Cilénia Baldaia

Predicting the Course of Disease in Hospitalized Patients With Acute Severe Ulcerative Colitis

BACKGROUND Up to one-third of patients with acute severe ulcerative colitis (ASUC) will fail intravenous steroid (IVS) treatment, requiring rescue therapy with cyclosporin (Cys), infliximab (IFX), or colectomy. Although several scores for predicting response to IVS exist, formal comparison is lacking. METHODS We performed a single-center retrospective analysis including 489 patients with ulcerative colitis. In patients with ASUC, the Mayo endoscopic subscore and the Oxford, Edinburgh, and Lindgren scores were assessed. Outcomes included IVS failure, need for rescue medical therapy, and surgery. RESULTS One hundred twelve patients presented with ASUC. Forty-two percent showed an incomplete or absent response to IVS, 28.6% received rescue therapy (22 with IFX, 10 with Cys, and 1 with sequential treatment), and 26.8% required surgery. The Lindgren score showed the highest performance in predicting IVS failure (are under the curve [AUC], 0.856; 95% confidence interval [CI], 0.784-0.928), need for medical rescue therapy (AUC, 0.826; 95% CI, 0.749-0.902), and surgery (AUC, 0.836; 95% CI, 0.712-0.960; all P < 0.01). CONCLUSIONS In our series, the Lindgren score was superior to the Mayo, Oxford, and Edinburgh scores in predicting major clinical outcomes in ASUC.

Acute (Not Decompensation)-on-Chronic Liver Failure

ria [2] . The concept that differentiates organ failure and dysfunction was also defined a priori, with a group of experts modifying the SOFA score for CLIF-SOFA [1] . A recent meta-analysis demonstrated that the latter score has greater accuracy for ACLF mortality prediction [3] . ACLF is a dynamic entity, potentially reversible, if the precipitating factor is identified and controlled, but this happens in only 50% of cases. Thus, defining diagnostic criteria and identifying patients at risk of progression to multi-organ failure will assist in the early implementation of supportive measures and prioritization in the liver transplant list. The presentation in 2013 of the results of a prospective observational European study (CANONIC) that included 1,343 patients hospitalized for liver cirrhosis allowed to clarify some of these concepts and was remarkable in this area. The authors of the article published in this issue of GE – Portuguese Journal of Gastroenterology retrospectively analyzed their experience over the last 3 years [4] . This analysis was carried out in a very particular context of an intensive care unit of a liver transplant center which would have had an impact on patient selection and characteristics. The primary objectives of the study were to evaluate the evolution and mortality and to compare the evolution of ACLF patients with and without bacterial infection as precipitant. Additionally, they evaluated the presence of acute kidney injury and its impact on prognosis.

Intrahepatic clear cell cholangiocarcinoma - An uncommon histologic subtype: case report and literature review

Clear-cell cholangiocarcinoma is a very uncommon variant of cholangiocarcinoma with a largely unknown natural history and prognosis. We report a case of a 51-year-old previously healthy woman presenting with a large liver nodule found on routine imaging. Needle biopsy of the lesion suggested a non-hepatocellular carcinoma. After extensive workup for other primary neoplasms, the patient underwent a partial hepatectomy. Histopathology was compatible with a moderately differentiated clear-cell cholangiocarcinoma. There was no evidence of liver disease in the remaining tissue. The patient underwent chemotherapy and remains in clinical remission after two years.

A Focal Liver Lesion in a Patient with Chronic Hepatitis B and Cirrhosis notalways Hepatocellular Carcinoma

Chronic liver disease and cirrhosis are known risk factors for hepatocellular carcinoma (HCC). We present a 68- year old male patient with chronic hepatitis B infection and cirrhosis admitted for investigation of a 10-cm solid liver nodule detected during surveillance ultrasound. Abdominal computed tomography (CT) revealed an additional 3 cm lesion in the right liver lobe and multiple lesions in the spleen without typical features of HCC. Histopathologic examination of the liver nodule biopsy was compatible with metastasis from a neuroendocrine tumor. The patient was referred for chemotherapy but unfortunately died 2 months later from infectious complications. The present case seemed unusual considering that the background chronic liver disease would make HCC a more likely diagnosis. The multiple comorbidities presented by our patient provided an additional challenge by broadening the differential diagnosis.

Genital Ischemia in a Patient Under Terlipressin Therapy

n w o d a o u d s n i 66-year-old male was admitted to our gastroenterology epartment with severe bilateral pneumonia. His medical istory was relevant for liver cirrhosis secondary to alpha-antitrypsin deficiency and systemic hypertension. He had o other relevant comorbidities, and did not smoke or drink lcoholic beverages. The patient’s clinical condition deteiorated with progressive liver failure. As he met criteria or hepatorenal syndrome, we decided to start treatment ith terlipressin. Three days later, the patient started omplaining of diffuse abdominal pain. His abdomen was sig-

7049 Endoscopic placement of esophageal expandable metal stents without fluoroscopic guidance.

The insertion of expandable metal stents (EMS) is a fundamental palliative treatment for esophageal malignant neoplasia. Endoscopic placement of stents is usually performed under fluoroscopic guidance. Aims: Evaluation of feasability, efficacy and safety of the endoscopic insertion of EMS in esophageal malignant neoplasia without fluoroscopic guidance. Patients and Methods: Retrospective study of 60 patients (pts) with nonresectable esophageal cancer in whom 72 EMS were placed. The EMS used were distal release Ultraflex™ (Microvasive®, Boston Scientific Corporation), 7-15 cm long and 18 mm in diameter (22 covered stents). 91% of the patients were previously submitted to dilation and/or Nd:YAG laser. The procedures were done under sedation with midazolam and EMS were placed under endoscopic control with no fluoroscopic guidance. Severity of dysphagia was graded in a 0 to 4 score according to the consistency of food causing symptoms: 0 no dysphagia; 1 solid food; 2 semi-solid food; 3 liquid food; 4 total dysphagia. Results: 49 men and 11 women. Mean age 65±11 years. The indications for EMS insertion were dysphagia (78%) and esophagorespiratory fistulas (22%). Mean stricture length: 7.0±1.9 cm.The neoplasia were located in the upper esophagus in 23%, in the middle in 47% and in the lower in 30%. A significant improvement in dysphagia after stent placement was observed (mean pre-treatment score: 3.1±0.7; mean score after stenting: 1.5±0.5 - p