Lídia Roque Ramos

Clinical and microbiological characteristics associated with mortality in spontaneous bacterial peritonitis: a multicenter cohort study.

Objectives Spontaneous bacterial peritonitis (SBP) is a prevalent and high mortality complication of cirrhosis. We aimed to describe these patients’ clinical and microbiological characteristics and evaluate their impact on outcomes. Methods This was a retrospective cohort study including 139 consecutive patients with positive culture SBP from three Portuguese centers diagnosed between 2009 and 2014. Multivariate logistic regression was used to study associations with 30-day mortality. Results The mean age of the patients was 62 years and 81% of patients were men. The mean model for end-stage liver disease score was 19. Hepatic encephalopathy, hepatorenal syndrome, and variceal bleeding developed in 47, 30, and 21% of patients, respectively. Gram-positive bacteria were isolated in the ascitic fluid of 42% of patients. Resistance to quinolones and multiresistance were found in 33 and 17% of patients, respectively. C-reactive protein level (adjusted odds ratio, 1.16 per 1 mg/l increment) and development of hepatorenal syndrome (adjusted odds ratio, 2.86) were associated independently with 30-day mortality (model’s area under the curve, 0.78). Conclusion In this cohort, SBP portended high early mortality. Gram-positive bacteria, bacteria resistant to quinolones, and multiresistant bacteria were identified in considerable proportions of patients. In the setting of the high early mortality and changing microbiological profile, SBP management strategies need to be improved.

Circumferential rectal laterally spreading tumor resected by endoscopic submucosal dissection in a Western center

A 78-year-old patient without relevant past medical history underwent colonoscopy for chronic diarrhea. Examination identified a laterally spreading tumor (LST), mixed-granular-type (nodules up to 1 cm) in the rectum, from the pectin line to the rectosigmoid transition. The LST covered 100% of the circumference of this segment (▶Fig. 1). Endoscopic evaluation was compatible with an adenomatous lesion with preserved pit pattern (Kudo IIIL/IV classification), without unequivocal endoscopic suspicion of invasive lesion (NICE 2; JNET 2B). After multidisciplinary evaluation, endoscopic resection by endoscopic submucosal dissection (ESD) was decided. The procedure was performed with the patient under general anesthesia. A gastroscope (GIF-HQ190; Olympus, Tokyo, Japan) and carbon dioxide insufflation were used. The lesion was gradually elevated with a colloid solution (Voluven [Fresenius Kabi Norge AS, Halden, Norway] + indigo carmine+ adrenaline), and the excision was performed by ESD using the FlushKnife (Fujifilm Corp., Tokyo, Japan) and the IT Knife nano (Olympus) (▶Fig. 2). En bloc resection was achieved, obtaining a circumferential specimen with a length of 15 cm, corresponding to the entire rectal mucosa (▶Fig. 3, ▶Video1). The procedure time was 420 minutes. Antimicrobial prophylaxis with a single dose of ceftriaxone (2 g) was given. There were no immediate complications and the patient was discharged 24 hours after the procedure. Histological examination revealed a tubulovillous adenomawith high grade dysplasia. Although the patient remained asymptomatic, endoscopic evaluation after 2 months revealed stenosis at the ESD site. Balloon dilation up to 15mm (diameter) was performed in a single session (▶Fig. 4). ESD is an organ-sparing endoscopic technique that allows en bloc resection of superficial gastrointestinal lesions regardless of their size, optimizing the histological evaluation [1]. This is particularly important in the rectum because of the high morbidity associated with the alternative surgical approaches [2]. Although described in Asian case reports [3, 4], to our knowledge this is the first report showing endoscopic treatment by ESD of a giant circumferential colorectal LST in a Western center.

