Luís Tomé

Levofloxacin or Clarithromycin-based quadruple regimens: what is the best alternative as first-line treatment for Helicobacter pylori eradication in a country with high resistance rates for both antibiotics?

BackgroundHelicobacter pylori eradication rates in Portugal are declining, due to increased resistance of this bacterium to antimicrobial agents, especially Clarithromycin. Quadruple Levofloxacin-containing regimens could be an option for first-line treatment, but its efficacy should be evaluated as fluoroquinolone resistance is rapidly increasing.Our aim was to compare the efficacy of Clarithromycin and Levofloxacin-based sequential quadruple therapies as first-line treatment options and determine factors associated with treatment failure.MethodsA total of 200 Helicobacter pylori infected patients were retrospectively included (female 57.5%; average age: 53.2u2009±u200915.7) and received either 10-day sequential therapy (Proton-Pump Inhibitoru2009+u2009Amoxicillin 1xa0g bid for 5xa0days and Proton-Pump Inhibitoru2009+u2009Clarithromycin 500xa0mgu2009+u2009Metronidazole/Tinidazole 500xa0mg bid/tid in the following 5xa0days; group A) or a 10-day modified sequential therapy with Levofloxacin 500xa0mg id instead of Clarithromycinxa0(group B). Eradication was confirmed with urea breath test. Variables that could influence success rate were analyzed.ResultsThere were no differences between groups in terms of gender, age, smoking habits and indications for treatment. The eradication rate obtained with Clarithromycin-based sequential treatment was significantly higher than with Levofloxacin-based therapy (90%, CI95%: 84–96% vs. 79%, CI95%: 71–87%, pu2009=u20090.001). Using full-dose proton-pump inhibitor and high-dose Metronidazole in group A, and full-dose proton-pump inhibitor and prescription from a Gastroenterologist in group B were associated with eradication success.ConclusionsTen-day Levofloxacin-based sequential treatment achieved inadequate efficacy rate (<80%) and should not be adopted as first-line therapy. Standard sequential therapy showed significantly better results in this naïve population. Using full-dose proton-pump inhibitor and higher doses of Metronidazole is essential to achieve such results.

Endoscopic Management of Colonic Perforation due to Ventriculoperitoneal Shunt: Case Report and Literature Review

The authors report the case of a 41-year-old woman with a colonic perforation due to a ventriculoperitoneal shunt (VPS) catheter. Left-sided colonic perforation was diagnosed by abdominal computed tomography 28 years after shunt placement, following acute meningitis caused by Escherichia coli. The proximal end of the VPS was exteriorized and it was decided to remove the distal end by colonoscopy. After pulling out the catheter with a polypectomy snare, it broke at the site where it was entering the colon, leaving a small perforation in the colonic wall which was closed with 2 endoclips. The endoluminal fragment of the catheter, being 20 cm in length, was removed through the rectum. The patient is asymptomatic at the 12-month follow-up. A review of the literature regarding 9 endoscopically managed cases of digestive tract perforation caused by VPS is presented.

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.

Flupirtine drug-induced liver injury in a patient developing acute liver failure

A patient is admitted with complaints of recent onset nausea, discomfort, jaundice and blood tests that reveal severe hepatitis. At the time, she had been taking medication with Hypericum perforatum (St John’s wort) for 6u2009months, and 6u2009weeks before this event, she took flupirtine maleate. A few days after being admitted, she developed encephalopathy progressing to acute liver failure (ALF) requiring unsuccessful liver transplantation. The patient was ultimately diagnosed with drug-induced liver injury (DILI). In this context, while H. perforatum could interfere with other medication or trigger DILI itself, flupirtine appears to have triggered the DILI, given its liver toxicity capacity. DILI is one of the major ALF causes and can jeopardise patient’s life. Accordingly, all efforts to reduce medication potentially hazardous to the liver are recommended.

Acute-on-chronic mesenteric ischaemia by early and diffuse atherosclerosis in a young adult patient

A 48-year-old Caucasian man with gypsy ethnicity had smoking habits (35 pack-years) and previous alcohol consumption (10u2009g/day; abstinent for 3u2009years). There was no relevant personal/family cardiovascular disease, history of illicit drug abuse, non-steroidal anti-inflammatory drug use or other previous/current medications. He had a 3-year history of chronic diarrhoea (3–4 bowel movements/day), abdominal pain and weight loss (25.9% of usual weight; body mass index=13.7u2009kg/m2). In the last month, an exacerbation of abdominal pain occurred with excruciating postprandial episodes requiring opioid analgesia. Laboratory analysis showed leucocytosis (34.8; N: 4–11×109/L), neutrophilia (90.6%), normocytic/normochromic anaemia (haemoglobin: 8.0; N: 13–17u2009g/dL), high Erythrocyte sedimentation rate (ESR) (54; N<20u2009mm/hour), faecal calprotectin (4890; n<50u2009mg/kg) and C-reactive proteinxa0(CRP) (10.7; N<0.5u2009mg/dL). Oesophagogastroduodenoscopy and ileocolonoscopy with biopsies showed multiple Helicobacter pylori -negative gastroduodenal ulcers (figure 1A,B) and non-specific mild ulceration of the terminal ileum and proximal colon, without …

