8%) were evaluated using only cell blocks. Malignant disease was detected in 352 (57.6%) cases, in which adenocarcinoma accounted for 236 (67%) cases. A benign disease was found in the other 259 cases, including 35.1% focal chronic pancreatitis and 32.4% pseudocysts. Aspiration samples were satisfactory in 595 (97.4%) patients after an average of 2.2 (1-4) passes of the needle. Regardless of the cytopathological examination technique, EUS-FNA confirmed malignancy in 269 of 352 (76.4%) cases, and a benign disease in 257 of 259 (99.2%) cases. For patients who received surgery with histologically confirmed lesions, the sensitivity, specificity, positive and negative predictive values, and accuracy of the smears versus cell blocks in diagnosing pancreatic tumors were 61% versus 85.2% (P<0.001), 100% versus 93.1%, 100% versus 98.4%, 36% versus 55.1% (P=0.046) and 68% versus 86.5% (P<0.001), respectively. The cell block technique demonstrated a hig-her sensitivity, negative predictive value and accuracy than cytological smears.

es and in cases where communication existed. A pre-cut needle knife was used to puncture the cyst... more es and in cases where communication existed. A pre-cut needle knife was used to puncture the cyst wall, aspirate the content and then enter at the cyst cavity (contrast was injected to ensure opacification of the cyst and subsequent drainage). Sphincterotomy catheter or balloons were used to enlarge and ensure a wide cystoenterostomy. All patients were followed with computerized tomography scans or ultrasound to ensure clinical resolution. Mean follow-up was 21 months. Results: 49/56 patients could be successfully treated. ED was successful in 49 patients (87%) and in 3 (13%) it failed. Mean follow-up was 21 months. During this period, there were 2 (10.5%) pseudocyst recurrences and only 1 (5.2%) recurrence of new episodes of pancreatic necrosis, and all were managed clinically and/or endoscopically. No mortality was related to the procedure. Conclusion: ED with daily necrosectomy is a useful method to remove infected and sterile pancreatic necrosis.

13.6%): 2 recurrences (referred to surgery), 2 developing abscesses (submitted a new EUS-guided e... more 13.6%): 2 recurrences (referred to surgery), 2 developing abscesses (submitted a new EUS-guided endoscopic drainage with success), 1 perforation that died (2.2%), and 1 case of bleeding (sent to surgery) in group I. In group II there were only 6 (18.1%) recurrences (submitted a new EUS-guided aspiration). None of the patients undergoing single-step aspiration developed infections, perforation or hemorrhage. Conclusion: The recurrence of pancreatic pseudocysts after endoscopic treatment was similar, either by means of plastic stents or by complete single-step aspiration.

Context EUS-FNA is increasingly being used in operable pancreatic carcinoma cases identified by C... more Context EUS-FNA is increasingly being used in operable pancreatic carcinoma cases identified by CT. Objectives Determine the safety, accuracy and clinical utility of EUS-FNA for T, N and TN staging and vascular injury assessment in proven ductal pancreatic carcinoma. Patients Fifty-two consecutive patients (29 women and 23 men) with histologically ductal pancreatic carcinoma, with an excellent possibility of mass resection assessed by helical computerized tomography, were studied. Mean age was 62.4 years (range: 27-82 years). Tumor locations were in the head (43 cases), body (5 cases) and tail (4 cases) of the pancreas. Mean tumor size from EUS was 3.7 cm (range: 0.8-6.2 cm). Methods We reviewed medical records and abdominal ultrasound, CT, EUS-FNA and the results were compared to surgical and histological findings. Results Ultrasound identified pancreatic abnormalities in 38 out of 52 patients (73.1%): pancreatic mass (25 cases), pancreatic head enlargement (8 cases), dilation of main pancreatic duct (3 cases), pancreatic cyst (1 case) and pancreatic calcification (1 case). CT showed a pancreatic mass (30 cases), pancreatic enlargement (17 cases), pancreatic cystic lesion (2 cases) and pancreatic calcification (1 case) in 50 out of 52 patients (96.2%). EUS-FNA found a clear pancreatic tumor image in all patients (100%). The accuracy of EUS for evaluating portal blood vessels, superior mesenteric artery, T alone, N alone and combined TN staging was 86.5%, 94.2%, 84.7%, 67.3% and 55.8%, respectively. In addition to cytological material from 50 patients, microfragments from 43 patients were sent for histological analysis. Two patients (3.8%) showed minor complications: self-limited bleeding and acute pancreatitis. Conclusions EUS-FNA is safe, and can help gastroenterologists and surgeons make surgical decisions regarding pancreatic carcinoma patients.

Bleeding from gastric varices is a life-threatening condition. We report our experience with cyan... more Bleeding from gastric varices is a life-threatening condition. We report our experience with cyanoacrylate injection. Twenty three patients with portal hypertension and gastric varices underwent intra-variceal injection of a cyanoacrylate/lipiodol solution (1:1). Study endpoint was variceal obliteration. Mean follow-up was 25.3 months. Variceal obliteration was achieved in 87% of patients. Recurrence occurred in one patient (4.3%) and rebleeding in another case (4.3%). Mild abdominal pain was described in 13% of patients. Overall mortality was 21.7% and rebleeding related mortality rate was 4.3%. Our results confirm that cyanoacrylate injection is effective and safe to eradicate gastric varices.

Primary gastric non-Hodgkin's lymphoma (NHL) is a co-morbidity that can be observed during the cl... more Primary gastric non-Hodgkin's lymphoma (NHL) is a co-morbidity that can be observed during the clinical course of acquired immunodeficiency syndrome (AIDS). We evaluated the prevalence, clinical-evolutive aspects and form of endoscopic presentation of primary gastric NHL associated with AIDS. Two hundred and forty-three HIV patients were submitted to upper digestive endoscopy, with evaluation of clinical, endoscopic and histological data. A CD4 count was made by flow cytometry and viral load was determined in a branched-DNA assay. Six cases (five men; mean age: 37 years; range: 29-46 years) of primary gastric NHL were detected. The median CD4 count was 140 cells/ mm 3 and the median viral load was 40,313 copies/mL. Upper digestive endoscopy revealed polypoid (in four patients) ulcero-infiltrative (two patients) and ulcerated (two patients) lesions and combined polypoid and ulcerated lesions (two patients). Histology of the gastric lesions demonstrated B cell NHL (four patients) and T cell NHL (two patients). Five of the six patients died of complications related to gastric NHL. We concluded that primary gastric NHL is an important cause of mortality associated with AIDS.

Figure 4. EUS aspect of the lesion: doppler sign inside it. Acta Gastroenterológica Latinoamerica... more Figure 4. EUS aspect of the lesion: doppler sign inside it. Acta Gastroenterológica Latinoamericana -Vol 40 / N°1 / Marzo 2010 x IMAGEN DEL NÚMERO Acta Gastroenterológica Latinoamericana -Vol 40 / N°1 / Marzo 2010

Arquivos de Gastroenterologia, 2007

A really different adverse event after endoscopic papillectomy!