H. Gouveia

Effect of Portal Hypertension in the Small Bowel: An Endoscopic Approach

Background and aim The effects of portal hypertension in the small bowel are largely unknown. The aim of the study was to prospectively assess portal hypertension manifestations in the small bowel. Methods We compared, by performing enteroscopy with capsule endoscopy, the endoscopic findings of 36 patients with portal hypertension, 25 cirrhotic and 11 non-cirrhotic, with 30 controls. Results Varices, defined as distended, tortuous, or saccular veins, and areas of mucosa with a reticulate pattern were significantly more frequent in patients with PTH. These two findings were detected in 26 of the 66 patients (39%), 25 from the group with PTH (69%) and one from the control group (3%) (Pxa0<xa00.0001). Among the 25 patients with PTH exhibiting these patterns, 17 were cirrhotic and 8 were non-cirrhotic (Pxa0=xa00.551). The presence of these endoscopic changes was not related to age, gender, presence of cirrhosis, esophageal or gastric varices, portal hypertensive gastropathy, portal hypertensive colopathy, prior esophageal endoscopic treatment, current administration of beta-blockers, or Child–Pugh Class C. More patients with these endoscopic patterns had a previous history of acute digestive bleeding (72% vs. 36%) (Pxa0=xa00.05). Active bleeding was found in two patients (5.5%). Conclusions The presence of varices or areas of mucosa with a reticulate pattern are manifestations of portal hypertension in the small bowel, found in both cirrhotic and non-cirrhotic patients. The clinical implications of these findings, as regards digestive bleeding, are uncertain, although we documented acute bleeding from the small bowel in two patients (5.5%).

Aberrant crypt foci: endoscopic assessment and cell kinetics characterization.

Background and aimsAberrant crypt foci (ACF) are preneoplastic lesions in animal models of colorectal cancer. The aim of the study is to investigate if ACF are involved in human colorectal carcinogenic process and if they can be helpful in predicting the presence of a colorectal neoplasia.MethodsThe study included, between 2003 and 2005, 182 patients, 62 with adenoma, 55 with colorectal carcinoma, 53 without colorectal lesions, and 12 with nonneoplastic mucosal polyps. The number of rectal ACF was determined by colonoscopy. Proliferation and apoptosis indexes were evaluated by immunohistochemistry in rectal ACF, in normal rectal mucosa, and in carcinomatous tissue.ResultsThe mean number of rectal ACF in patients with rectal neoplasia was 12.64, significantly higher than in patients with neoplastic lesions elsewhere in the colon (pu2009=u20090.01). The apoptosis index in ACF of patients with colorectal carcinoma or adenoma aged 50xa0years or older was significantly lower than in younger patients (1.3% vs 2.7%, pu2009=u20090.01) and, in patients with carcinoma, lower than in normal mucosa (1.1% vs 2.1%, pu2009=u20090.002). The proliferation index was significantly higher in ACF of patients with colorectal neoplasia aged less than 50xa0years than in normal mucosa (10.9% vs 7.7%, pu2009=u20090.02). The apoptosis index in ACF foci of patients with carcinoma (1.1%) was significantly lower than in patients without lesions (2.2%) and than in normal mucosa (2%). The mean number of ACF is significantly higher in patients with polyps larger than 1xa0cm (11.28 vs 6.27, pu2009=u20090.02).ConclusionAberrant crypt foci probably precede the appearance of neoplasia and may be helpful in predicting the presence of a colorectal neoplastic lesion.

Gastric splenosis: a rare cause of digestive bleeding.

with coffee grounds vomit and melena during the previous 48 hours. He had been subject to a major abdominal surgery with splenectomy at age of 38, after a traumatic injury. Regular medication was low-dose acetylsalicylic acid. On physical examination: blood pressure was 100/73 mmHg; heart rate 74 bpm; cardiac-pulmonary auscultation was normal and abdomen was tender and painless; rectal examination confirmed melena. Laboratory data: hemoglobin 11.7 g/dL; platelets 221 x 10^/μL; INR 1.2; aPTT 24.5; BUN 44 mg/dL; creatinine 0.7 mg/dL. Esophagogastroduodenoscopy visualized an ulcer located on the greater curvature of the proximal gastric body with well delimited borders over an elevated formation (Fig. 1). On computed tomography there was a solid nodular lesion on the greater curvature of the stomach with enhancement on arterial phase highly suggestive of gastric splenosis (Fig. 2A). This hypothesis was confirmed with scintigraphy (Fig. 2B). The patient was medicated with pantoprazole. Three weeks after discharge, endoscopy was repeated revealing frank ulcer healing. Gastric splenosis: a rare cause of digestive bleeding

Desgarro esofágico espontáneo extenso con hemorragia digestiva alta tratado con la aplicación de un endoclip

A 61-years-old male presented with emesis after some retching episodes. He had liver cirrhosis but no previous bleeding. An upper endoscopy revealed an extensive 10 cm tear involving the mucosa and submucosa layers of the distal esophagus sparing a 2 cm long segment proximal to the Z-line (Fig. 1). The laceration presented a slowly oozing haemorrhage that was stopped with the injection of 6 cc of epinephrine 1:10,000 and application of 17 endoclips to close the laceration. Recurrent bleeding 8 days later was controlled with further application of 4 endoclips. No further haemorrhagic recurrence occurred and an endoscopy procedure was repeated at week 6 (Fig. 2) and week 24 when no lesion was seen. Spontaneous extensive esophageal tear with upper digestive haemorrhage treated by endoclip application