Elisa Gravito-Soares

Spontaneous fungal peritonitis: a rare but severe complication of liver cirrhosis

Introduction and aim Spontaneous bacterial peritonitis is the most common infectious complication in cirrhosis. Spontaneous fungal peritonitis is rare and remains unknown. In this work, spontaneous fungal peritonitis as well as risk factors and prognosis are characterized. Patients and methods A retrospective case–control study of 253 consecutive admissions by peritonitis in cirrhotic patients was carried out between 2006 and 2015. Comparison of patients with spontaneous fungal peritonitis (cases) and spontaneous bacterial peritonitis with positive microbiologic ascitic fluid culture (controls) was performed. Variables such as sociodemographic and clinical features, cirrhosis etiology, liver dysfunction scores, ascitic and laboratory parameters, invasive procedures, and prognosis were evaluated. Results Of the 231 patients, eight (3.5%) developed spontaneous fungal peritonitis, 62.5% of cases being coinfected with bacteria. Candida spp. was isolated in 87.5% of cases, mainly Candida albicans (37.5%) and C. krusei (25.0%). Patients with spontaneous fungal peritonitis had higher ascitic fluid lactate dehydrogenase (288.4±266.6 vs. 161.0±179.5; P=0.011), blood leukocyte count (15187.5±5432.3 vs. 10969.8±6949.5; P=0.028), blood urea nitrogen (69.8±3.1 vs. 36.3±25.5; P=0.001), higher number of invasive procedures (colonoscopy: 25.0 vs. 0.8%, P=0.001; urinary catheterization: 87.5 vs. 49.6%, P=0.038; nasogastric intubation: 87.5 vs. 26.9%, P=0.001), and longer duration of hospital stay (30.0±32.9 vs. 18.9±17.0 days; P=0.031). No statistical difference was found between the two groups for Model for End-Stage Liver Disease, Model for End-Stage Liver Disease–sodium, and Child–Pugh scores. Spontaneous fungal peritonitis was associated with a worse prognosis, particularly severe sepsis/septic shock (87.5 vs. 42.8%, P=0.023), admission in the gastroenterology intensive care unit (87.5 vs. 24.4%; P=0.001), and overall (62.5 vs. 31.9%; P=0.039) or 30-day mortality (50.0 vs. 24.4%; P=0.034), with a mean diagnosis-death time of 17.6±11.5 days. Conclusion Despite being a rare condition, spontaneous fungal peritonitis was associated with worse prognosis and higher mortality than SBP. The ascitic fluid lactate dehydrogenase, blood leukocyte count and urea nitrogen, invasive procedures, and longer admission time were independent risk factors for spontaneous fungal peritonitis.

Fecal microbiota transplantation in recurrent Clostridium difficile infection in a patient with concomitant inflammatory bowel disease

The use of fecal microbiota transplantation in recurrent Clostridium difficile infection and coexistent inflammatory bowel disease remains unclear. A 61-year-old man with ulcerative pancolitis was diagnosed with a third recurrence of Clostridium difficile infection, previously treated with metronidazole, vancomycin and fidaxomicin. Fecal microbiota transplantation of an unrelated healthy donor was performed by the lower route. After a twelve month follow-up, the patient remains asymptomatic without Clostridium difficile infection relapses or inflammatory bowel disease flare-ups. Fecal microbiota transplantation is relatively simple to perform, well-tolerated, safe and effective in recurrent Clostridium difficile infection with ulcerative pancolitis, as an alternative in case of antibiotic therapy failure.

Groove Pancreatitis with Biliary and Duodenal Stricture: An Unusual Cause of Obstructive Jaundice

Introduction Groove pancreatitis is an uncommon cause of chronic pancreatitis that affects the groove anatomical area between the head of the pancreas, duodenum, and common bile duct. Clinical case A 67-year-old man with frequent biliary colic and an alcohol consumption of 30–40 g/day was admitted to the hospital complaining of jaundice and pruritus. Laboratory analysis revealed cholestasis and the ultrasound scan showed intra-hepatic biliary ducts dilatation, middle third cystic dilatation of common bile duct, enlarged Wirsung and pancreatic atrophy. The magnetic resonance cholangiopancreatography showed imaging findings compatible with groove pancreatitis. An esophagogastroduodenoscopy later excluded duodenal neoplasia. He was submitted to a Roux-en-Y cholangiojejunostomy because of common bile duct stricture. Five months later a gastrojejunostomy was performed due to a duodenal stricture. The patient remains asymptomatic during follow-up. Discussion Groove pancreatitis is a benign cause of obstructive jaundice, whose main differential diagnosis is duodenal or pancreatic neoplasia. When this condition causes duodenal or biliary stricture, surgical treatment can be necessary.

