Artur Antunes

Impact of Early Surgery and Immunosuppression on Crohnʼs Disease Disabling Outcomes

Background and Aims: The definition of early therapeutic strategies to control Crohns disease aggressiveness and prevent recurrence is key to improve clinical practice. This study explores the impact of early surgery and immunosuppression onset in the occurrence of disabling outcomes. Methods: This was a multicentric and retrospective study with 754 patients with Crohns disease, who were stratified according to the need for an early surgery (group S) or not (group I) and further divided according to the time elapsed from the beginning of the follow-up to the start of immunosuppression therapy. Results: The rate of disabling events was similar in both groups (S: 77% versus I: 76%, P = 0.700). The percentage of patients who needed surgery after or during immunosuppression therapy was higher among group S, both for first surgeries after the index event (38% of groups S versus 21% of group I, P < 0.001) and for reoperations (38% of groups S versus 12% of group I, P < 0.001). The time elapsed to reoperation was shorter in group I (HR = 2.340 [1.367–4.005]), stratified for the onset of immunosuppression. Moreover, reoperation was far more common among patients who had a late start of immunosuppression (S36: 50% versus S0–6: 27% and S6–36: 25%, P < 0.001) and (I36: 16% versus I0–6: 5% and I6–36: 7%, P < 0.001). Conclusions: Although neither early surgery nor immunosuppression seem to be able to prevent global disabling disease, an early start of immunosuppression by itself is associated with fewer surgeries and should be considered in daily practice as a preventive strategy.

Risk factors for severity and recurrence of colonic diverticular bleeding

BACKGROUND Colonic diverticular bleeding is the most common cause of lower gastrointestinal bleeding. Risk factors related to severity and repeated bleeding episodes are not completely clearly defined. OBJECTIVE To characterize a Portuguese population hospitalized due to colonic diverticular bleeding and to identify the clinical predictors related to bleeding severity and rebleeding. METHODS Retrospective analysis of all hospitalized patients diagnosed with colonic diverticular bleeding from January 2008 to December 2013 at our institution. The main outcomes evaluated were bleeding severity, defined as any transfusion support requirements and/or signs of hemodynamic shock, and 1-year recurrence rate. RESULTS Seventy-four patients were included, with a mean age of 75.7 ± 9.5 years; the majority were male (62.2%). Thirty-six patients (48.6%) met the criteria for severe bleeding; four independent risk factors for severe diverticular bleeding were identified: low hemoglobin level at admission (≤ 11 g/dL; OR 18.8), older age (≥ 75 years; OR 4.7), bilateral diverticular location (OR 14.2) and chronic kidney disease (OR 5.6). The 1-year recurrence rate was 12.9%. We did not identify any independent risk factor for bleeding recurrence in this population. CONCLUSION In this series, nearly half of the patients hospitalized with diverticular bleeding presented with severe bleeding. Patients with low hemoglobin levels, older age, bilateral diverticular location and chronic kidney disease had a significantly increased risk for severe diverticular bleeding. In addition, a small number of patients rebled within the first year after the index episode, although we could not identify independent risk factors associated with the recurrence of diverticular bleeding.

Olmesartan-Induced Enteropathy: An Unusual Cause of Villous Atrophy

We report a case of a 63-year-old-man presenting with chronic diarrhea and weight loss while on olmesartan treatment for hypertension. Investigation showed multiple nutritional deficiencies associated with diffuse intestinal villous atrophy. Serologies for celiac disease were negative and other causes of villous atrophy were excluded. Olmesartan as a precipitant agent was suspected and withdrawn. Clinical improvement occurred in days with no need for other therapeutic measures. Follow-up at three months showed clinical remission and almost complete recovery of intestinal atrophy. Olmesartan is an angiotensin receptor blocker commonly prescribed for the management of hypertension. Spruelike enteropathy associated with this drug is a recently described entity with few cases reported. It presents with chronic diarrhea and intestinal villous atrophy and should be included in its differential diagnosis. This case intends to alert clinicians for the possibility of this event in a patient on treatment with this drug.

