無線膠囊內窺鏡（CE）是一種用於檢查整個胃腸道，尤其是小腸的無創技術。它極大地改善了許多小腸疾病的診斷和管理方式，如不明原因的消化道出血，克羅恩病，小腸腫瘤，息肉綜合征等。儘管膠囊內窺鏡有很好的臨床表現，但它仍然有一定的局限性。主要問題是每次檢查產生約50,000 幅低質量的圖像，對於醫生來說，評估如此大量的圖像是一項非常耗時、耗力的工作。 / 到目前為止，對於膠囊內窺鏡的分析和評估，學者們都把膠囊內窺鏡圖像視為單獨的，獨立的觀測對象。事實並非如此，因為圖像之間往往有顯著的重疊。特別是當膠囊內窺鏡在被小腸蠕動緩緩推動時，它可以捕捉同一病灶的多個視圖。我們的研究目的是使用所有可用的資訊，包括多幅圖像，研究對於膠囊內窺鏡的電腦輔助診斷（CAD）系統。 / 在這篇論文中，我們提出了一個嵌入分類器的多類隱馬爾可夫模型（HMM）的方案，它可以融合多幅相鄰圖像的時間資訊。由於膠囊內窺鏡圖像的品質比較低，我們首先進行預處理，以加強膠囊內窺鏡圖像，增加其對比度，消除噪聲。我們調查研究了多種圖像增強的方法，並調整了它們的參數使其適用於膠囊內窺鏡圖像。 / 對於基於單幅圖像的有監督的分類，AdaBoost 作為一個集成分類器來融合多個分類器，即本論文中的支持向量機（SVM），k-近鄰（k-NN），貝葉斯分類。在分類之前，我們提取和融合了顏色，邊緣和紋理特徵。 / 對於無線膠囊內窺鏡的視頻摘要，我們提出了有監督和無監督的兩類方法。對於有監督方法，我們提出了一個基於隱馬爾可夫模型的，靈活的，可擴展的框架，用於整合膠囊內窺鏡中連續圖像的時間資訊。它可以擴展到多類別，多特徵，多狀態。我們還提出了聯合隱馬爾可夫模型和並行隱馬爾可夫（PHMM）模型對系統進行改進，它們可以被看作是決策級的資訊融合。聯合隱馬爾可夫模型通過多層次的隱馬爾可夫模型，結合不同的資訊來源，對膠囊內窺鏡視頻進行分類和視頻摘要。 並行隱馬爾可夫模型採用貝葉斯推理，在決策時融合多個不同來源的資訊。對於無監督的方法，我們首先提出了一種基於顏色的特徵提取方法。在反色顏色空間中對亮度不變的色度不變矩用來表示膠囊內窺鏡圖像的顏色特徵。接著，我們又提出了一種基於輪廓元（Contourlet）變換的局部二元模式（LBP）作為紋理特徵。在特徵空間中，我們測量了相鄰圖像的距離，並把它視為一個位於二維平面上的開放輪廓上的點。 然後，我們採用一個無參數的關鍵點檢測方法檢測在視頻片段上的突變關鍵點。基於這些突變關鍵點，我們對膠囊內窺鏡視頻進行分割。最後，在每段被分割的視頻片段上，我們通過提取有代表性的關鍵幀來實現膠囊內窺鏡視頻摘要。我們分別用模擬和真實的病人數據進行實驗，對提出的方法進行驗證，結果表明了我們所提出的方案的有效性。它在實現自動評估膠囊內窺鏡圖像上具有很大的潛力。 / Wireless Capsule Endoscopy (CE) is a non-invasive technology to inspect the whole gastrointestinal (GI) tract, especially the small intestine. It has dramatically changed the way of diagnosis and management of many diseases of the small intestine, such as obscure gastrointestinal bleeding, Crohn’s disease, small bowel tumors, polyposis syndromes, etc. Despite its promising clinical findings, it still has some limitations. The main problem is that it requires manual assessment of approximately 50,000 low quality images per examination which is highly time-consuming and labor-intense. / CE analysis and assessment so far treated CE images as individual and independent observations. It is obviously not the case as there is often significant overlap among images. In particular, CE captures multiple views of the same anatomy as the capsule is slowly propelled by peristalsis. Our broader work aims to perform computer aided diagnosis (CAD) in endoscopy using all available information, including multiple images. / In this dissertation, a framework of multi-class Hidden Markov Models (HMM) embedded with statistical classifiers for combining information from multiple CE images is proposed. Due to the low quality of CE image, pre-processing is performed to enhance CE images by increasing the contrast and removing noises. Several image enhancement methods are investigated and customized for CE images. For frame-based supervised classification, AdaBoost is used as the ensemble classifier to combine multiple classifiers, i.e. support vector machine (SVM), k-nearest neighbor (k-NN), and Bayes classifier. Before classification, color, edge and texture features are extracted and fused. Finally, both supervised and unsupervised methods are proposed for CE study synopsis. For supervised method, a flexible and extensible framework based on HMM is developed to integrate temporal information in CE images. It can be extended to multi-class, multi-features, and multi-states. Improvements can be made by combined HMM and Parallel HMM (PHMM) which are introduced as decision-level fusion schemes. Combined HMM considers different sources via a multi-layer HMM model to perform classification and video synopsis. PHMM employs Bayesian inference to combine the recognition results at decision level. For unsupervised method, illumination-independent opponent color moment invariants and local binary pattern (LBP) based on Contourlet transform are explored as color and texture features, respectively. Pair-wise image dissimilarity is measured in the feature space and treated as points on an open contour in a 2-D plane. CE video is segmented based on sudden change points which are detected using a non-parametric key-point detection method. From each segment, representative frames are extracted to summarize the CE video. Validation results on simulated and real patient data show promising performance of the proposed framework. It has great potential to achieve automatic assessment for CE images. