Higher frequency of gastric neoplasia in advanced chronic liver disease patients: Impact of screening endoscopy in an intermediate-high risk country.

BACKGROUND: The Baveno VII guidelines were proposed to identify which patients could safely avoid screening esophagogastroduodenoscopy (EGD) for gastroesophageal varices. We aimed to evaluate the frequency of gastric neoplasia in compensated advanced chronic liver disease (cACLD) patients who underwent EGD for screening of gastroesophageal varices (GOEV) compared to a healthy population. METHODS: Retrospective study that enrolled all cACLD patients who underwent EGD for GOEV screening (January 2008-June 2018) in a tertiary reference center. cACLD patients were compared with asymptomatic healthy individuals who underwent EGD in a private hospital setting (April 2017-March 2018). RESULTS: We evaluated 1845 patients (481 cACLD patients, 1364 healthy individuals). A significantly higher frequency of gastric neoplasia was observed in patients with cACLD compared to healthy individuals (4.0% vs. 1.0 %; p < 0.001). Rare histopathological subtypes (WHO Classification) accounted for 28.7 % of gastric carcinoma cases in the cACLD cohort. Seven cases of gastric neoplasia (36.8 % of gastric neoplasia cases in the cACLD patients) were diagnosed in patients who, according to the Baveno VII criteria, would have not been submitted to EGD. CONCLUSION: We found an increased frequency of gastric neoplasia in patients with cACLD in comparison with healthy individuals. In countries with intermediate-high risk for GC, continuing to perform EGD could be beneficial.

Diet of the critically endangered blackchin guitarfish Glaucostegus cemiculus revealed using DNA metabarcoding.

We present the first assessment of the diet of the blackchin guitarfish Glaucostegus cemiculus (Geoffroy Saint-Hilaire, 1817) for West Africa using DNA metabarcoding on stomach contents of individuals captured in the Bijagós Archipelago, Guinea-Bissau. The diet was dominated by crustaceans, particularly caramote prawn Penaeus kerathurus (frequency of occurrence [FO] = 74%, numerical frequency [NF] = 54%) and fiddler crab Afruca tangeri (FO = 74%, NF = 12%). Bony fishes were present in 30% of the stomachs. We highlight the importance of conservation action for intertidal habitats and their associated benthic invertebrates for the survival of the critically endangered blackchin guitarfish.

Renal anastomosing haemangioma.

Anastomosing haemangioma is a rare subtype of haemangioma, a benign vascular tumour. Its rarity stems from its low incidence and difficulty in obtaining an accurate diagnosis. In addition, its histological resemblance to malignant neoplasms may lead to unnecessary overtreatment. Here, we report the case of an asymptomatic male patient with a slight increase in kidney function who underwent an abdominal ultrasound and a CT scan for suspected renal cell carcinoma. Subsequently, the patient underwent laparoscopic left radical nephrectomy. Histological analysis revealed an anastomosing haemangioma. The patient is currently asymptomatic with no relapse or imaging progression. We also present a literature review on anastomosing haemangioma.

Pseudoaneurysm of radial artery after coronary angiography.

Iatrogenic pseudoaneurysms (IPA) are a rare complication of transradial coronary intervention. This brief report aims to present a case report of a radial artery pseudoaneurysm and to review the current management of this entity. Because of the increased performance of transradial coronary intervention, IPA have become more common. Doppler ultrasonography is a fundamental tool to aid the differential diagnosis with other pathologies. There is no consensus on the treatment, which may range from conservative management to surgical repair. Close surveillance after the procedure and early diagnosis are essential to avoid serious complications, such as ischemia of the hand. The management of IPA depends upon morphological characteristics and associated symptoms.

Detection and evaluation of volatile and non-volatile antifungal compounds produced by Bacillus spp. strains.

