Daniela Tiemi Sato

Gallbladder-associated ectopic liver: A rare finding during a laparoscopic cholecystectomy

INTRODUCTION Ectopic hepatic tissue is due to an uncommon failure of embryological liver development that is rarely described in the world medical literature. The incidence of ectopic liver (EL) has been reported to be anywhere from 0.24% to 0.47% as diagnosed at laparotomy or laparoscopy. We describe a case of EL adherent to the gallbladder, removed at laparoscopic cholecystectomy. PRESENTATION OF CASE A 37-year-old female was admitted for elective cholecystectomy having had an episode of acute cholecystitis provoked by gallstones. During the procedure, a 30mm×10mm×5mm section of EL tissue attached to the anterior wall of the gallbladder was identified and removed by en-bloc excision during laparoscopic cholecystectomy. Histological examination confirmed the absence of malignant degeneration of the hepatic tissue. The patient recovered well postoperatively and was discharged the day after the operation. She was well when seen six months later. DISCUSSION EL has been reported in several sites, such as the gallbladder, gastrohepatic ligament, adrenal glands, esophagus, and thoracic cavity. EL is often clinically silent and discovered incidentally during abdominal surgical procedures or autopsies. Because patients with ectopic liver may suffer complications such as torsion, peritoneal bleeding, fatty change, and evolution to cirrhosis or malignant degeneration to hepatocellular carcinoma, any ectopic liver tissue needs to be correctly identified and removed. CONCLUSION Despite the rare occurrence of EL, it should be recognized and removed by the surgeon to prevent a higher risk of complications and malignant transformation.

Diospyrobezoar as a cause of small bowel obstruction.

Phytobezoar, a concretion of indigestible fibers derived from ingested vegetables and fruits, is the most common type of bezoar. Diospyrobezoar is a subtype of phytobezoar formed after excessive intake of persimmons (Diospyros kaki). We report the case of a diabetic man with a 5-day history of abdominal pain after massive ingestion of persimmons who developed signs of complicated small bowel obstruction. The patient had a previous history of Billroth II hemigastrectomy associated with truncal vagotomy to treat a chronic duodenal ulcer 14 years earlier. Since intestinal obstruction was suspected, he underwent emergency laparotomy that revealed an ileal obstruction with small bowel perforation and local peritonitis due to a phytobezoar that was impacted 15 cm above the ileocecal valve. After segmental intestinal resection, the patient had a good recovery and was discharged on the 6th postoperative day. This report provides evidence that diospyrobezoar should be considered as a possible cause of small bowel obstruction in patients who have previously undergone gastric surgery.

Oral administration of curcumin (Curcuma longa) can attenuate the neutrophil inflammatory response in zymosan-induced arthritis in rats

PURPOSE To evaluate the effect of curcumin in the acute phase of zymosan-induced arthritis. METHODS Twenty-eight male rats were subjected to intra-articular infiltration of zymosan of both knees and, in four the infiltration was made with saline. The animals were divided into five groups second received every six hours by gavage: corn oil by (positive and negative control); curcumin (100 mg/kg); prednisone 1 mg/kg/day; prednisone 8 mg/kg. All animals were sacrificed after six, 12, 24 and 48 hours of the infiltration. The knees were removed for evaluation of neutrophil infiltration. The number of neutrophils was counted by computer-assisted analysis of the images. The neutrophil infiltrate was stratified into four grades: 0 = normal; + = mild; ++/+++ = moderate; > ++++ = severe. The results were compared using the Mann-Whitney test and the variance by Kruskal-Wallis test adopting a significance level of 5% (p<0.05). RESULTS Curcumin reduces inflammatory activity in the first six hours after zymosan-induced arthritis when compared to saline (p<0.01). This was also observed in animals subjected to administration of prednisone (1 mg/kg) and those treated with prednisone (8 mg/kg). Curcumin was more effective than lower doses of prednisone in the first six hours after induction of the arthritis. After 12, 24 and 48 hours, curcumin does not have the same anti-inflammatory effects when compared to prednisone. After 48 hours, prednisone is more effective than curcumin in reducing the inflammatory infiltrate regardless of the dose of prednisone used. CONCLUSION Oral administration of curcumin reduces inflammation in the first six hours after experimentally zymosan-induced arthritis.

Oxidative stress and changes in the content and pattern of tissue expression of β-catenin protein in diversion colitis

OBJECTIVE: The aim of this study is to verify if oxidative stress is related to changes in content and pattern of β-catenin protein expression in an experimental model of diversion colitis. METHODS: Sixty Wistar rats were submitted to intestinal bypass. The animals were divided into three groups according to the sacrifice to take place in six, 12 and 18 weeks. For each group, five animals only underwent laparotomy (control). The presence of colitis was diagnosed by histological study, and its severity, by inflammation grading scale. Cellular oxidative stress was measured by comet assay. Tissue expression of β-catenin protein was analyzed by the immunohistochemistry and quantification of its tissue content by computerized morphometry. Statistical analysis was performed with the Students t-test, median, Mann-Whitney, ANOVA and Kruskal-Wallis, adopting a significance level of 5% (p <0.05). RESULTS: Colon segments without fecal stream developed colitis, which worsened with time of exclusion. Segments without fecal stream suffer higher levels of oxidative stress when compared to those with stream, and it worsens with time of exclusion. The levels of cellular oxidative stress are directly related to the degree of inflammation. The total content of β-catenin in segments without fecal stream reduces after six weeks, and does not vary thereafter. The content of β-catenin in the apical portion of the colon crypts decreases with time, whereas in the basal region, it increases. The total content of β-catenin is inversely related to the degree of inflammation and levels of tissue oxidative stress levels. CONCLUSION: There are changes in tissue content of E-cadherin and increased expression of β-catenin in proliferative regions of colonic crypts, related with oxidative tissue stress.