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Zhao, Qian. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2012. / Includes bibliographical references (leaves 142-175). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstract also in Chinese. / Abstract --- p.ii / Acknowledgments --- p.vii / List of Tables --- p.xiii / List of Figures --- p.xv / Chapter 1 --- The Relevance of Synopsis --- p.1 / Chapter 1.1 --- Problem Statement --- p.1 / Chapter 1.2 --- Application - Capsule Endoscopy Assessment --- p.4 / Chapter 1.3 --- Literature Review --- p.9 / Chapter 1.3.1 --- Methods Based on Frame Classification --- p.11 / Chapter 1.3.2 --- Methods Integrating Temporal Information --- p.14 / Chapter 1.4 --- Contributions --- p.19 / Chapter 1.5 --- Organization --- p.23 / Chapter 2 --- Preliminary --- p.25 / Chapter 2.1 --- Hidden Markov Model (HMM) --- p.25 / Chapter 2.2 --- Factorial HMM --- p.35 / Chapter 3 --- Temporal Integration in Capsule Endoscopy Image Analysis --- p.37 / Chapter 3.1 --- Pre-processing --- p.38 / Chapter 3.2 --- Feature Extraction --- p.43 / Chapter 3.3 --- Frame-based Supervised Classification --- p.47 / Chapter 3.3.1 --- Supervised Classification using Individual Frames --- p.47 / Chapter 3.3.2 --- Ensemble Learning Based on AdaBoost --- p.50 / Chapter 3.4 --- Sequence-based Supervised Classification --- p.52 / Chapter 3.5 --- Experiments --- p.58 / Chapter 3.5.1 --- Capsule Endoscopy Image Enhancement --- p.60 / Chapter 3.5.2 --- Frame-based Supervised Classification --- p.67 / Chapter 3.5.3 --- Image Sequence Classification --- p.68 / Chapter 3.6 --- Discussion --- p.80 / Chapter 3.7 --- Summary --- p.82 / Chapter 4 --- Capsule Endoscopy Study Synopsis --- p.98 / Chapter 4.1 --- Supervised Synopsis Using Statistical Models --- p.98 / Chapter 4.2 --- Unsupervised Synopsis via Representative Frame Extraction --- p.100 / Chapter 4.2.1 --- Feature Extraction --- p.100 / Chapter 4.2.2 --- Non-parametric Key-point Detection --- p.111 / Chapter 4.2.3 --- Representative Frame Extraction --- p.112 / Chapter 4.3 --- Experiments --- p.119 / Chapter 4.3.1 --- Supervised Synopsis Based on HMM --- p.119 / Chapter 4.3.2 --- Unsupervised Synopsis --- p.125 / Chapter 4.4 --- Discussion --- p.132 / Chapter 4.5 --- Summary --- p.133 / Chapter 5 --- Conclusions and Future Work --- p.138 / Chapter 5.1 --- Conclusions --- p.138 / Chapter 5.2 --- Future Work --- p.141 / Bibliography --- p.142

A feature extraction approach based on color is firstly proposed. Exploiting color histogram of an image, we can obtain distribution of different colors in images. Then we employ minimum distance classifier based on a new distance criterion to judge status of regions. In this section, we also validate benefits of WCE image enhancement to the proposed CAD system. / Finally, we propose a new approach of chrominance moment as another kind of feature to discriminate normal regions from abnormal regions, which makes full use of Tchebichef polynomials and HSI color space. This new feature extraction scheme preserves illumination invariance without numerical approximation. / In conclusion, this thesis investigates several major and challenging problems such as WCE images enhancement and feature extractions in CAD for WCE images, and proposes several novel schemes to solve those problems. Extensive experiments are reported to demonstrate effectiveness of the proposed algorithms. / Next, we investigate automatic diseases detection for WCE images to partially solve the second problem. In this part we explore different features that are suitable for detection of diseases from three viewpoints, i.e., color, texture and chromaticity, because clinicians mainly use these clues to diagnose. At the same time, we introduce their corresponding classifiers. / We further