Américo Silva

Primary malignant melanoma of the esophagus: A case report

The authors present the clinical case of an 87-year-old Caucasian male admitted to the emergency room with hematemesis. He had a history of intermittent dysphagia during the previous month. Endoscopic evaluation revealed an eccentric, soft esophageal lesion located 25-35 cm from the incisors, which appeared as a protrusion of the esophagus wall, with active bleeding. Biopsies were acquired. Tissue evaluation was compatible with a melanoma. After excluding other sites of primary neoplasm, the definitive diagnosis of Primary Malignant Melanoma of the Esophagus (PMME) was made. The patient developed a hospital-acquired respiratory infection and died before tumor-directed treatment could begin. Primary malignant melanoma represents only 0.1% to 0.2% of all esophageal malignant tumors. Risk factors for PMME are not defined. A higher incidence of PMME has been described in Japan. Dysphagia, predominantly for solids, is the most frequent symptom at presentation. Retrosternal or epigastric discomfort or pain, melena or hematemesis have also been described. The characteristic endoscopic finding of PMME is as a polypoid lesion, with variable size, usually pigmented. The neoplasm occurs in the lower two-thirds of the esophagus in 86% of cases. PMME metastasizes via hematogenic and lymphatic pathways. At diagnosis, 50% of the patients present with distant metastases to the liver, the mediastinum, the lungs and the brain. When possible, surgery (curative or palliative), is the preferential method of treatment. There are some reports in the literature where chemotherapy, chemohormonotherapy, radiotherapy and immunotherapy, with or without surgery, were used with variable efficacy. The prognosis is poor; the mean survival after surgery is less than 15 mo.

Modeling Nematic Liquid Crystals: Analytical Solution for the Balance of Torques Equation With Moment of Inertia and Surface Viscosity

We investigate the director relaxation of a nematic liquid crystal cell by considering the molecular moment of inertia, surface viscosity and anchoring energies at the boundaries. The problem solved here corresponds to a more complete description of the nematic director reorientation, since it incorporates ingredients that are usually neglected due to the mathematical difficulty raised by the moment of inertia and surface viscosity. In order to face this problem, we apply the half space approximation for the sample with the surfaces characterized by a time dependent easy direction, which can be mechanically or optically induced in the system. The results show that both, the molecular moment of inertia and the surface viscosity, have influence on the relaxation process of the director. In particular, the presence of the molecular moment of inertia introduces a finite phase velocity and, consequently, leads to a non-instantaneous response time for the distortion propagation in a liquid crystal cell.

Treatment of Postoperative Leaks of the Upper Gastrointestinal Tract with Colonic Self-Expandable Metal Stents

Introduction: The use of self-expandable metal stents (SEMS) for the treatment of postoperative leaks of the upper gastrointestinal tract is already established. However, there are discrepancies between the relatively small caliber of the esophageal stents available and the postsurgical luminal size, which may determine an inadequate juxtaposition. As colonic stents have a bigger diameter, they might be more adequate. Additionally, stents with a larger diameter might have a lower risk of migration. Materials and Methods: The aim of this study was to evaluate the efficacy and complications associated with the use of colonic fully covered SEMS (FSEMS) in the treatment of postoperative leaks in critical patients. All patients with postoperative leaks of the upper gastrointestinal tract treated with colonic stents (Hanarostent® CCI) between 2010 and 2013 were retrospectively included. Results: Four patients with postoperative leaks were treated with colonic SEMS. The underlying surgeries were a gastric bypass, an esophagogastrectomy for Boerhaave syndrome, a primary repair of esophagopleural fistula due to Boerhaave syndrome, and an esophagectomy due to esophageal cancer. The leaks were detected on average 17 days after the initial surgery. All patients needed admission to a critical care unit after index surgery. Stent placement was technically feasible in all patients. The median residence time of the stents was 7 weeks, and no complications were verified when they were removed. There were no cases of stent migration. The treatment was successful in all patients, with complete healing of the leaks. Discussion and Conclusions: The placement of colonic FSEMS seems to be successful and safe in the treatment of postoperative leaks of the upper gastrointestinal tract.