Comparison of the prognostic value of Chronic Liver Failure Consortium scores and traditional models for predicting mortality in patients with cirrhosis

BACKGROUND AND AIM Recently, the European Association for the Study of the Liver - Chronic Liver Failure (CLIF) Consortium defined two new prognostic scores, according to the presence or absence of acute-on-chronic liver failure (ACLF): the CLIF Consortium ACLF score (CLIF-C ACLFs) and the CLIF-C Acute Decompensation score (CLIF-C ADs). We sought to compare their accuracy in predicting 30- and 90-day mortality with some of the existing models: Child-Turcotte-Pugh (CTP), Model for End-Stage Liver Disease (MELD), MELD-Na, integrated MELD (iMELD), MELD to serum sodium ratio index (MESO), Refit MELD and Refit MELD-Na. METHODS Retrospective cohort study that evaluated all admissions due to decompensated cirrhosis in 2 centers between 2011 and 2014. At admission each score was assessed, and the discrimination ability was compared by measuring the area under the ROC curve (AUROC). RESULTS A total of 779 hospitalizations were evaluated. Two hundred and twenty-two patients met criteria for ACLF (25.9%). The 30- and 90-day mortality were respectively 17.7 and 37.3%. CLIF-C ACLFs presented an AUROC for predicting 30- and 90-day mortality of 0.684 (95% CI: 0.599-0.770) and 0.666 (95% CI: 0.588-0.744) respectively. No statistically significant differences were found when compared to traditional models. For patients without ACLF, CLIF-C ADs had an AUROC for predicting 30- and 90-day mortality of 0.689 (95% CI: 0.614-0.763) and 0.672 (95% CI: 0.624-0.720) respectively. When compared to other scores, it was only statistically superior to MELD for predicting 30-day mortality (p=0.0296). CONCLUSIONS The new CLIF-C scores were not statistically superior to the traditional models, with the exception of CLIF-C ADs for predicting 30-day mortality.

Blue Rubber Bleb Nevus Syndrome: A Delayed Diagnosis

( Fig. 1 ). The lesions were present since childhood and although they grew in size, they only troubled the patient in rare episodes of self-limiting bleeding secondary to trauma. Laboratory tests were normal. She underwent a colonoscopy and an upper endoscopy and we noticed multiple purplish lesions of similar characteristics in the rectum ( Fig. 2 ), hypopharynx, and esophagus ( Fig. 3 ), without stigmata of recent hemorrhage, but not in the colon, stomach, or duodenum. The characteristics of these lesions were consistent with hemangiomas. Smallbowel video capsule endoscopy also revealed multiple hemangiomas in the jejunum and distal ileum. We assumed the diagnosis of a multifocal venous vascular malformation, with cutaneous and gastrointestinal involvement. A computed tomography of the brain, chest, abdomen, and pelvis was performed, showing no other vascular malformations or bone deformities with the exception of those in the cervical spine consistent with rheumatoid arthritis. Given the clinical and imagiological features, we established the diagnosis of a sporadic type of blue rubber bleb nevus syndrome (BRBNS). BRBNS is a rare syndrome and should be considered in the presence of multifocal

Pain and Swelling after Percutaneous Endoscopic Gastrostomy Removal: An Unexpected Evolution

Gastrostomy site metastization is considered an uncommon complication of percutaneous endoscopic gastrostomy (PEG) placement in patients with head and neck tumours, but it is important to consider this possibility when evaluating gastrostomy-related symptoms. The authors present the case of a 40-year-old male with excessive alcohol consumption and active smoking, diagnosed with a stage IV oropharyngeal squamous cell carcinoma. The patient developed a paraneoplastic demyelinating motor polyneuropathy that, associated with tumour mass effect, caused dysphagia with need for nasogastric tube feeding. Treatment with radiotherapy and then chemoradiotherapy was administered and a PEG was placed with the pull method. Cancer remission and resolution of polyneuropathy was achieved, so PEG was removed. Two weeks later, the patient presented with pain and swelling at the gastrostomy site suggesting a local abscess, with improvement after drainage and antibiotic therapy. After 1 month, there was a tumour mass at the gastrostomy site and an oropharyngeal cancer metastasis was diagnosed. The patient underwent surgical excision of abdominal wall metastasis and abdominal disease was controlled. Nevertheless, there was subsequent oropharyngeal neoplasia recurrence and the patient died 6 months later. This case raises the discussion about gastrostomy placement methods that could avoid gastrostomy site metastization, the possible differential diagnosis, and diagnostic workout. Surgical resection may allow metastatic disease control, but by primary disease evolution greatly affects prognosis.