advance a new texture feature extraction method, curvelet based local binary pattern, to detect abnormal regions in WCE images. This method takes advantage of curvelet transform and local binary pattern to describe textural features of WCE images. / Wireless capsule endoscopy (WCE) is a state-of-the-art technology to diagnose gastrointestinal (GI) tract diseases without invasiveness. However, there exist two major problems concerning WCE images. One problem is that many images for diagnosis have rather low contrast and are noisy, which causes difficulties to diagnosis and also to computer-aided detection, so it is necessary to enhance these images. The other one is that the viewing process of video data per examination is very time consuming because of the great amount of video data. If we can use computerized methods to help the physicians detect some abnormal regions in WCE images, it will certainly reduce the burden of physicians. Focusing on these two goals, this thesis mainly studies some main challenging problems in computer-aided diagnosis (CAD) system for WCE images. To solve the first problem, we put forward an adaptive curvature strength diffusion method to enhance WCE images. Based on local characteristics analysis of WCE images, we propose a new concept of curvature strength. Then, we employ curvature strength diffusion to enhance WCE images with an adaptive choice of conductance parameter. Finally, we extend the curvature strength diffusion to color space since WCE images are color images. / Li, Baopu. / Adviser: Max Q. H. Meng. / Source: Dissertation Abstracts International, Volume: 70-06, Section: B, page: 3640. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2008. / Includes bibliographical references (leaves 126-150). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstracts in English and Chinese. / School code: 1307.

ABSTRACT ASSESSING BASELINE AND POST-DISCHARGE RISK FACTORS IN SUBJECTS WITH AND WITHOUT SLEEP APNEA UNDERGOING ENDOSCOPY WITH DEEP SEDATION Background: Outpatient procedures encompass over 60% of all surgeries in the United States, and the prevalence of obstructive sleep apnea (OSA) remains high among adult surgical ambulatory patients. Ambulatory surgery poses problems for patients with OSA because narcotics and anesthetics used during surgery can complicate the negative effects of OSA, leading to cardiac events, brain hypoxia, and even death. This study was designed to evaluate the prevalence of cardiopulmonary risk factors among post endoscopic patients with diagnosed and undiagnosed sleep apnea. Methods: The study involved a prospective, descriptive cross-sectional design and incorporated a pre-test or post-test data collection approach, using Actigraphy, pulse oximetry and 24-hour ECG monitoring via Bluetooth technology to monitor outpatients undergoing endoscopy with deep Propofol sedation. Patients were recruited pre-procedure to obtain a resting baseline ECG, and pre-procedure values were then monitored post procedure continuously for 24 hours. A p-value less than 0.05 was considered to be statistically significant. A target sample included 50 adult outpatients from a Florida suburban endoscopy center. Results: Pulse oximetry and Actigraph scores revealed no difference based on OSA. The ANOVA for oxygen desaturation events and sleep quality indices reflected no differences across groups. Sleep quality had no measurable influence on adverse events and was similar across groups; participants diagnosed with OSA slept longer than those in the untreated or no OSA group. Regressions for sleep quality indices reflected no differences among groups. Conclusions: There remains a lack of literature on cardiopulmonary and ECG indicators of cardiac risks in patients with OSA in the 24 hours following discharge from ambulatory surgery. This dissertation characterized the ECG at baseline and post-discharge among post-endoscopy outpatients with OSA and without OSA. Further research is recommended.