Tissue content of sulfomucins and sialomucins in the colonic mucosa, without fecal stream, undergoing daily intervention with sucralfate

PURPOSE To measure the content of acidic mucin, sialomucin, and sulfomucins in the colonic mucosa without fecal stream submit to intervention with sucralfate (SCF). METHODS Thirty-six rats were submitted to a right colostomy and a distal mucous fistula and divided into two groups according to sacrifice to be performed two or four weeks. Each group was divided into three subgroups according daily application of enemas containing saline, SCF at 1.0 g/kg/day or 2.0 g/kg/day. Colitis was diagnosed by histological analysis. Acid mucins were determined with the Alcian-Blue and sulfomucin and sialomucin by high iron diamine-alcian blue (HID-AB) techniques. The mucins were quantified by computer-assisted image analysis. Mann-Whitney and ANOVA tests were used to analyze the results establishing the level of significance of 5% for both (p<0.05). RESULTS SCF enemas decreased the inflammation score and was related to the concentration used and time of the intervention. SCF at both concentrations increased the content of acid mucin, which was related to the concentration used and to the improvement in the inflammatory score. There was an increase in the content of sulfomucins and sialomucins in SCF groups. SCF increased sulfomucins from 2 weeks of intervention, which was not related to the dose or time of application. The increase in sialomucin content was related to the time and dose used in the intervention. CONCLUSION Sucralfate increased the content of acidic mucins, primarily at the expense of sialomucin, which was affected by the dose and time of intervention.

Tricholithobezoar Causing Gastric Perforation

A bezoar is an intraluminal mass formed by the accumulation of undigested material in the gastrointestinal tract. Trichobezoar is a rare condition seen almost exclusively in young women with trichotillomania and trichotillophagia. When not recognized, the trichobezoar continues to grow, which increases the risk of severe complications such as gastric ulceration and even perforation. Formation of a gallstone within the trichobezoar (tricholithobezoar) is an event that has not yet been described. We report the case of a 22-year-old woman admitted to the emergency room with signals and symptoms of an epigastric mass and perforative acute abdomen. Radiological study revealed bilateral pneumoperitoneum. Personal history revealed depressive syndrome, trichotillomania and trichophagia. With a diagnosis of visceral perforation, an urgent exploratory laparotomy was performed. This confirmed the diagnosis of gastric perforation due to a large trichobezoar with the formation of a gastrolith that was removed by anterior gastrotomy. Biochemical study of the gastric stone revealed that it was composed of bile salts. There were no complications. The patient was discharged on the 5th postoperative day and was referred for psychiatric treatment.

Evaluation of the application of enemas containing sucralfate in tissue content of neutral and acid mucins in experimental model of diversion colitis

PURPOSE To evaluate the effects of sucralfate on tissue content of neutral and acids mucins in rats with diversion colitis. METHODS Thirty-six rats were submitted to a proximal right colostomy and a distal mucous fistula. They were divided into two groups according to sacrifice to be performed two or four weeks after intervention. Each group was divided into three subgroups according daily application of enemas containing saline, sucralfate at 1.0 g/kg/day or 2.0 g/kg/day. Colitis was diagnosed by histological analysis and neutral and acid mucins by Periodic Acid Schiff and Alcian Blue techniques, respectively. The contents of mucins were quantified by computer-assisted image analysis. Students t paired and ANOVA test were used to compare the contents of both types of mucins among groups, and to verify the variance with time, establishing level of signification of 5% for both (p<0.05). RESULTS Enemas containing sucralfate improves the inflammation and increases the tissue contents of neutral and acid mucins. The content of neutral mucins does not change with the time or concentration of sucralfate used, while acid mucins increases with concentration and time of intervention. CONCLUSIONS Sucralfate enemas improve the inflammatory process and increase the tissue content of neutral and acid mucins in colon without fecal stream.

Blue Rubber Bleb Nevus Syndrome as a Cause of Lower Digestive Bleeding

Introduction. Blue rubber bleb nevus syndrome is a rare disorder that is characterized by multiple recurrent vascular malformations that involve the skin and the gastrointestinal tract. The disease can present chronic anemia and severe episodes of gastrointestinal bleeding. Case Report. A 41-year-old man was admitted with recurrent episodes of lower gastrointestinal bleeding and anemia that had worsened over the last 3 months. The physical examination showed soft, diffuse, compressible, bluish nodules on all of the skin surfaces of the body. A biopsy from one of these skin lesions allowed a histological diagnosis of cavernous hemangioma. He submitted to a colonoscopy, which showed hemorrhoids and a plane vascular lesion mainly located on the right colon with recent signs of bleeding; this lesion was treated by local excision and sclerosis. The pathological study of the colon specimens also reflected the presence of cavernous hemangioma. The cutaneous hemangiomas and the presence of colonic venous malformations were compatible with blue rubber bleb nevus syndrome. The patient presented a favorable follow-up with clinical control of the anemia and without relapse of the gastrointestinal bleeding two years after the procedure. Conclusion. Although rarely diagnosed, blue rubber bleb nevus syndrome may be responsible for lower digestive bleeding.