Cristina Teixeira

Metabolic syndrome and colorectal neoplasms: An ominous association.

AIM To evaluate the association of metabolic syndrome (MS) and colorectal cancer and adenomas in a Western country, where the incidence of MS is over 27%. METHODS This was a prospective study between March 2013 and March 2014. MS was diagnosed according to the National Cholesterol Education Program-ATP III. Demographic characteristics, anthropometric measurements, metabolic risk factors, and colonoscopic pathologic findings were assessed in patients with MS (group 1) who underwent routine colonoscopy at our department. This data was compared with consecutive patients without metabolic syndrome (group 2), with no differences regarding sex and age. Patients with incomplete colonoscopy, family history, or past history of colorectal neoplasm were excluded. Informed consent was obtained and the ethics committee approved this study. Statistical analysis was performed using Students t-test and χ(2) test, with a P value ≤ 0.05 being considered statistically significant. RESULTS Of 258 patients, 129 had MS; 51% males; mean-age 67.1 years (50-87). Among the MS group, 94% had high blood pressure, 91% had increased waist circumference, 60% had diabetes, 55% had low high-density lipoprotein cholesterol level, 50% had increased triglyceride level, and 54% were obese [body mass index (BMI) 30 kg/m(2)]. 51% presented 4 criteria of MS. MS was associated with increased prevalence of adenomas (43% vs 25%, P = 0.004) and colorectal cancer (13% vs 5%, P = 0.027), compared with patients without MS. MS was also positively associated with multiple (≥ 3) adenomas (35% vs 9%, P = 0.024) and sessile adenomas (69% vs 53%, P = 0.05). No difference existed between location (P = 0.086), grade of dysplasia (P = 0.196), or size (P = 0.841) of adenomas. In addition, no difference was found between BMI (P = 0.078), smoking (P = 0.146), alcohol consumption (P = 0.231), and the presence of adenomas. CONCLUSION MS is positively associated with adenomas and colorectal cancer. However, there is not enough information in western European countries to justify screening in patients with MS. To our knowledge, no previous study has evaluated this association in Portuguese patients.

Sweet Syndrome and Pulmonary Tuberculosis in a Crohns Disease PatientTreated with Anti-TNFñ

A 36-year-old man with Crohn’s Disease (CD), under infliximab therapy, was admitted with fever and skin lesions on the face, trunk and upper limbs. Skin biopsy was consistent with Sweet Syndrome (SS). He was treated with corticosteroids, with transient clinical improvement, but without healing of skin lesions. After 2 weeks, the fever relapsed and the patient complained of night sweats. Chest X-ray and CT-scan revealed pulmonary diffuse micronodular pattern with a condensation suggestive of pulmonary tuberculosis. Tuberculin test and IGRA were positive. Bronchoalveolar lavage culture was positive for M. tuberculosis. The patient started anti-tuberculosis standard regimen and discontinued anti-TNFα therapy. During treatment, there was clinical and radiological worsening and development of CD flare. We admitted an immune reconstitution inflammatory syndrome and anti- TNFα was reintroduced after 2 months, with improvement in CD symptoms, complete healing of skin lesions and resolution of TB. To our knowledge, this is the first case reported in the literature that presents the association between SS and pulmonary tuberculosis in a patient on anti-TNFα treatment for CD, complicated with IRIS. Early recognition of this association is essential for a effective treatment. Diagnosis and therapy of SS and pulmonary tuberculosis in a patient with CD are herein discussed.

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.

Colorectal Cancer Screening: What Is the Population's Opinion?

Background: Colorectal cancer (CRC) is the first cause of death by cancer in Portugal and mortality has been increasing in the last 30 years. Materials and Methods: During a raising awareness campaign performed by our Gastroenterology Department, in Setúbal, Portugal, an anonymous written questionnaire was developed and presented in order to evaluate the populations knowledge and attitude regarding CRC screening. Results: The following results were reported: 140 persons; mean age 54.6 years; 61.4% women; 22.1% had a family history of colorectal cancer. The main risk factors mentioned by the respondents were family history of CRC, previous history of intestinal polyps, and intestinal infection. Screening was considered useful by all respondents. About 60% of the respondents had been counselled, at least, on one screening technique, mainly by their general practitioner: colonoscopy in 31, fecal occult blood test in 44, and flexible sigmoidoscopy in 9. Most of the respondents had had the appropriate screening test, according to their age and family history. Fourteen of the respondents had not undergone the recommended screening. Their answers showed that this was due to fear of pain/discovering a disease as well as embarrassment. Conclusion: Although the majority of the respondents were aware of the importance of CRC screening, results show that there are still several misconceptions about risk factors, fear, and reluctance concerning the screening techniques. Awareness actions are useful to clarify possible questions and inform the population in order to increase compliance with screening.

Hypogammaglobulinemic sprue manifested as chronic intestinal failure: An uncommon but effective indication for home parenteral nutrition

Gonçalo Nunes1, Cláudio Martins2, Cristina Teixeira2, Miguel Fróis Borges3, Ana Paula Oliveira2, Jorge Fonseca1,4 1Department of Gastroenterology, GENE Artificial Feeding Team, Hospital Garcia de Orta, Almada, Portugal 2Department of Gastroenterology, Hospital de São Bernardo, Setúbal, Portugal 3Department of General Surgery, Hospital Garcia de Orta, Almada, Portugal 4Centro de investigação interdisciplinar Egas Moniz (CiiEM), Monte da Caparica, Portugal