Vocal folds are the twin in-folding of the mucous membrane stretched horizontally across the larynx. They vibrate modulating the constant air flow initiated from the lungs. The pulsating pressure wave blowing through the glottis is thus the source for voiced speech production. Study of vocal fold dynamics during voicing are critical for the treatment of voice pathologies. Since the vocal folds move at 100 - 350 cycles per second, their visual inspection is currently done by strobosocopy which merges information from multiple cycles to present an apparent motion. High Speed Digital Laryngeal Imaging(HSDLI) with a temporal resolution of up to 10,000 frames per second has been established as better suited for assessing the vocal fold vibratory function through direct recording. But the widespread use of HSDLI is limited due to lack of consensus on the modalities like features to be examined. Development of the image processing techniques which circumvents the need for the tedious and time consuming effort of examining large volumes of recording has room for improvement. Fundamental questions like the required frame rate or resolution for the recordings is still not adequately answered. HSDLI cannot get the absolute physical measurement of the anatomical features and vocal fold displacement. This work addresses these challenges through improved signal processing. A vocal fold edge extraction technique with subpixel accuracy, suited even for hard to record pediatric population is developed first. The algorithm which is equally applicable for pediatric and adult subjects, is implemented to facilitate user inspection and intervention. Objective features describing the fold dynamics, which are extracted from the edge displacement waveform are proposed and analyzed on a diverse dataset of healthy males, females and children. The sampling and quantization noise present in the recordings are analyzed and methods to mitigate them are investigated. A customized Kalman smoothing and spline interpolation on the displacement waveform is found to improve the feature estimation stability. The relationship between frame rate, spatial resolution and vibration for efficient capturing of information is derived. Finally, to address the inability to measure physical measurement, a structured light projection calibrated with respect to the endoscope is prototyped.

Acute Upper Gastrointestinal Bleeding (AUGIB) accounts for 7000 deaths in the UK annually and is the single leading indication for transfusion of blood components. A large UK audit in 2007 reported high case fatality and rates of further bleeding. Since many deaths are determined by pre-existing co-morbidity, strategies to improve outcome should be targeted at preventable deaths and therefore focus upon improved control of haemorrhage and prevention of further bleeding, which are investigated in this thesis. Data for the analyses presented originate from the UK national audit of AUGIB, a laboratory study and a cross sectional survey. Five broad themes were investigated including service provision and timing of endoscopy, the use of transcatheter arterial embolisation (TAE) or surgery for refractory bleeding, the impact of coagulopathy on outcome, management of acute variceal haemorrhage (AVH) and haemostatic derangements after AVH, and the use of red blood cells (RBCs). Although there was no evidence of a “weekend effect” for mortality, earlier endoscopy (<12 hours) was associated with improved control of haemorrhage in higher risk patients compared to later endoscopy (>24 hours). TAE was an effective and safe modality for refractory bleeding, but the high post-surgical mortality (29%) raises questions about the appropriateness of case selection for surgery. Coagulopathy after non-variceal haemorrhage was associated with a 5-fold increase in risk-adjusted mortality. Further bleeding after AVH was strikingly high (26%) with notable deficiencies in the use of vasopressors, antibiotics and endotherapy. Global assessments of coagulation demonstrated that thrombin generation after AVH was normal, but clot strength was poor with excessive fibrinolysis. Platelets, fibrinogen and antifibrinolytics improved haemostasis ex vivo but coagulation factor transfusion had no effect. RBC transfusion practice is variable. This work on AUGIB provides new data highlighting areas of sub-optimal care, and informs both current practice and research questions for new interventional trials.

Optical transfection is a promising technique for the delivery of foreign genetic material into cells by transiently changing the permeability of the cell membrane. Of the different optical light sources that have been used, femtosecond laser based transfection has been one of the most effective methods for optical transfection which is generally implemented using a free-space bulk optical setup. Here in this thesis, a few novel fabrication methods are devised to obtain easy and inexpensive fabrication of microlensed optical fibers, which can be used to replace traditional optical setup and perform femtosecond optical transfection. These fabrication methods offer the flexibility to fabricate a microlens which can focus femtosecond laser pulses at 800 nm to a small focal spot whilst keeping a relatively large working distance. In conventional optical transfection methods the foreign genetic material to be transfected is homogenously mixed in the medium. This thesis reports the first realization of an integrated optical transfection system which can achieve transfection along with localized drug delivery by combining lensed fiber based optical transfection system with a micro-capillary based microfluidic system. Finally, based on an imaging fiber (coherent optical fiber bundle), the first endoscope-like integrated system for optical transfection with subcellular resolution epifluorescence imaging was built. The transfection efficiency of these fiber based systems is comparable to that of a standard free-space transfection system. Also the use of integrated system for localized gene delivery resulted in a reduction of the required amount of genetic material for transfection. The miniaturized, integrated design opens a range of exciting experimental possibilities, such as the dosing of tissue slices to study neuron activities, targeted drug delivery, and in particular for using endoscope-like integrated systems for targeted in vivo optical microsurgery.