Unusual Colon Polyps

Question: A 71-year-old man was referred to our department for evaluation of microcytic anemia, with low iron blood and low iron deposits. He denied any rectal bleeding, urgency, or tenesmus. He had a history of rheumatoid arthritis and pulmonary embolism. Analysis shows anemia (hemoglobin, 11.5 g/dL) and positive fecal occult blood test. A total colonoscopy was performed. Multiple rectal polyps were detected ( 10) within 5 and 10 cm of the anal margin; some sessile and congestive, about 5–7 mm in diameter, and 3 multilobulated, about 20 mm in diameter. All were coated with a whitish exudate on the cephalic portion (Figure A–D). Some were removed for histologic evaluation; the others were removed during a second endoscopy. No other changes were seen from the proximal rectum to the cecum. What is the most likely diagnosis? See the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Conflicts of interest: The authors disclose no conflicts.

Refractory Chronic Pouchitis and Autoimmune Hemolytic Anemia Successfully Treated with Vedolizumab

Pouchitis is the most common adverse event among patients with ulcerative colitis (UC) who underwent restorative proctocolectomy with ileal pouch-anal anastomosis. Although initial acute episodes typically respond to antibiotics, patients may become antibiotic dependent or develop refractory disease [1]. Immunosuppressants, anti-TNFs, topical therapy, and surgery are therapeutic options when refractoriness is established but final decision is still based on a case-by-case basis [2]. Recently, few case reports of successful use of Vedolizumab and Ustekinumab in refractory pouchitis have been published [3, 4]. Autoimmune hemolytic anemia (AIHA) is a rare extraintestinal manifestation of UC, usually responding to proctocolectomy [5], with no previous reports of AIHA starting after surgery. We report the singular case of a patient with chronic pouchitis (CP) and AIHA, refractory to antibiotics, steroids, and anti-TNF therapy, who achieved endoscopic remission and subsequent anemia resolution after starting Vedolizumab. A 20-year-old woman was diagnosed with extensive severe acute UC at the age of 16. She underwent an ileal pouch-anal anastomosis due to refractoriness to steroids and Infliximab. One year later, a relapsing CP was diagnosed based on disabling symptoms, elevated inflammatory markers, pouchoscopy, and histologic findings. Initially she was treated with antibiotics (ciprofloxacin plus metronidazole) and oral budesonide with partial clinical response. Complementary study excluded infectious pouchitis, Crohn’s disease, vasculitis, ischemia, and autoimmune pouchitis. Simultaneously she was diagnosed with a severe symptomatic AIHA with the lowest hemoglobin level of 5 g/dL, which required therapy with high doses of steroids. AIHA diagnosis was established according to the increased total bilirubin levels (3 times the upper limit of normal) with predominance of unconjugated bilirubin, increased lactate dehydrogenase (2.5 times higher than the normal range), consumption of haptoglobin (< 10 mg/dL), increased reticulocyte count, positive Coombs test (direct and indirect), and increased erythroblasts count with normal myeloid-erythroid ratio

Midgut Volvulus after Percutaneous Endoscopic Gastrostomy

We report a 47-year-old man who underwent endoscopic gastrostomy placement due to feeding refusal and regurgitation. Procedure was unremarkable. Two days later, the patient presented signs of intestinal obstruction. Computed tomography imaging showed a well-positioned gastrostomy tube, small pneumoperitoneum, and small bowel volvulus (SBV) in the upper right abdomen with proximal small bowel dilated loops. Exploratory laparotomy revealed mesenteric torsion, leading to SBV, with no evidence of intestinal malrotation. Volvulus was successfully untwisted via surgery. This case highlights to the possible association between SBV and gastrostomy placement.