Ana Lagos

Oral intake throughout the patients' lives after palliative metallic stent placement for malignant gastroduodenal obstruction: a retrospective multicentre study.

Objectives Patients with inoperable malignant gastric outlet obstruction (GOO) have been managed with self-expandable metal stents to improve oral intake. Recent studies have shown conflicting results on the capacity of self-expandable metal stents to restore food intake in the long term. This study evaluated the clinical effectiveness of enteral stent placement for GOO throughout the patients’ lives. Methods This was a multicentre, retrospective study with a long-term follow-up of 74 patients who underwent enteral stenting for symptomatic GOO. Data were collected to analyse improvements in oral intake for the patients’ entire lives as assessed by the GOO scoring system (GOOSS), technical success, stent patency, complications, the need for reintervention, survival and the prognostic factors associated with stent patency. Results Technical and clinical success was achieved in 100 and 97.2% of the patients, respectively. A total of 71/74 patients (95.9%) continued oral intake for the rest of their lives and 58/74 patients (78.4%) needed no further intervention until death. Solid food intake (GOOSS 2–3) continued until death in 47/74 patients (63.5%). The GOOSS score improved (P<0.001) during the follow-up compared with the baseline. The median survival and the mean stent patency were 8 and 76.6 weeks, respectively. The complication rate was 18.9%. Malignant stent reobstruction was observed in 7/74 patients (9.5%). A Cox multivariate analysis showed that duodenal location of the obstruction was the only independent factor associated with stent patency (hazard ratio=5.28; 95% confidence interval=1.14–24.45; P=0.033). Conclusion Enteral stenting in patients with unresectable GOO is safe and clinically effective. Ninety-five per cent of patients are able to resume oral intake for the rest of their lives, and the great majority remain free from further intervention. In approximately two-thirds of patients, solid food intake continues until death.

Reversible Henoch–Schönlein purpura complicating adalimumab therapy

The tumour necrosis factor antagonists have demonstrated efficacy in the induction of remission and its maintenance in numerous chronic inflammatory conditions. These agents are generally well tolerated but with the increasing number of patients receiving anti-tumour necrosis factor-α (anti-TNFα) therapy, more adverse reactions are expected to occur. Cutaneous eruptions complicating treatment with anti-TNFα agents are common, occurring in around 20% of patients. Most reactions are mild-to-moderate and rarely warrant treatment withdrawal. We herein present a case of Henoch-Shönlein purpura (HSP) vasculitis following treatment with the monoclonal anti-TNFα antibody adalimumab for ileo-colic Crohns disease. The reaction occurred after 18 months of adalimumab therapy and discontinuation of the anti-TNFα resulted in rapid improvement of the condition. The causal relationship has become even more likely when the purpura reappeared after restarting adalimumab. The patient started infliximab, with disease control and no cutaneous side effects. To the best of our knowledge, this is the second case report of HSP complicating adalimumab therapy. Although adalimumab is theoretically less related to immune-mediated reactions, clinicians must be aware that adverse side effects may still occur. This is the first case that shows that infliximab can be safely used in patients with adalimumab related HSP. We discuss the literature and potential causal mechanisms and propose possible approaches to its management.

Sustained relief of obstructive symptoms for the remaining life of patients following placement of an expandable metal stent for malignant colorectal obstruction