This dissertation merges the optical design and computational aspects of imaging systems to create novel devices that solve engineering problems in optical science and attempts to expand the solution space available to the optical designer. This dissertation is divided into two parts: the first discusses a new active illumination depth sensing modality, while the second part discusses a passive illumination system called plenoptic, or lightfield, imaging. The new depth sensing modality introduced in part one is called depth through controlled aberration. This technique illuminates a target with a known, aberrated projected pattern and takes an image using a traditional, unmodified imaging system. Knowing how the added aberration in the projected pattern changes as a function of depth, we are able to quantitatively determine depth of a series of points from the camera. A major advantage this method permits is the ability for illumination and imaging axes to be coincident. Plenoptic cameras capture both spatial and angular data simultaneously. This dissertation present a new set of parameters that permit the design and comparison of plenoptic devices outside the traditionally published plenoptic 1.0 and plenoptic 2.0 configurations. Additionally, a series of engineering advancements are presented, including full system ray traces of raw plenoptic images, Zernike compression techniques of raw image files, and non-uniform lenslet arrays to compensate for plenoptic system aberrations. Finally, a new snapshot imaging spectrometer is proposed based off the plenoptic configuration.

Objetivos. Describir las características histológicas y endoscópicas que se presentan en pacientes diagnosticados con cáncer gástrico en el Hospital Nacional Daniel Alcides Carrión del Callao. Materiales y métodos. Se realizó un estudio tipo serie de casos que incluyó a todos los pacientes con diagnóstico histológico de cáncer gástrico durante el periodo de enero de 2009 a diciembre de 2011. La información se obtuvo de los registros del servicio de anatomía patológica del Hospital Nacional Daniel Alcides Carrión. Se consignó la edad y sexo de los pacientes, el tipo histológico, la localización endoscópica, así como la presencia de metaplasia intestinal, el grado histológico y la morfología del cáncer. Resultados. Se incluyeron 120 pacientes. La edad promedio fue de 65,4 ± 13,6 años; 59 (49%) fueron de sexo masculino. Según el tipo histológico se encontró el tipo intestinal en 68 (56%); difuso en 45 (38%), y mixto en 7 (6%). Según su localización, 23 (19%) se localizaron en fondo; 52 (43%) en el cuerpo; 39 (33%) en el antro, y 6 (5%) en el píloro. Los pacientes con cáncer gástrico de tipo intestinal presentaron una edad promedio mayor que los que tuvieron el tipo difuso (69,1 ± 10,3 versus 59,3 ± 15,3). De los pacientes con cáncer gástrico tipo intestinal, 60,3% tuvo localización proximal, en comparación a 66,6% de los pacientes con tipo difuso. Conclusión. En la población en estudio, el cáncer gástrico de tipo difuso se presenta a una edad más temprana que el de tipo intestinal, además de estar más frecuentemente localizados a nivel proximal. / Objetivos. To describe the histologic and endoscopic characteristics reported among patients diagnosed with gastric cancer in “Daniel Alcides Carrion” National Hospital in Callao. Materials and methods. We performed a case series including all patients with histological diagnosis of gastric cancer from January 2009 to December 2011. Data were obtained from the registers of the pathology service of Daniel Alcides Carrion National Hospital. Factors such as age and gender of patients, histologic type, endoscopic location, presence of intestinal metaplasia, histologic degree, and cancer morphology were evaluated. Results. 120 patients were included. Mean age was 65.4 ± 13.6 years; 59 (49%) were male. Based on the histologic type, intestinal type was found among 68 (56%); diffuse type among 45 (38%), and a mixed type in 7 (6%). Regarding the site, 23 (19%) of gastric cancers were located in the fundus; 52 (43%) in the body; 39 (33%) in the antrum, and 6 (5%) in the pylorus. Patients with gastric cancer of the intestinal type were in average older than those with a diffuse type (69.1 ± 10.3 versus 59.3 ± 15.3). 60.3% of intestinal-type gastric cancers were located proximally, versus 66.6% of diffuse-type cancers. Conclusion. Among the studied population, diffuse-type gastric cancer appears at an earlier age than the intestinal type, and its most common location is proximal.