The identification of antifungal compounds produced by microorganisms is crucial in the context of sustainable agriculture. Bacteria of the genus Bacillus have a broad spectrum of action that can influence plant growth and control pests, vectors of public health relevance and phytopathogens. Lipopeptides are the main compounds related to the biological control of several pathogen species. Strains with biotechnological potential are identified by means of in vitro bioassays and molecular tests. In this study, strains from the Bacillus Bank of Brazilian Agricultural Research Corporation (EMBRAPA/DF/Brazil) were selected to control the fungal pathogens Sclerotinia sclerotiorum and Fusarium oxysporum by pairing assays. The detection of genes for biosynthesis of antifungal compounds from strains with high pathogen-inhibition capacity was correlated with peptide synthesis, such as bacillomycin D, fengycin d, bacilysin and surfactin. Their gene expression in contact with the pathogen was analyzed by Real-Time PCR. The volatile organic compounds produced by selected Bacillus strains were identified and quantified. In co-culture assays, the inhibition zone between Bacillus strains and Sclerotinia sclerotiorum was evaluated by scanning electron microscopy. Thirteen potentially anti-pathogenic strains were selected. Genes related to the synthesis of antifungal peptides were detected in 11 of them. In five strains, all tested genes were detected. Bacillomycin was the most frequently found lipopeptide gene. The fungus-bacteria interaction potentiated the production of volatiles. Several ketones and other volatile compounds with antifungal activity were identified. Relevant morphological changes in the fungus were observed when paired with bacteria. The study demonstrated the efficacy of the selected strains with regard to the biological control of phytopathogens and their biotechnological potential.

Management of median arcuate ligament syndrome: a case-based review.

Dunbar syndrome or median arcuate ligament syndrome is a rare pathology that has a great impact on the quality of life of patients. This brief report aims to present a case report of a successful treatment of Dunbar syndrome and to review the current management of this entity. We present the case of a 37 year-old patient, who was treated by median arcuate ligament laparoscopic resection. The median arcuate ligament syndrome is associated with significant morbidity. There are no diagnostic criteria established so alternative causes of abdominal pain must be excluded. Celiac artery decompression by laparoscopic approach is currently the preferred treatment. Early diagnosis and treatment of this pathology allow a significant improvement in the quality of life of patients.

Paradoxical embolism: a rare cause of acute upper limb ischemia.

Paradoxical embolism is a rare cause of arterial embolism, even more those resulting in acute ischemia of the upper limb. A case of a 45-year-old patient with acute paradoxical upper limb embolization and acute limb ischemia is presented. A review of the most recent evidence on the diagnosis and management of paradoxical embolism were explored. The cardiac defect most associated with paradoxical embolism is a patent foramen oval. The diagnosis can be performed by transthoracic or transesophageal echocardiography. Closure of the foramen oval is a safe and effective procedure; however, there is no clear consensus on when it should be performed, so the strategy should be individualized. A high level of suspicion of paradoxical embolism should exist in the presence of simultaneous venous and arterial embolism. The investigation of the embolic source is fundamental to avoid the recurrence of events.

Clinicopathological characteristics and prognostic factors of small bowel lymphomas: a retrospective single-center study.

Background: There is little information on diagnosis and management of small bowel lymphomas, and optimal management strategies are still undefined. This study aims to describe their main clinical and pathological characteristics and identify poor prognostic factors. Methods: A retrospective observational study of all patients with histological diagnosis of small bowel lymphoma between January 2010 and December 2020 was performed. Results: We included 40 patients, with male predominance (60%) and mean age of 60.7 years. The ileum was the most common location, and the most common histological subtypes were follicular lymphoma and diffuse large B-cell lymphoma. Clinical presentation was variable from asymptomatic patients (30%) to acute surgical complications (35%) including perforation, intestinal obstruction, ileal intussusception, or severe bleeding. Diagnosis was established by endoscopy in 22 patients (55%), and the most common findings included polyps, single mass, diffuse infiltration, or ulceration, whereas 18 (45%) required surgery because of acute presentations or tumor resection, and lymphoma was diagnosed postoperatively. Surgery was curative in one-third of those patients. Median survival was 52 months. Acute presentation (P = 0.001), symptomatic disease (P = 0.003), advanced stage (P = 0.008), diffuse large B-cell lymphoma (P = 0.007), anemia (P = 0.006), hypoalbuminemia (P < 0.001), elevated lactate dehydrogenase (P = 0.02), elevated C-reactive protein (P < 0.001), and absence of treatment response (P < 0.001) were significant predictors of mortality. Conclusion: Small bowel lymphoma is a rare malignancy with diverse clinical and endoscopic presentations that require a high index of suspicion. Primary factors associated with worse outcome included acute presentation, advanced stage, histological subtype, biochemical abnormalities, and absence of treatment response.