Ulcerous Esophagitis in a Young Immunocompetent Patient

ttp://dx.doi.org/10.1016/j.jpge.2016.02.004 341-4545/© 2016 Sociedade Portuguesa de Gastrenterologia. Published C BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4 owel syndrome (IBS). The patient denied regular mediation or recent use of any drugs, namely antibiotics or on-steroidal anti-inflammatory drugs. Laboratory studies howed an increased C-reactive protein and a negative HIV erology. An esophagogastroduodenoscopy (EGD) revealed everal ulcers in the lower third of the esophagus, the largest ith 15 mm and raised borders (Fig. 1). Biopsies were taken rom the edges and bottom of the ulcer. The patient was dmitted and empirically started on proton pump inhibitor PPI) and acyclovir. Serologies ruled out HSV 1 and 2, CMV, BV and VZV recent infections and syphilis. Histological xamination showed an intense chronic inflammatory infilrate involving the mucosal, submucosal and muscular layers Fig. 2a) and an epithelioid granuloma with a giant cell Fig. 2b). There were no viral cytopathic effects or acid-fast acilli. Hence, our patient had a non-caseous esophageal ranulatomatosis. We excluded tuberculosis, sarcoidosis and ranulomatosis with polyangiits (Wegener’s granulomatosis) ased on a negative Mantoux and IGRA tests and normal hest X-ray, angiotensin conversion enzyme levels, serum lectrophoresis and renal function. At this point, we conidered the hypothesis of Crohn’s disease and given the atient’s complaints of intermittent diarrhea and abdominal iscomfort, labeled as IBS, an ileocolonoscopy was perormed. Several areas of erythema with aphthous erosions, nd ulcers, stellar and circular, the largest with 10 mm,

Gastric gastrointestinal stromal tumor and neuroendocrine pancreatic tumor: Always neurofibromatosis?

254 Dear Editor, A 52-year-old female patient presented to the emergency department with hematemesis, hypotension and tachycardia. She had a history of hypertension and denied other illnesses. The gastroscopy revealed an ulcerated 35 mm subepithelial lesion in the upper gastric corpus. The computed tomography excluded suspicious lymph nodes and metastasis. On endoscopic ultrasound (EUS) (UCT 10-140 AL5; Olympus) the lesion was hypoechoic and heterogeneous with ill-defi ned borders [Figure 1a] and originated in the fourth layer. Incidentally, an isoechoic 5.8 mm Doppler negative nodule was identifi ed in the pancreatic tail [Figure 1b]. Fine needle aspiration was taken with a 22C needle from the gastric lesion and with a 25-gauge needle from the pancreatic nodule. Cell block cytology was consistent with a gastric stromal tumor [Figure 2a-c] and a neuroendocrine pancreatic tumor [Figure 3a and b]. The patient was readmitted 6 days after discharge with recurrent bleeding and hemodynamic instability and underwent an atypical gastrectomy. At 2 years follow-up there is no evidence of gastric stromal tumor recurrence nor pancreatic neuroendocrine tumor size increase or metastasis.

Hepatic haemangiomatosis: multinodular liver in an asymptomatic elderly man

A 66-year-old man, overweight and a heavy drinker, was sent to our clinic to investigate multiple liver nodules detected on ultrasound. The patient had no symptoms, and physical examination was unremarkable. Laboratory evaluation disclosed an isolated two-fold increase of γ-glutamyltransferase. The MRI revealed multiple millimetric hypervascular nodules suggestive of liver haemangiomatosis, though malignancy could not be ruled out. Liver biopsy was consistent with hepatic haemangiomatosis. We discuss the differential diagnosis and therapeutical approach of a patient with hepatic haemangiomatosis involving the entire liver without associated symptoms or liver dysfunction.

Acute hepatitis in a young woman with systemic lupus erythematosus: a diagnostic challenge

A 48-year-old woman with systemic lupus erythematosus diagnosis was on naproxen, hidroxichloroquine and acetylsalicylic acid. She had self-suspended all medication and resumed 1 year later. Five days after the medication was resumed, she developed acute hepatitis, with biochemical hepatic cytolysis, hypergamaglobulinaemia and a serum antinuclear antibody titre of 1/2560. Idiopathic autoimmune hepatitis was considered, but drug-induced liver injury could not definitely be ruled out. Patient declined liver biopsy. Oral prednisolone was started. Within 3 months with prednisolone being tapered to 10 mg/day, a new flare occurred. Liver biopsy was performed and it favoured autoimmune hepatitis diagnosis. We discuss the diagnostic options and treatment approach in a patient with autoimmune disease and possible drug-induced liver injury who initially declined liver biopsy.