INTRODUÇÂO: O termo lesão subepitelial se refere a qualquer protrusão ao lúmen do trato gastrointestinal recoberta por mucosa de aspecto normal. A realização de biópsias endoscópicas apresenta rendimento diagnóstico limitado. A ecoendoscopia é considerada o teste diagnóstico de escolha para avaliar diversas características da lesão subepitelial. OBJETIVO: Em relação às lesões subepiteliais gástricas, avaliar dados clínicos, topográficos e ecoendoscópicos como fatores preditores do diagnóstico histopatológico. MÉTODOS: selecionados 55 pacientes adultos atendidos no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, no período de outubro de 2003 a agosto de 2011 com diagnóstico de lesão subepitelial gástrica à endoscopia digestiva alta, submetidos à ecoendoscopia, com diagnóstico histopatológico, utilizando-se como procedimentos de investigação a ecoendoscopia e a análise histológica/imuno-histoquímica do material obtido por punção ecoguiada e/ou ressecção/biópsia endoscópica/cirúrgica. As seguintes variáveis foram incluídas para análise, relacionando-as ao diagnóstico histopatológico: tamanho; camada ecoendoscópica; aspecto ecográfico; limites; detecção de fluxo ao Doppler e distribuição topográfica gástrica. RESULTADO: Utilizando modelo logístico para variáveis associadas aos diagnósticos (p <,05), observamos que no caso do tumor gastrointestinal estromal (GIST) a probabilidade da lesão localizar-se na cárdia é baixa (4,5%); há maior risco de GIST em pacientes acima de 57 anos (RC=8,9, IC95%7.6,10.2), lesão >= 21mm (RC=7,15, IC95%5.88, 8.43), com fluxo ao Doppler (RC =9, IC95%6.6, 11.4), limite irregular (RC= 7,75, IC95%6, 9.4) e inserida na 4ª. camada parietal (RC=18,8 IC95% 16.7, 20.94); o leiomioma apresentou alta probabilidade (95%) para cárdia com RC = 390 (IC95% 387, 394); o modelo de regressão múltipla indicou as variáveis dimensão, distribuição topográfica gástrica e camada parietal como significativas para GIST, e distribuição topográfica gástrica (cárdia) para leiomioma. CONCLUSÃO: Existe associação entre a localização da lesão subepitelial gástrica na topografia da cárdia e os diagnósticos de Leiomioma e GIST, com comportamento inverso, sendo o leiomioma o diagnóstico mais provável nesta situação.O modelo logístico de regressão múltipla indica que as variáveis significativas para afastar o diagnóstico de GIST são localização na cárdia, fora da 4a. camada parietal ecoendoscópica e diâmetro da lesão de até 20mm / BACKGROUND: The term subepithelial mass (SEM) refers to any protrusion of the lumen of the gastrointestinal tract covered by a normal appearance mucosa. The performance of endoscopic biopsies has limited diagnostic yield. Endoscopic ultrasonography (EUS) is considered the diagnostic test of choice to assess various characteristics of SEM. AIM: to investigate the association between patients\' clinical characteristics, EUS features and gastric topography with the histopathological diagnosis of gastric SEM, using as diagnostic gold standard the histological and immunohistochemical analysis of the material obtained by fine-needle aspiration and/or surgical resection. METHODS: fifty-five patients selected at the Clinics Hospital - University of São Paulo, from October 2003 to August 2011 with a endoscopic diagnosis of gastric SEM, who underwent EUS, with histopathologic confirmed diagnosis. The following variables were included for analysis: size, echoendoscopic layer, sonographic appearance, echogenicity, irregular outer limits, Doppler flow signal and topographic distribution. RESULTS: Applying logistic regression for variables associated with the diagnoses (P < .05), we found that in the case of gastrointestinal stromal tumor (GIST) the probability of the lesion to be located in the cardia is low (4.5%); there is greater risk of GIST in patients older than 57 years (OR = 8.9, 95% CI 7.6,10.2), with lesion >= 21mm (OR = 7.15, 95% CI 5.88, 8:43), positive Doppler (OR = 9, 95% CI 6.6, 11.4), irregular outer limits (OR = 7.75, 95% CI 6, 9.4) and located at 4th. parietal layer (OR = 18.8 95% CI16.7, 20.94); if leiomyoma, the likelihood of this lesion in the cardia was high (greater than 95%) with odds ratio of 390; multiple regression model indicated the size, topographic distribution and gastric parietal layer as significant for GIST, and gastric topographic distribution (cardia) for leiomyoma. CONCLUSION: There is an association between the location of gastric subepithelial lesion in the topography of cardia and diagnostics of leiomyoma and GIST, with opposite behavior, being leiomyoma the most likely diagnosis. Multiple regression analysis indicates cardia location, lesion outside 4th. parietal layer and diameter of up to 20mm as significant variables to exclude GIST diagnosis