CLINICAL AND PATHOLOGICAL CHARACTERIZATION OF HEPATIC LYMPHOMAS: A RETROSPECTIVE SINGLE-CENTER STUDY.

BACKGROUND: The incidence of hepatic lymphoma has been increasing recently and diagnosis can be challenging as clinical presentation and radiological findings are usually variable and non-specific. OBJECTIVE: The aims of this study were to describe their main clinical, pathological and imaging characteristics and identify poor prognostic factors. METHODS: A retrospective study that included all patients with histological diagnosis of liver lymphoma over a 10-year period at our center was performed. RESULTS: A total of 36 patients were identified, with mean age of 56.6 years and male predominance (58%). There were three patients with primary liver lymphoma (8.3%) and 33 with secondary liver lymphoma (91.7%). The most common histological type was diffuse large B-cell lymphoma (33.3%). The most common clinical manifestations included fever, lymphadenopathy, weight loss, night sweats and abdominal discomfort; three patients (11.1%) were asymptomatic. Computed tomography scan revealed heterogenous radiological patterns including a single nodule (26.5%), multiple nodules (41.2%) or diffuse infiltration (32.4%). The mortality rate during follow-up was 55.6%. Higher levels of C-reactive protein (P=0.031) and absence of treatment response (P<0.001) were significantly associated with higher mortality. CONCLUSION: Hepatic lymphoma is a rare disease that may involve liver as part of a systemic disease or, less commonly, be confined to this organ. Clinical presentation and radiological findings are often variable and non-specific. It is associated with high mortality and poor prognostic factors include higher levels of C-reactive protein and absence of response to treatment.

Small Bowel Adenocarcinoma in a Patient with Crohn's Disease: The Role of Balloon-Assisted Enteroscopy.

Introduction: Small bowel adenocarcinoma is a rare but well-known complication of Crohn's disease. Diagnosis can be challenging, as clinical presentation may mimic an exacerbation of Crohn's disease and imaging findings may be indistinguishable from benign strictures. The result is that the majority of cases are diagnosed at the time of operation or postoperatively at an advanced stage. Case Presentation: A 48-year-old male with a previous 20-year history of ileal stenosing Crohn's disease presented with iron deficiency anemia. The patient reported melena approximately 1 month earlier but was currently asymptomatic. There were no other laboratory abnormalities. Anemia was refractory to intravenous iron replacement. The patient underwent computerized tomography enterography, which revealed multiple ileal strictures with features suggesting underlying inflammation and an area of sacculation with circumferential thickening of adjacent bowel loops. Therefore, the patient underwent retrograde balloon-assisted small bowel enteroscopy, where an area of irregular mucosa and ulceration was found at the region of ileo-ileal anastomosis. Biopsies were performed and histopathological examination revealed tubular adenocarcinoma infiltrating the muscularis mucosae. The patient underwent right hemicolectomy plus segmental enterectomy of the anastomotic region where the neoplasia was located. After 2 months, he is asymptomatic and there is no evidence of recurrence. Discussion: This case demonstrates that small bowel adenocarcinoma may have a subtle clinical presentation and that computed tomography enterography may not be accurate enough to distinguish benign from malignant strictures. Clinicians must, therefore, maintain a high index of suspicion for this complication in patients with long-standing small bowel Crohn's disease. In this setting, balloon-assisted enteroscopy may be a useful tool when there is raised concern for malignancy, and it is expected that its more widespread use could contribute to an earlier diagnosis of this severe complication.