BACKGROUND self-expanding metal stents are currently being used as a definitive palliative treatment for malignant colorectal obstruction in patients with incurable disease. Few studies have followed large numbers of patients from stent placement until death, and those few have reported conflicting results in the long-term clinical outcome data. AIMS this study evaluated the clinical effectiveness of stent placement for malignant colorectal obstruction throughout the patients lives and related factors affecting stent patency, clinical success and complications. METHODS this was a multicentre, retrospective study of 89 consecutive patients who had undergone attempted expandable stent placement for symptomatic malignant colorectal obstruction during a 10-year period. Data were collected to analyse the sustained relief of obstructive symptoms throughout the patients lives, as well as the technical success, immediate clinical success, stent patency, complications, reinterventions, survival, prognostic factors associated with stent patency and long-term clinical efficacy and risk factors for complications. RESULTS technical and immediate clinical success were achieved in 95.5% and 91.0% of patients, respectively. A total of 68 out of 89 patients (76.4%) maintained relief of obstruction from stent implantation until death without reintervention. Twenty patients (22.5%) had complications including perforation (n = 4; 4.5%), stent obstruction (n = 8; 9.0%), migration (n = 5; 5.6%) and haemorrhage (n = 3; 3.4%). Stent-related mortality was seen in 1 patient (1.1%). The estimated median survival and estimated mean stent patency were 87.0 and 322.7 days, respectively. In total, 12 of the initial 89 patients (13.5%) needed a colostomy for long-term relief of the obstructive symptoms. Univariate and multivariate analysis detected no significant prognostic factors associated with stent patency, long term clinical efficacy and risk factors for complications; however, the multivariate logistic model revealed a non-significant trend by which the use of chemotherapy was a risk factor for migration (OR = 11.89; p = 0.06). CONCLUSIONS for palliation of incurable malignant colorectal obstruction, expandable stents can provide sustained relief of obstruction in approximately 75% of patients. The procedure is associated with acceptable morbidity, need for reintervention and minimal mortality.

Gastric plasmablastic lymphoma in HIV-negative patient

An 82-year-old female patient presented with melena, epigastric pain, progressive abdomen fullness and weight loss (8 kg) in the past 2 months. During physical examination, cutaneous pallor was evident and a large abdominal mass in epigastrium was palpable. There was no peripheric lymphadenopathy or hepatosplenomegaly. Blood count showed microcytic anemia and ferropenia (Hb = 7.5 g/dl, VGM = 79 fL; ferritin = 21 g/l, iron saturation = 23 %). Differential leukocyte counts, hepatic transaminase and lactate dehydrogenate levels were within normal limits. Upper gastrointestinal endoscopy revealed large gastric body ulceration with areas of mucosal hyperemia and pallor (Fig. 1). Computed tomography of the abdomen (Fig. 2) showed diffuse wall thickening involving the gastric fundus, body and antrum. Histological examination of the biopsy specimens revealed a diffuse, monomorphous proliferation of the tumour cells with features of immunoblasts, CD138, MUM-1, and kappa light chains positive (Fig. 3). These plasmablast-like features of tumour cells and lack of CD45 and B-cell associated antigens, disclosed the diagnosis of plasmablastic lymphoma (PBL). Serology was negative for the human immunodeficiency virus (HIV), the electrophoretic pattern of serum proteins was normal and the bone marrow biopsy was free of lymphoma at histological evaluation. The patient started treatment with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy, but died before the second cycle was given.

Rectal intramural hematoma: a rare complication of endoscopic tattooing.

I P e A 59-year-old man had a sessile polyp in the rectum (A) removed by colonoscopic polypectomy. Histologic examination revealed it to be a villous adenoma with carcinoma. Three weeks later, the polypectomy scar was tattooed with a commercially available, ready-to-use sterile suspension containing purified carbon particles (Spot; GI Supply, El Paso, Tex). The needle was inserted at an oblique angle, and approximately 4 mL was injected in small aliquots (0.5 mL). Three days later, the patient was admitted for perianal tenderness and abdominal distension. He had almost a complete absence of bowel movements for 2 days and was unable to produce stool. He was afebrile. The abdomen was slightly tender in the lower quadrants, but there were no peritoneal signs. External examination of the perineum was unremarkable, but digital rectal examination was painful. No hemorrhoids, fistulae, abscesses, or fissures were found. Laboratory test results revealed anemia (hemoglobin 7.9 g/dL); the platelet count was 340 10/L and the white blood cell

Malignant Rectal Gastrointestinal Stromal Tumour: Case Report and Review of Literature

Gastrointestinal stromal tumour (GIST) is an uncommon mesenchymal tumour located throughout the gastrointestinal tract. GISTs are commonly found in the stomach (60–70 %), followed by the small intestine (20–25 %); only 5 % of all GISTs originate in the rectum [1]. GISTs typically express CD117, a c-kit proto-oncogene, which can be detected immunohistochemically. In this report, the authors describe a rare case of GIST of the rectum.