Red cell distribution width and red cell distribution width to total serum calcium ratio as major predictors of severity and mortality in acute pancreatitis

BackgroundAcute pancreatitis (AP) is associated with considerable morbidity and mortality. Current severity scores include multiple variables and some of them are only complete within 48xa0h of admission. Red cell distribution width (RDW) is a simple and routine parameter that seems to be related to inflammatory status. Our aims were to evaluate the diagnostic value of RDW in severity and mortality of AP comparing with other prognostic scoring systems.MethodsRetrospective case-control study of a total of 312 patients with AP admitted between 2014 and 2016. Patients with severe AP (cases) were compared with patients with mild AP (controls) in the 1:1 proportion. Additionally, a comparison between survivor and nonsurvivor AP patients was performed. Diagnosis and severity of AP were defined according to the revised Atlanta classification 2012. Variables evaluated included demographics, comorbidities, hospital stay, laboratorial parameters, arterial blood gas analysis, prognostic scores within 24xa0h of admission (Ranson, BISAP and Modified Marshall) and mortality.ResultsIncluded 91 cases of severe AP, most males (58.2%u2009vsu200951.6%; pu2009=u20090.228) with mean age of 64.8u2009±u200916.3xa0years (vs 67.9u2009±u200913.7; pu2009=u20090.239). RDW0h was higher in patients with severe AP (14.6u2009±u20091.3u2009vsu200912.7u2009±u20090.5; pu2009<u20090.001), as well as RDW0h-to-serum calcium ratio (1.8u2009±u20090.3u2009vsu20091.3u2009±u20090.1; pu2009<u20090.001). After multivariate and ROC curve analysis, RDW0h (AUROC: 0.960; pu2009<u20090.001) and RDW0h-to-serum calcium ratio (AUROC:u20090.973; pu2009<u20090.001) were the major predictors of severe AP for a cut-off value of 13.0 (S:u200992.7%; Sp:u200984.3%) and 1.4 (S:u200996.3%; Sp:u200984.3%), respectively. These factors were superior to prognostic scores, such as Ranson (AUROC:u20090.777; pu2009<u20090.001;u2009cut-off:u20093.0), BISAP (AUROC:u20090.732;u2009pu2009<u20090.001;u2009cut-off:u20092.0) and Modified Marshall (AUROC:u20090.756; pu2009<u20090.001; cut-off:u20091.0). The mortality rate was 8.8% (16/182), all cases associated with severe AP (17.6%;u200916/91). RDW0h and RDW0h-to-serum calcium ratio were higher in nonsurvivor AP patients (15.3u2009±u20091.4u2009vsu200913.5u2009±u20091.3; pu2009<u20090.001 and 2.0u2009±u20090.3 vs 1.6u2009±u20090.3; pu2009<u20090.001, respectively). In multivariate and ROC curve analysis, RDW0h (AUROC:u20090.842; pu2009<u20090.001;u2009cut-off:u200914.0), RDW24h (AUROC:u20090.848; pu2009<u20090.001;u2009cut-off:u200913.8) and RDW0h-to-serum calcium ratio (AUROC:u20090.820; pu2009<u20090.001;u2009cut-off:u20091.7) were independent predictors for AP mortality, superior to conventional prognostic scoring systems Ranson (AUROC:u20090.640; pu2009=u20090.003; cut-off:3.0), BISAP (AUROC:u20090.693; pu2009=u20090.017;u2009cut-off:u20092.0) and Modified Marshall (AUROC:u20090.806; pu2009<u20090.001;u2009cut-off:1.0).ConclusionsRDW is a simple routine parameter, available at admission. This AP cohort showed that RDW0hu2009>u200913.0 and RDW0h-to-total serum calcium ratiou2009>u20091.4 were excellent predictors for severity and RDW0hu2009>u200914.0 and RDW0h-to-total serum calcium ratiou2009>u20091.7 were very-good predictors for mortality, being superior to conventional prognostic scoring systems.