Introdução: O adenocarcinoma do intestino delgado é uma complicação rara mas bem estabelecida da doença de Crohn. O seu diagnóstico pode ser desafiante, na medida em que a apresentação clínica pode mimetizar uma agudização da doença de Crohn e os achados imagiológicos podem ser indistinguíveis de estenoses benignas. Em consequência, a maioria dos casos são diagnosticados durante ou após a cirurgia em estadio avançado. Descrição do caso: Um homem de 48 anos com antecedentes de doença de Crohn ileal estenosante, com 20 anos de evolução, apresentou-se com anemia ferropénica. O doente referia melenas aproximadamente um mês antes, mas encontrava-se atualmente assintomático. Não apresentava outras alterações laboratoriais de relevo. A anemia era refratária a suplementação com ferro endovenoso. Foi submetido a enterografia por tomografia computorizada, que revelou múltiplas estenoses ileais com caraterísticas sugestivas de atividade inflamatória e uma área de saculação com espessamento circunferencial das ansas de intestino delgado adjacentes. Assim, foi submetido a enteroscopia assistida por balão, onde se identificou uma área de mucosa irregular e ulceração na região da anastomose ileo-ileal. Biópsias desta área revelaram a presença de adenocarcinoma tubular com infiltração até à muscularis mucosae. O doente foi submetido a hemicolectomia direita com enterectomia segmentar da região da anastomose onde a neoplasia se encontrava localizada. Ao fim de 2 meses, o doente encontra-se assintomático e sem evidência de recorrência. Discussão: Este caso demonstra que o adenocarcinoma do intestino delgado pode ter uma apresentação clínica subtil e que a enterografia por tomografia computorizada pode não ter precisão suficiente para distinguir estenoses benignas de neoplasias malignas. Os clínicos devem, portanto, manter um elevado índice de suspeição diagnóstica para esta complicação em doentes com doença de Crohn ileal de longa duração. Neste contexto, a enteroscopia assistida por balão pode ser uma ferramenta útil em casos de suspeita de neoplasia maligna, esperando- se que possa contribuir para um diagnóstico mais precoce desta complicação severa.

Colonic perineurioma of the transverse colon: presentation of a rare neoplasm in an atypical location.

A 51-year-old male with previous medical history of dyslipidemia performed screening colonoscopy, which revealed a sessile polypoid lesion with a diameter of approximately 8 mm located at the proximal transverse colon, which was resected en bloc with a cold snare. Remarkably, histopathological examination revealed a proliferation of spindle cells in the lamina propria entrapping colonic crypts without evidence of nuclear pleomorphism, mitotic figures or necrosis. On immunohistochemistry, spindle cells were diffusely positive for glucose transporter-1 and negative for S100, DOG1, CD34 and smooth muscle actin. These features were consistent with a diagnosis of colonic perineurioma.

Primary gastric choriocarcinoma: a rare and aggressive gastrointestinal malignancy.

A 40-year-old male with no previous medical history presented to emergency department with a 2-week history of progressive dyspnea. He also described night sweats and weight loss (15 kg) during the last 3 months. Thoraco-abdominal computed tomography showed multiple bilateral lung nodules associated with supra-clavicular, hilar and peri-esophageal lymphadenopathies and gastric parietal thickening. These imaging features were suggestive of primary gastric cancer with lung and lymph node metastases. Therefore, he undergone upper digestive endoscopy that showed a large ulcerated protruding lesion at the greater curvature of the body suggestive of malignancy. Gastric biopsies of the lesion confirmed a solid neoplasia constituted by solid nests and sheets of highly pleomorphic, bizarre cells with cytotrophoblastic and syncytiotrophoblastic differentiation that, on immunohistochemistry, stained positive for ß-HCG, SALL-4 and glypican-3. CT-guided biopsy of lung nodules revealed malignant cells with similar histopathological and immunohistochemical features. Elevated serum alpha-fetoprotein and ß-HCG were also detected. Clinical and ultrasound examination were negative for testicular masses. These findings were consistent with a primary gastric choriocarcinoma presenting with lung and lymph node metastases (stage IV). Although chemotherapy was started, the patient evolved unfavorably and died after 9 months. Primary gastric choriocarcinoma is a rare and aggressive gastrointestinal malignancy. This case demonstrates its rapid growth rate and high metastatic potential that may lead to symptoms from secondary involvement of distant organs.