Contexto: A hemorragia digestiva alta (HDA) resulta em 200 a 300 mil internações por ano nos Estados Unidos, com uma mortalidade de 2,5% a 10%. A úlcera péptica representa a causa mais comum de HDA, correspondendo por um terço a metade de todos os casos. Apesar das melhorias na compreensão de sua etiologia, a incidência de sangramento da úlcera péptica, sua complicação mais comum, não se alterou nas últimas décadas. A terapia endoscópica para HDA pode reduzir drasticamente o risco de ressangramento ou sangramento contínuo, a necessidade de cirurgia de urgência, o número de unidades de concentrado de hemácias para transfusão, o tempo de internação hospitalar e a mortalidade. O tratamento endoscópico da úlcera hemorrágica já percorreu um longo caminho desde injeções de adrenalina e outras soluções, o uso da termocoagulação, até a aplicação de dispositivos mecânicos, como o clipe metálico e a ligadura elástica. Objetivo: Permanece por esclarecer qual é a modalidade endoscópica (ou combinação de modalidades) que apresenta os melhores resultados no tratamento da hemorragia digestiva decorrente da úlcera péptica. Portanto, o objetivo desta revisão sistemática é comparar as diferentes modalidades de tratamento endoscópico da HDA decorrente da úlcera péptica, utilizando ensaios clínicos randomizados. Fontes de dados: Os estudos foram identificados através de pesquisa em bases de dados eletrônicas e listas de referência de artigos. As bases de dados pesquisadas foram Medline, Embase, Cochrane, LILACS, Dare e CINAHL. Critérios de elegibilidade de estudo, participantes e intervenções: Os estudos selecionados foram os ensaios clínicos randomizados comparando as diferentes modalidades endoscópicas para o tratamento de pacientes com hemorragia digestiva alta causada por úlcera péptica. Os estudos incluídos avaliaram técnicas endoscópicas contemporâneas de hemostasia: terapia de injeção endoscópica (todas as soluções, simples ou múltiplas), termocoagulação (heater probe, coagulação com plasma de argônio, coagulação com micro-ondas, eletrocoagulação monopolar, bipolar e multipolar), aplicação de clipes metálicos e tratamento combinado. Os desfechos avaliados foram as taxas de hemostasia inicial, ressangramento, cirurgia de urgência e de mortalidade. Avaliação de vieses: Ao nível de cada estudo, os revisores determinaram a adequação da randomização e da alocação; cegamento de pacientes, profissionais de saúde, coletores de dados e avaliadores de resultados; bem como o relato e a extensão das perdas de seguimento. Também foi avaliado se as técnicas de hemostasia endoscópica foram devidamente descritas e, se os desfechos foram adequadamente definidos em cada estudo. A análise de sensibilidade foi realizada quando a heterogeneidade (I2) foi superior a 50% e uma nova meta-análise foi calculada excluindo o(s) estudo(s) discrepante(s). Uma análise adicional foi realizada em cada comparação, incluindo apenas os ensaios de qualidade metodológica mais elevada. Resultados principais: Um total de 28 ensaios clínicos randomizados (envolvendo 2988 pacientes) foram avaliados nesta revisão, eles foram divididos em sete grupos de comparação de acordo com as modalidades estudadas em cada estudo. A terapia de injeção endoscópica como modalidade única foi inferior à sua combinação com o clipe metálico e com a termocoagulação na avaliação de taxa de ressangramento (diferença dos riscos [DR] = -0,10, intervalo de confiança de 95% [IC95%] = -0,18 a -0,03 e [DR] = -0,08, [IC95%] = -0,14 a -0,02, respectivamente) e na necessidade de cirurgia de urgência ([DR] = -0,11, [IC95%] = -0,18 a -0,04 e [DR] = -0,06, [IC95%] = -0,12 para -0,00, respectivamente). A aplicação de clipes metálicos foi superior à terapia de injeção endoscópica na avaliação da taxa de ressangramento ([DR] = -0,13, [IC95%] = -0,19 para -0,08), e os resultados da comparação entre a aplicação de clipes metálicos como monoterapia e a sua combinação com a terapia de injeção endoscópica não apresentaram diferenças estatísticas. A comparação entre o clipe metálico e a termocoagulação encontrou uma considerável heterogeneidade entre as intervenções utilizadas em cada estudo e nos resultados encontrados das meta-análises. A comparação da termocoagulação com a terapia de injeção endoscópica não evidenciou qualquer diferença estatística entre as modalidades, e a combinação delas é superior à técnica de termocoagulação sozinha ao avaliar a taxa de ressangramento ([DR] = -0,11, [IC95%] = -0,21 para - 0,02). Conclusões: A terapia de injeção endoscópica não deve ser empregada isoladamente. A aplicação de clipes metálicos é superior à terapia de injeção endoscópica, e a associação da injeção endoscópica não melhora a eficácia hemostática do uso isolado do clipe metálico. Como modalidade única, uma técnica de termocoagulação tem uma eficácia hemostática semelhante à terapia de injeção endoscópica, e estas modalidades combinadas parecem ser superiores à técnica de termocoagulação sozinha. Portanto, recomendamos a aplicação de clipes metálicos ou o uso combinado de uma