Hematidrosis, Hemolacria, and Gastrointestinal Bleeding

blood urea nitrogen 61 mg/dL; creatinine 3.3 mg/dL; Creactive protein 19 mg/L, and INR 1.0. Urinalysis showed 1,178.7 mg/dl of proteinuria, with 3–5 red and white blood cells per high-power field, without dysmorphic cells. Total cholesterol (353 mg/dL) and triglyceride (261 mg/dL) were increased, and serum protein electrophoresis revealed hypoalbuminemia (1.8 g/dL). In a 24-h specimen of urine, protein was 2,716 mg. During hospitalization, the patient developed a sudden episode of hematemesis. On physical examination, he had hemodynamic stability and epigastric tenderness without guarding or rebound tenderness. The upper endoscopy showed diffuse mucosal redness, small ring-like petechiae, submucosal hemorrhages, and superficial ulcers in the gastric body, antrum, and duodenum ( Fig. 1 ). There was a rapid clinical deterioration, with the development of hemolacria (bloody tears), hematidrosis (bloody sweat), macroscopic hematuria, and appearance of a palpable purpura on the lower limbs, abdomen, and trunk ( Fig. 2 ). The patient developed multiple organ failure and required hemodialysis and mechanical ventilation. Given the clinical set, we considered the diagnosis of a vasculitis and started corticosteroids (1,000 mg of methylprednisolone per day). A chest high-resolution computed tomography scan was performed, and besides

Gastrointestinal Bleeding Secondary to Scurvy in an Alcoholic Malnourished Cirrhotic Patient

On physical examination, his conjunctivae were pale, and he had severe periodontitis with gingival hypertrophy and purplish areas consistent with necrosis (Figure 1). His skin revealed follicular hyperkeratosis, and his legs were hairless (Figure 2). Laboratory blood tests showed hemoglobin 7.1 g/L, mean corpuscular volume 104.7 f/L, white blood cell count 11.4 x 10/L, platelets 89 x 10/L, international normalized ratio 1.83, total bilirubin 3.5 mg/dL, albumin 2.9 g/dL, creatinine 0.89 mg/dL, magnesium 1.1mg/dL, calcium7.7mg/dL,phosphorus2.0mg/dL, ferritin 10ng/mL, transferrin56mg/dL,vitaminB92.1ng/mL,vitamin B12 582 pg/mL, and vitamin C 0.14 mg/dL. Colonoscopy showed multiple intramucosal hemorrhages in the cecum and

Midgut Volvulus as a Complication of Intestinal Malrotation in Pregnancy

A 38-year-old woman in the 27th week of gestation was admitted for sudden onset of epigastric pain, vomiting, and nausea, which worsened after food ingestion. The patient described 1 year of self-limited episodes of abdominal pain that improved with defecation and were associated with a change in frequency and consistency of stools that were interpreted as irritable bowel syndrome. On physical examination, she had stable vital signs, a distended abdomen, and tenderness in both upper quadrants. Blood tests showed leukocytosis 21.8 x 10/L and Creactive protein 10 mg/L. Abdominal x-ray was normal, and abdominal ultrasonography revealed a small amount of anechogenic fluid between intestinal loops and in the hepatorenal recess. Obstetric ultrasonography showed fetal well-being. Upper endoscopy was inconclusive because of abundant gastric residual fluid. Contrast-enhanced magnetic resonance imaging revealed features of malrotation (the large bowel was predominantly located on the left side and the small bowel predominantly on the right side) and a whirlpool image in the proximal small bowel (Figure 1). A diagnosis of a small bowel volvulus and midgut malrotation was made. Due to the risk of miscarriage, the patient refused surgery, and a conservative management with antibiotics, intravenous fluids, and parenteral nutrition was started. One week later, although the patient presented with normal vital signs, the abdominal pain and vomiting worsened and there was an increase in C-reactive protein to 102 mg/L. The patient accepted surgery, which confirmed the midgut malrotation associated with small bowel volvulus, and a Ladd’s procedure was done (Figure 2). Treitz ligament was absent. No complications were described postoperatively, and she gave birth to a healthy newborn with no apparent malformations at 38 weeks gestation.

Fever and haematochezia: an unusual association

A 72-year-old male patient presented to the emergency room for haematochezia followed by syncope. In the past 2 days he had fever and asthenia. From his medical records, we registered a peripheral vascular disease, with an aortobifemoral bypass graft placed 12 years prior; 6 years later, the graft had a thrombosis event and the patient was submitted to an axillofemoral bypass graft. On physical examination, he had haemodynamic instability and fever (38°C); the abdominal examination showed no abnormalities. Laboratory tests were as follows: haemoglobin: 10.7 g/L, white cell count: 17.7×109/L; international …