Liver biopsy in inflammatory bowel disease patients with sustained abnormal liver function tests: a retrospective single-center study.

Background: Inflammatory bowel disease (IBD) may be associated with a wide range of hepatobiliary manifestations. This study aimed to characterize the spectrum of hepatobiliary disorders in patients with IBD who underwent liver biopsy for sustained abnormal liver function tests (LFT). Method: A retrospective study was performed of all patients with IBD who underwent liver biopsy between January 2010 and December 2020 for sustained abnormal LFT (at least 6-month duration). Results: A total of 101 patients were included, mostly male (62.4%), with a mean age of 44.4±13.3 years. The most common IBD type was Crohn's disease (61.4%). Median time interval between abnormal LFT and biopsy was 14 (7-36) months. Abnormal LFT was predominantly hepatocellular in 40 patients (39.6%), cholestatic in 26 (25.7%) and mixed in 35 (34.7%). The most frequent diseases were nonalcoholic fatty liver disease (NAFLD) in 33 patients (32.7%), drug-induced liver disease (DILI) in 30 (29.7%), autoimmune hepatitis (AIH) in 13 (12.9%) and primary sclerosing cholangitis (PSC) in 13 (12.9%). Three patients had primary biliary cholangitis. Remarkably, 70 patients (69.3%) already had fibrosis by the time of liver biopsy and in 6 (5.9%) liver disease was already detected in the stage of cirrhosis. Conclusions: Abnormal LFT in IBD patients had a wide range of etiologies and histology was often essential for reaching a correct diagnosis. NAFLD, DILI, AIH and PSC were the most common diagnoses and patients often presented in cirrhotic stage. Therefore, liver biopsy must be considered early in IBD patients with unexplained sustained abnormal LFT.

Juvenile polyps with osseous metaplasia treated by endoscopic mucosal resection.

A 17-year-old male with no previous medical history presented with a 1-year history of rectal bleeding, mucus discharge and occasional rectal prolapse. Colonoscopy revealed several polypoidal growth masses in the distal rectum, formed by multiple sessile polyps with a glistening mucus-covered surface and fleshy, friable appearance, that coalesced forming large conglomerates. Given their complexity and large size, piecemeal endoscopic mucosal resection of the rectal lesions was performed and histopathological examination revealed ulcerated polypoid mucosa with mixed inflammatory cell infiltrate in the lamina propria and dilated cystic mucus-filled glands. Remarkably, bony trabeculae surrounded by osteoblastic cells were also seen. These findings were consistent with juvenile polyps with foci of osseous metaplasia. Osseous metaplasia has been described in a wide variety of tissue types, such as prostate, uterus, breasts, lungs and urinary tract, with respect to both neoplastic and non-neoplastic conditions. However, it is exceedingly rare in colonic polyps and, to the best of our knowledge, only 9 cases have been described in juvenile polyps.

Caracterização clínica e patológica dos linfomas hepáticos: um estudo retrospetivo unicêntrico / Clinical and pathological characterization of hepatic lymphomas: a retrospective single-center study