A Rare Case of Epigastric Pain and Vomiting

DIS 5.5.0 DTD YGAST61126 proof 23 November 2017 5:39 pm ce G 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 Question: A 63-year-old woman was admitted to the emergency room for vomiting and abdominal pain localized in the epigastric region for the past 48 hours. Past medical history included ulcerative colitis, arterial hypertension, and asthma. Four months before admission, she had complained of occasional episodes of epigastric pain and had undergone an esophagogastroduodenoscopy (EGD) that had revealed a parahiatal hernia with an intrathoracic 88 89 90 91 92 93 94 95 96 97 98 fundus and gastric corpus. She had a computed tomography scan that an revealed immense hiatal hernia, without signs of torsion. On physical examination at admission the patient was apyretic, her blood pressure was 179/110 mm Hg, pulse rate was 92 beats/min, and her respiratory rate was 18 breaths/min. Epigastric tenderness was noted with no palpable abdominal mass or organomegaly, and abdominal sounds were present. Blood test results revealed a normal hemoglobin (14 g/dL), leukocytosis (12.7 10 cells/mm) with neutrophilia (84%), hypokalemia (3.1 mEq/L), a slightly elevated C-reactive protein (2.09 mg/dL), and normal liver tests. There was an unsuccessful attempt to place a nasogastric tube. An abdominal radiograph revealed 2 large air bubble signs in the chest (Figure A). EGD was performed (Figure B). 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. 99 100 101 102 103 104 105 Conflicts of interest The authors disclose no conflicts.

Colonic Gallstone Ileus: A Rare Case

A 72-year-old woman with a history of atrial fibrillation, arterial hypertension, thyroidectomy, and mitral insufficiency presented to the emergency department with nausea, vomiting, and abdominal pain for the last 24 h. At physical examination, the patient had right upper abdominal pain and Murphy’s sign. Abdominal ultrasound revealed gallstones, thickened gallbladder wall, and sonographic Murphy’s sign. Blood tests showed normal liver tests and inflammatory parameters (INR 2.1). She was admitted for acute cholecystitis. Due to comorbidities, intravenous antibiotherapy was started and cholecystectomy was delayed until cardiac evaluation and anticoagulation correction. On the 6th day of hospitalization, the patient presented abdominal distension, hyperactive bowel sounds, and mild diffuse tenderness. CT scan demonstrated a thickened gallbladder wall with fistula to the colonic hepatic flexure, and a gallstone of 2.2 cm in the sigmoid colon causing proximal gas distension of the bowel (Fig. 1). Colonoscopy revealed an impacted gallstone at 30 cm from the anal verge and adjacent mucosal ulceration (2 ulcers of 5 mm). Attempted endoscopic removal with snare and basket was unsuccessful (Fig. 2). Due to colonic distension and higher surgical risk associated with the one-stage procedure, the patient underwent enterolithotomy and cholecystectomy was delayed and performed 2 months later, without complications.

Esophageal lichen planus: a rare case

Lichen planus is a rare, idiopathic disease that usually involves the skin and mucosae. Oral lesions occur in two thirds of cases and may occur without skin involvement. Esophageal lichen planus occur more frequently in middle-age women, it is frequently asymptomatic but may cause odynophagia and dysphagia. Esophageal lichen planus has been associated with squamous cell carcinoma. The most effective treatment is systemic corticotherapy, but relapse is expected in 85% with steroid withdrawal. We present the case of esophageal lichen planus in a 50-year-old man.

Colonic diverticulosis and the metabolic syndrome: an association?

BACKGROUND AND OBJECTIVES Colonic diverticulosis (CD) is related to advanced age and a lack of dietary fiber. Recently, several studies have shown that metabolic syndrome (MS) is also implicated in the etiopathogenesis of CD. This study aimed to assess the association between MS, obesity and CD. METHODS This was a prospective study of a one-year duration. The MS was defined according to the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III). Demographic data, risk factors for MS and endoscopic findings of patients who underwent a total colonoscopy in the department were collected. Obesity was defined as a body mass index ≥ 30 kg/m2. Informed consent was obtained. The local Ethics Committee and National Data Protection Committee approved the study. Statistical analysis was performed with SPSS 21 and statistical significance was defined as p < 0.05. RESULTS The study included 203 patients, 95 males with a mean age of 65.5 years. CD was diagnosed in 30.5% of patients. Univariate analysis showed that age, hypertension, increased waist circumference and hyperlipidemia were associated with colonic diverticulosis. There was no association with gender, obesity or type 2 diabetes mellitus. Multivariate analysis showed that age and a greater waist circumference increased the risk of diverticulosis. Age-adjusted analysis showed that MS was associated with diverticulosis. The prevalence of adenoma in patients with CD was similar to that in patients without CD. CONCLUSION In this series, MS was significantly associated with CD. The identification of risk groups is important since diverticulosis can have serious and potentially fatal complications. To our knowledge, this is the first Southern European prospective study evaluating the association between MS and CD.

Mantle cell lymphoma presenting as multiple lymphomatous polyposis of the gastrointestinal tract

The gastrointestinal (GI) tract is the most common extranodal site affected by lymphoma, accounting for 5–20% of all cases.1 The incidence and location of primary GI lymphoma varies around the world. Overall, the most commonly involved sites are the stomach followed by the small bowel and ileocecal region.2 Concerning histological subtypes, mucosa-associated lymphoid tissue lymphoma is more common in the stomach, mantle cell lymphoma (MCL) in the terminal ileum, jejunum and colon, enteropathy-associated T-cell lymphoma in the jejunum, and follicular lymphoma in the duodenum with a geographic variation in its distribution.3 MCL is a rare and distinct subtype of B-cell neoplasm, comprising approximately 6–9% of all malignant lymphoma in Western Europe, with an incidence of 1–2 cases/105 people/year.4 Endoscopic features of GI lymphomas are heterogeneous, encompassing ulcers, erosions, polyps and so on. GI polyposis