Clinical applicability of Tokyo guidelines 2018/2013 in diagnosis and severity evaluation of acute cholangitis and determination of a new severity model

Abstract Objective: To determine the diagnostic accuracy of Tokyo guidelines (TG) 2018/2013 (TG18/TG13) and predictors of poor prognosis in acute cholangitis. Methods: Retrospective 1-year study of consecutive hospital admissions for acute cholangitis. Prognosis was defined in terms of 30 d in-hospital mortality. Results: Of the 183 patients with acute cholangitis, diagnostic accuracy based on Charcot’s triad, TG07 and TG18/TG13 was 67.8, 86.9 and 92.3% (p < .001), respectively. Regarding severity based on TG18/TG13, 30.6% of cases were severe. A poor prognosis was found in 10.9% of patients. After multivariate analysis, systolic blood pressure <90 mmHg (OR 11.010; p < .001), serum albumin <3 g/dL (OR 1.355; p = .006), active oncology disease (OR 3.818; p = .006) and malignant aetiology of obstructive jaundice (OR 2.224; p = .021) were independent predictors of poor prognosis. The discriminative ability of the model with these four variables was high (AUROC 0.842; p < .001), being superior to TG18/TG13 (AUROC 0.693; p = .005). Conclusions: TG18/TG13 showed high diagnostic accuracy in acute cholangitis. Compared with TG18/TG13, the simplified severity model ≥2 allows easy selection of patients who will benefit from admission to the intensive care unit and early biliary decompression.

Endoscopic Mucosal Resection with Circumferential Incision in Difficult Colorectal Lesions

A 76-year-old man with a medical history of hypertension and atrial fibrillation under apixaban was submitted to anterior resection for rectal adenocarcinoma following neoadjuvant radiochemotherapy. At the fifth year of postoperative endoscopic surveillance, an 18mm flat lesion (Paris type 0-IIb, nongranular laterally spreading lesion [LST-NG] and Kudo pit pattern type IIIs/IV) was found at the proximal transverse colon. A conventional endoscopic mucosal resection (EMR) attempt was ineffective due to nonlifting of the central portion of the lesion; biopsies were taken and the site was tattooed (SPOT®GI Supply, Camp Hill, PA, USA). Pathology showed a low-grade dysplasia adenoma and the patient was referred to our institution. Colonoscopy showed the 18-mm flat lesion in an area of tattooed mucosa (Fig. 1a). Initially, inject-and-cut EMR and a modified aspirative EMR using a rim-free cap were tried without success. Therefore, it was decided to perform a hybrid endoscopic submucosal dissection (ESD). First, an injection of submucosa using epinephrine-saline mixture (1: 100,000) and methylene blue was performed with difficulty in elevating the central portion of the lesion; then, submucosal access and circumferential incision were made using a ClearCut-knife 2 mm I-type (Finemedix Co. Ltd, Daegu, Republic of Korea); and, finally, an en-bloc resection using an oval 15-mm diathermic snare (Olympus, Spain) was performed without complications (Fig. 1b–d). Pathology of resection specimen (Fig. 2) showed a tubular adenoma with low-grade dysplasia (R0 resection) (Fig. 3a, b). Periprocedural management included stopping anticoagulation in the

Endoscopic Resection of a Rectal Neuroendocrine Tumor: Hybrid Endoscopic Submucosal Dissection

A 67-year-old man was referred to our institution due to a 10-mm yellowish subepithelial lesion in the middle rectum incidentally diagnosed during screening colonoscopy. Conventional biopsies showed a well-differentiated neuroendocrine tumor (NET). Abdominopelvic computed tomography and endoscopic ultrasound showed limited submucosal invasion and no locoregional/distant metastasis. It was decided to perform a hybrid endoscopic submucosal dissection (ESD) technique. First, submucosal injection was performed using methylene-blue-stained saline containing 1: 100,000 epinephrine with adequate lesion lifting; second, a circumferential incision with a 1–2 mm free margin (ERBE VIO 300D: Endocut I, effect-1) was made using a ClearCut knife 2 mm I-type (Finemedix, South Korea); third, a partial submucosal dissection was done, using the same knife and settings; and fourth, an en bloc resection with an oval 15-mm diathermic snare (Olympus, Spain) was performed (Forced Coag, effect-2 80 W) without complications and resection time of 9 min (Fig. 1a–f). Histopathology showed a 9-mm NET G1 (WHO classification, 0 mitoses/10 HPF, Ki-67: 1.8%; pT1a AJCC stage 1), limited to the submucosa with free lateral (1.0 mm) and deep (0.6 mm) resection margins (Fig. 2a–g). Considering R0 resection of a < 10-mm rectal NET (R-NET), no followup was scheduled. Despite the increasing incidence due to the widespread use of screening colonoscopy, R-NET are relatively rare and often well differentiated [1–5]. Endoscopic resection plays a central role in the resection of small well-differentiated R-NET (< 10 mm) and selected cases measuring 10–20 mm, given the low risk of metastasis [2–4]. There is no consensus regarding the best endoscopic resection technique [1, 2, 4, 5], including conventional polypectomy, endoscopic mucosal resection (EMR) or ESD. Conventional polypectomy should be avoided as complete resection is often not achieved [1, 4] and EMR shows a suboptimal complete resection rate (30–70%) due to frequent submucosal involvement affecting mostly the vertical margin [1, 3, 5]. Incomplete resection requires endoscop-