terapia de injeção endoscópica com um método de termocoagulação para o tratamento de pacientes com hemorragia digestiva alta por úlcera péptica / Background: Upper Gastrointestinal bleeding (UGIB) results in 200,00 to 300,000 hospital admissions annually in the United States, with a mortality of 2,5% to 10%. Peptic ulcer disease represents the most common cause of UGIB, accounting for a third to a half of all episodes. Despite improvements in the understanding of its etiology, the incidence of bleeding from peptic ulcer disease, the most common complication, has not changed. Endoscopic therapy for active UGIB can dramatically reduce the risk of rebleeding or continued bleeding, the need for surgery, the number of units of packed erythrocytes required for transfusion, the length of hospital stay and mortality. Endoscopic treatment for ulcer bleeding has come a long way from injections of epinephrine and other solutions, the use of thermocoagulation, to the application of mechanical devices such as hemoclips and banding ligator. Objective: It remains unclear which is the endoscopic modality (or combination of modalities) that presents the best results in the treatment of peptic ulcer bleeding. Therefore, the objective of this systematic review is to compare the different modalities of endoscopic hemostatic therapy, using randomized clinical trials. Data sources: Studies were identified by searching electronic databases and scanning reference lists of articles. The searched databases were Medline, Embase, Cochrane, LILACS, DARE and CINAHL. Study eligibility criteria, participants and interventions: The studies selected were the randomized clinical trials comparing different endoscopic modalities for the treatment of patients presenting with acute upper gastrointestinal bleeding caused by peptic ulcer disease. The included trials assessed contemporary endoscopic hemostatic techniques: endoscopic injection therapy (all injectates, single or multiple), thermal coagulation (heater probe, argon plasma and microwave coagulation, monopolar, bipolar and multipolar electrocoagulations), hemoclip placement and combination treatment. The outcomes measured were the rates of initial hemostasis, rebleeding, emergency surgery and overall mortality. Risk of bias assessment: At the study level, the reviewers determined the adequacy of randomization and concealment of allocation; blinding of patients, of health care providers, of data collectors, and of outcome assessors; and the correct report and extent of loss to follow-up. It was also evaluated whether the endoscopic hemostatic techniques were properly described and if the outcomes were appropriately defined in each study. A sensitivity analysis was held when the heterogeneity (I2) was over 50% and a new meta-analysis was calculated excluding the outlier(s). An additional analysis was made at each comparison, including only the higher methodological quality trials. Main results: A total of 28 trials, involving 2988 patients were evaluated in this review, they were divided into seven comparison groups according to the modalities studied in each trial. Injection Therapy as single modality was inferior to its combination with Hemoclip and with Thermal Coagulation Therapy when evaluating rebleeding rate (risk difference [RD] = -0.10, 95% confidence interval [95%CI] = -0.18 to -0.03 and [RD] = -0.08, [95%CI] = -0.14 to -0.02, respectively) and need for emergency surgery ([RD] = -0.11, [95%CI] = -0.18 to -0.04 and [RD] = -0.06, [95%CI] = -0.12 to -0.00, respectively). Hemoclip was superior to Injection Therapy in the evaluation of rebleeding rate ([RD] = -0.13, [95%CI] = -0.19 to -0.08), and the results of the comparison between Hemoclip alone versus its combination with Injection Therapy did not present any statistical differences. The comparison between Hemoclip and Thermal Coagulation encountered a considerable heterogeneity between the trials in the interventions used and in the results found. The comparison of Thermal Coagulation versus Injection Therapy did not evidence any statistical difference between the modalities, and the combination of these is superior to the Thermal Coagulation alone when evaluating rebleeding rate ([RD] = -0.11, [95%CI] = -0.21 to -0.02. Conclusions: Injection therapy should not be used as single modality. The application of Hemoclip is superior to injection therapy, and the combined application of an injectate does not improve the hemostatic efficacy of the use of Hemoclip alone. As single modality, a thermal coagulation technique has a similar hemostatic efficacy as injection therapy, and these combined modalities appear to be superior to thermal coagulation technique alone. Therefore, we recommend the application of Hemoclips or the combined use of an Injection Therapy with a Thermal Coagulation method for the treatment of patients presenting with acute peptic ulcer bleeding