Rita Carvalho

Endometriosis: A Rare Cause of Large Bowel Obstruction

Large bowel obstruction can result in significant morbidity and mortality, especially in cases of acute complete obstruction. There are many possible causes, the most common in adults being colorectal cancer. Endometriosis is a benign disease, and the most affected extragenital location is the bowel, especially the rectosigmoid junction. However, transmural involvement and acute occlusion are very rare events. We report an exceptional case of acute large bowel obstruction as the initial presentation of endometriosis. The differential diagnosis of colorectal carcinoma may be challenging, and this case emphasizes the need to consider intestinal endometriosis in females at a fertile age presenting with gastrointestinal symptoms and an intestinal mass causing complete large bowel obstruction.

Isolated Visceral Angioedema Induced by Angiotensin-Converting Enzyme Inhibitor

Visceral angioedema is a rare complication of therapy with angiotensin-converting enzyme (ACE) inhibitors. Clinical presentation includes nausea, vomiting, abdominal pain and diarrhea. Early detection of this entity can prevent recurrent episodes and unnecessary invasive procedures, including surgery. This article describes a 46-year-old-woman who presented to the emergency department with abdominal pain, associated with nausea and vomiting. She had been taking ramipril for 15 days. A computed tomography was performed which revealed thickening of a jejunal segment, with submucosal edema. ACE inhibitor-associated angioedema was suspected and the medication was discontinued, with resolution of symptoms in 48 h. After 7 months of follow-up, the patient is asymptomatic. Despite of its rarity, ACE inhibitor-induced small-bowel angioedema should be included in the differential diagnosis when patients receiving ACE inhibitor therapy present with abdominal complaints.

Acute Hepatitis in the DRESS Syndrome

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe, idiosyncratic reaction characterized by diffuse maculopapular rash, facial edema, lymphadenopathy, fever, eosinophilia and/or other leukocyte abnormalities, and involvement of internal organs as liver, kidney, heart and lung. Diagnosing this entity is specifically complicated due to the multiplicity of organs involved. DRESS syndrome must be recognized promptly and the causative drug withdrawn in order to improve patient outcomes. Indeed, it is a potentially life-threatening condition, with a reported mortality between 5 and 20%. We describe a case of a 22-year old woman admitted to our hospital with acute diffuse, pruritic rash associated with crampy abdominal pain, vomiting, diarrhea and fever three weeks after starting sulfasalazine therapy. Initially, laboratory parameters revealed normal white blood cell count and normal liver enzymes, but during hospitalization, eosinophilia developed and liver enzymes, including transaminases and cholestatic parameters, dramatically increased. The diagnostic of DRESS syndrome was made and sulfasalazine was withdrawn and as there were signs of disease severity, systemic corticotherapy was initiated, with gradually improvement of the rash and symptoms resolution. The patient was discharged home after thirty days of hospitalization.

Comparison of the AIMS65 Score with Other Risk Stratification Scores in Upper Variceal and Nonvariceal Gastrointestinal Bleeding

To the Editor: The authors read with interest the article about the performance of three risk stratifying scores in patients with upper gastrointestinal bleeding (UGIB) applied in a Korean population, by Choe et al., recently published in Gut and Liver. UGIB is one of the most common emergencies for gastroenterologists, and, as previously discussed in the mentioned article, early risk stratification is important to determine priorities and define which patients benefit from early endoscopy and more aggressive clinical intervention. Although there are risk scores to predict clinical outcomes in UGIB, the most used being the Glasgow-Blatchford score (GBS), Rockall score (RS), and AIMS65 score (AIMS65), uncertainty still exists about the optimal score that could be uniformly applied in clinical practice. In addition, because most studies about risk scoring excluded patients with variceal bleeding, few data are available on the use of this scores in patients with variceal bleeding. We recently conducted a retrospective single-center study which compared the performance of three scoring systems (GBS, RS, and AIMS65) in Portuguese patients. The consecutive patients admitted to our institution’s emergency department with UGIB over a period of 12 months (between January 2016 and December 2016) were included. Both patients with variceal and nonvariceal bleeding were included. Two major endpoints were considered: (1) composite endpoint–need for any clinical intervention (transfusion, endoscopic therapy, surgery or radiological intervention) and (2) UGIB related mortality at 30 days after admission. The accuracy of each scoring system for the considered endpoints was calculated using the area under the receiver operating characteristic curve (AUROC), with 95% confidence interval. Statistical analysis was performed on MedCalc statistical software (Medcalc Software, Mariakerke, Belgium). A total of 202 patients were included, the majority (75%)