Cytomegalovirus ulcerative oesophagitis in a young healthy immunocompetent patient

Cytomegalovirus (CMV) gastrointestinal disease usually arises in patients with immunodeficiency or immunosuppression, being rare in immunocompetent hosts. Although increasing in incidence, few cases of CMV gastrointestinal disease have been described among young healthy patients. Currently, there is uncertainty in approaching these patients, including the need for antiviral therapy that remains to be established. This case report describes a CMV ulcerative oesophagitis in a young healthy immunocompetent patient with good evolution with no need for antiviral therapy, the youngest case being reported in the literature until now.

Successful and Safe Endoscopic Removal of a Dental Prosthesis from the Colon Using an Adapted Capuchon Hood

Successful and Safe Endoscopic Removal of a Dental Prosthesis from the Colon Using an Adapted Capuchon Hood

Cytomegalovirus Disease of the Upper Gastrointestinal Tract: An Emerging Infection in Immunocompetent Hosts

organ transplantation, and active malignancy undergoing chemotherapy [1–4, 6–9] . Gastrointestinal involvement by CMV is common. Endoscopic findings are nonspecific, with mucosal ulceration being the most common [1, 7, 10] . The gold standard in CMV disease diagnosis is histopathology of the involved organ, with high sensitivity in both early and late phases. Histological findings include typical intranuclear inclusions or positive immunohistochemical staining for CMV [1, 2, 11] . Regarding the management of CMV gastrointestinal disease, ganciclovir is recommended as the first choice, despite the potential for hematological toxicity, central nervous system disorders, hepatotoxicity, irreversible infertility, and teratogenesis. In patients with normal renal function, intravenous ganciclovir 5 mg/kg twice daily or oral valganciclovir 900 mg twice daily should be used for 2–3 weeks. Available alternative therapies, such as foscarnet, also had nonnegligible toxicity including nephrotoxicity and hydroelectrolytic disturbances. Additionally, the widespread use of these drugs may lead to the emergence of resistant viral strains. The length of treatment is determined by once weekly monitoring of CMV viral loads. A longer period of time is usually required for gastrointestinal tissue-invasive disease. Maintenance therapy (oral valganciclovir 900 mg once daily) is reserved for CMV gastrointestinal disease relapse, after a reinduction regimen [3, 6, 9] . In immunocompromised

Large Pedunculated Lipoma of the Colon: Endoscopic Resection Using “Loop-and-Let-Go” Technique

copy was performed showing a large, yellowish, and pedunculated subepithelial lesion with 30 mm of head diameter and 45 mm of stalk length, located at the sigmoid colon (Fig. 1a–c). Considering the lesion benignity in a symptomatic patient, it was decided to perform the polyp resection using a minimally invasive technique – “loopand-let-go.” A 30-mm endoloop® (Olympus, Tokyo, Japan) was maneuvered to capture the lipoma’s head and then carefully placed at the stalk base. A visible reduction in lesion vascularization was verified following sheathcontrolled closure (Fig. 1d–g). A formalin-filled container was given to the patient in case of polyp recovery. The patient recovered the colonic polyp within 4 days of endoscopic ligation and it was sent for histological characterization (Fig. 2a, b). Specimen histopathology showed a 30-mm adipose tissue on the submucosal layer, in relation to a fully-resected submucosal lipoma (Fig. 3a–c). The patient became asymptomatic with an uneventful course. Follow-up colonoscopy at 2 months was normal. Gastrointestinal lipomas are rare subepithelial benign tumors, being more common in the colon [1–4]. Diagnosis is usually easy because of typical endoscopic features.