Uncertainties in the Management of a Lynch Syndrome Patient: A Case Report

Introduction: Lynch syndrome (LS), the most common hereditary colorectal cancer syndrome, is characterized by mutations in mismatch repair (MMR) genes leading to an increased cancer risk, namely colorectal cancer. Case: In the context of surveillance colonoscopy, a 40-mm flat lesion (0-IIa+b, Paris classification) was identified and submitted to piecemeal mucosal endoscopic resection in a 64-year-old LS patient with an MLH1 germline mutation (262delATC) and two previous segmental resections due to metachronous colorectal cancer. Pathology raised the suspicion of superficial submucosal invasive carcinoma with poor differentiation. Immunochemistry showed heterogeneous MLH1 expression and PMS2 loss. In a short-term follow-up colonoscopy, another 30-mm advanced carcinoma was identified. The patient was referred to surgery. Conclusion: This case raises several issues: (1) the potentially fast tumorigenesis and progression to carcinoma in LS and implications for endoscopic screening and surveillance; (2) pitfalls in the interpretation of MMR proteins immunochemistry; (3) the role of endoscopic resection in LS.

Efficacy of Endoscopic Retrograde Cholangiopancreatography in the Treatment of Biliary Complications following Liver Transplant: 10 Years of a Single-Centre Experience

Background and Aims: Biliary tract complications following liver transplant remain an important source of morbidity and mortality. Endoscopic retrograde cholangiopancreatography (ERCP) has become a common therapeutic option before other invasive procedures. The aim of this study was to evaluate ERCP efficacy in managing this type of complications. Methods: Retrospective study of all patients who underwent therapeutic ERCP due to post-liver transplant biliary complications between September 2005 and September 2015, at a deceased donor liver transplantation centre. Results: Therapeutic ERCP was performed in 120 patients (64% men; mean age 46 ± 14 years). Biliary complications were anastomotic strictures (AS) in 70%, non-anastomotic strictures (NAS) in 14%, bile leaks (BL) in 5.8%, and bile duct stones (BDS) in 32%. The mean time between liver transplant and first ERCP was: 19 ± 30 months in AS, 17 ± 30 months in NAS, 61 ± 28 months in BDS, and 0.7 ± 0.6 months in BL (p < 0.001). The number of ERCP performed per patient was: 3.8 ± 2.4 in AS, 3.8 ± 2.1 in NAS, 1.9 ± 1 in BDS, and 1.9 ± 0.5 in BL (p = 0.003). The duration of the treatment was: 18 ± 19 months in AS, 21 ± 17 months in NAS, 10 ± 10 months in BDS, and 4 ± 3 months in BL (p = 0.064). Overall, biliary complications were successfully managed by ERCP in 46% of cases, either as an isolated procedure (43%) or rendez-vous ERCP (3%). Per complication, ERCP was effective in 39% of AS, in 12% of NAS, in 91% of BDS, and in 86% of BL. Globally, the mean follow-up of the successful cases was 43 ± 31 months. Percutaneous transhepatic cholangiography and/or surgery were performed in 48% of patients in whom ERCP was unsuccessful. The odds ratio for effective endoscopic treatment was 0.2 for NAS (0.057-0.815), 12.4 for BDS (1.535-100.9), and 6.9 for BL (0.798-58.95). No statistical significance was found for AS (p = 0.247). Conclusions: ERCP allowed the treatment of biliary complication in about half of patients, avoiding a more invasive procedure. Endoscopic treatment was more effective for BDS and BL.

A Rare Clinical Presentation of Cholangiocarcinoma

Cholangiocarcinoma is an uncommon tumor, often diagnosed in the context of obstructive jaundice. Brain metastasis rarely occurs with the cerebellum being a rare site of spread of this type of tumor. Few cases of cholangiocarcinoma have been reported in the literature and this type of tumor is associated with a very poor outcome. We present a very rare form of clinical presentation of cholangiocarcinoma with neurologic symptoms due to cerebellar metastases.

Challenging and uncommon diagnosis of long-evolution ascites

This is a case report of a 45-year-old Caucasian man with chronic alcoholism. No history of liver disease or asbestos exposure. He complained of ascites during the last 3u2009years with worsening in the last year with severe ascites development. Diagnostic paracentesis showed SAAG 1.1 and high cellularity with neutrophil count >250u2009cells/µL. Ascitic fluid cytology revealed reactive mesothelial hyperplasia. Thoracoabdominopelvic ultrasonography/CT/MRI and fludeoxyglucose positron emission tomography/CT showed ‘omental cake’ pattern suggesting peritoneal carcinomatosis. An exploratory laparoscopy revealed moderate interloop adhesions and necrosis with whitish exudate in the right pelvic excavation. Biochemical/cytological/histological/microbiological study only revealed reactive mesothelial cells, necrosis and lymphohistiocytic inflammatory infiltrate. A second exploratory laparoscopy with liver and peritoneal biopsies and appendectomy/mesoappendix excision showed a well-differentiated tubulopapillary mesothelioma. The patient was referred for intraperitoneal chemotherapy and is undergoing monthly therapeutic paracentesis.