Endoscopy Timing in Patients with Acute Upper Gastrointestinal Bleeding

Background/Aims The role of very early (≤12 hours) endoscopy in nonvariceal upper gastrointestinal bleeding is controversial. We aimed to compare results of very early and early (12–24 hours) endoscopy in patients with upper gastrointestinal bleeding demonstrating low-risk versus high-risk features and nonvariceal versus variceal bleeding. Methods This retrospective study included patients with nonvariceal and variceal upper gastrointestinal bleeding. The primary outcome was a composite of inpatient death, rebleeding, or need for surgery or intensive care unit admission. Endoscopy timing was defined as very early and early. We performed the analysis in two subgroups: (1) high-risk vs. low-risk patients and (2) variceal vs. nonvariceal bleeding. Results A total of 102 patients were included, of whom 59.8% underwent urgent endoscopy. Patients who underwent very early endoscopy received endoscopic therapy more frequently (p=0.001), but there was no improvement in other clinical outcomes. Furthermore, patients at low risk and with nonvariceal bleeding who underwent very early endoscopy had a higher risk of the composite outcome. Conclusions Very early endoscopy does not seem to be associated with improved clinical outcomes and may lead to poorer outcomes in specific populations with upper gastrointestinal bleeding. The actual benefit of very early endoscopy remains controversial and should be further clarified.

Secondary Aortoduodenal Fistula Causing MassiveUpper Gastrointestinal Bleeding

A 53-year-old man, with past medical history of hypertension, alcoholism, lung adenocarcinoma submitted to right upper lobectomy and peripheral artery disease with previous aortobifemoral bypass was admitted in the emergency department for acute massive hematemesis. At observation, he was hypotensive and tachycardic. A nasogastric tube was placed, with drainage of large amounts of red blood. There were no other relevant findings on physical examination. Laboratory tests revealed normocytic normochromic anemia (hemoglobin 8.8g/dL) and mild hyperlactacidemia. After initial resuscitation, emergent upper gastrointestinal endoscopy (UGE) was performed, revealing a grey regular mass covered by network-like material, adhering to a pulsatile zone of the distal duodenum wall (Figures 1A & 1B). The patient immediately underwent abdominal contrast-enhanced computed tomography (CT) which showed infrarenal aorto-bifemoral prosthesis, with the wall of the fourth duodenal portion not being identified, confirming the suspected diagnosis of secondary aortoduodenal fistula (SADF) (Figure 2). Vascular surgery with exclusion of the SADF and placement of endoprothesis was successfully performed. One year after the surgery, the patient remains asymptomatic.

The albumin-bilirubin score predicting the mortality of patients with decompensated cirrhosis.

We read with interest the article by Zou et al. (1), published in March 2016. In their retrospective study of 631 patients, the authors concluded that the performance of the albumin-bilirubin (ALBI) score was comparable with that of Child-Pugh and model for end-stage liver disease (MELD) scores for predicting the in-hospital mortality of patients with acute upper gastrointestinal bleeding (GIB) and liver cirrhosis (2). However, the authors did not compare GIB with other types of decompensated cirrhosis.

A Complex Case of Cholestasis in a Patient with ABCB4 and ABCB11 Mutations

The low-phospholipid-associated cholelithiasis (LPAC) syndrome is a form of symptomatic cholelithiasis occurring in young adults, characterized by recurrence of symptoms after cholecystectomy and presence of hepatolithiasis. The case refers to a healthy 39-year-old Caucasian male who presented with abdominal pain and jaundice. His blood tests showed conjugated hyperbilirubinemia and elevated liver enzymes (total bilirubin 6.65 mg/dL, γ-glutamyltransferase 699 IU/L) and abdominal computed tomography revealed dilation of common bile duct and left intrahepatic ducts. Magnetic resonance cholangiopancreatography identified choledocholithiasis, retrieved by endoscopic retrograde cholangiopancreatography, after which there was a worsening of jaundice (total bilirubin 23 mg/dL), which persisted for several weeks, possibly due to ciprofloxacin toxicity. After an extensive workup including liver biopsy, the identification of two foci of hepatolithiasis on reevaluation abdominal ultrasound raised the hypothesis of LPAC syndrome and the patient was started on ursodeoxycholic acid, with remarkable improvement. Genetic testing identified the mutation c.1954A>G (p.Arg652Gly) in ABCB4 gene (homozygous) and c.1331T>C (p.Val444Ala) in ABCB11 gene (heterozygous). In conclusion, we describe the unique case of an adult male with choledocholithiasis, hepatolithiasis, and persistent conjugated hyperbilirubinemia after retrieval of stones, fulfilling the criteria for LPAC syndrome and with possible superimposed drug-induced liver injury, in whom ABCB4 and ABCB11 mutations were found, both of which had not been previously described in association with LPAC.