ABSTRACT Background: The incidence of hepatic lymphoma has been increasing recently and diagnosis can be challenging as clinical presentation and radiological findings are usually variable and non-specific. Objective The aims of this study were to describe their main clinical, pathological and imaging characteristics and identify poor prognostic factors. Methods A retrospective study that included all patients with histological diagnosis of liver lymphoma over a 10-year period at our center was performed. Results A total of 36 patients were identified, with mean age of 56.6 years and male predominance (58%). There were three patients with primary liver lymphoma (8.3%) and 33 with secondary liver lymphoma (91.7%). The most common histological type was diffuse large B-cell lymphoma (33.3%). The most common clinical manifestations included fever, lymphadenopathy, weight loss, night sweats and abdominal discomfort; three patients (11.1%) were asymptomatic. Computed tomography scan revealed heterogenous radiological patterns including a single nodule (26.5%), multiple nodules (41.2%) or diffuse infiltration (32.4%). The mortality rate during follow-up was 55.6%. Higher levels of C-reactive protein (P=0.031) and absence of treatment response (P<0.001) were significantly associated with higher mortality. Conclusion Hepatic lymphoma is a rare disease that may involve liver as part of a systemic disease or, less commonly, be confined to this organ. Clinical presentation and radiological findings are often variable and non-specific. It is associated with high mortality and poor prognostic factors include higher levels of C-reactive protein and absence of response to treatment.

RESUMO Contexto A incidência de linfoma hepático tem aumentando recentemente e o diagnóstico pode ser desafiante, na medida em que a apresentação clínica e os achados imagiológicos são geralmente variáveis e inespecíficos. Objetivo: Os objetivos deste estudo foram descrever suas principais características clínicas, patológicas e de imagem e identificar fatores de mau prognóstico. Métodos: Foi realizado um estudo retrospetivo que incluiu todos os pacientes com diagnóstico histológico de linfoma hepático num período de 10 anos no nosso centro. Resultados: Foram identificados 36 pacientes, com média de idade de 56,6 anos e predomínio de género masculino (58%). Havia três pacientes com linfoma hepático primário (8,3%) e 33 com linfoma hepático secundário (91,7%). O tipo histológico mais comum foi o linfoma difuso de grandes células B (33,3%). As manifestações clínicas mais comuns incluíram febre, linfadenopatia, emagrecimento, hipersudorese noturna e desconforto abdominal; 3 (11,1%) pacientes eram assintomáticos. A tomografia computadorizada revelou padrões radiológicos heterogêneos, incluindo um único nódulo (26,5%), múltiplos nódulos (41,2%) ou infiltração difusa (32,4%). A taxa de mortalidade durante o seguimento foi de 55,6%. Níveis mais elevados de proteína C reativa (P=0,031) e ausência de resposta ao tratamento (P<0,001) foram significativamente associados a maior mortalidade. Conclusão O linfoma hepático é uma doença rara que pode envolver o fígado como parte de uma doença sistêmica ou, menos comumente, estar confinado a este órgão. A apresentação clínica e os achados radiológicos são frequentemente variáveis e inespecíficos. Associa-se a elevada mortalidade e fatores de mau prognóstico incluem níveis mais elevados de proteína C reativa e ausência de resposta ao tratamento.

Acute gastrointestinal graft-versus-host disease with cytomegalovirus and Epstein-Barr virus superinfection in a patient with COVID-19.

A 60-year-old female was diagnosed with acute myeloid leukemia. After initial remission with chemotherapy, she relapsed and underwent allogeneic hematopoietic stem cell transplantation (HSCT). Two months later, she presented to emergency department with watery diarrhea, abdominal pain and fever. She also tested positive for SARS-CoV2 on nasopharyngeal swab by polymerase chain reaction (PCR) and both cytomegalovirus (CMV) and Epstein-Barr virus (EBV) were detected in peripheral blood. Flexible sigmoidoscopy showed diffuse edema, erythema and loss of vascular pattern with interspersed segments of mucosal denudation and exudate and bBiopsies revealed epithelial cell apoptosis, diffuse crypt atrophy and dropout, with ulceration and both CMV and EBV were detected in colon mucosa, consistent with acute severe gastrointestinal graft-versus-host disease complicated by CMV and EBV superinfection. Despite starting therapy with methylprednisolone, ganciclovir and rituximab,she presented unfavorable evolution and died after 5 weeks.

Low risk of local recurrence after a successful en bloc endoscopic submucosal dissection for noninvasive colorectal lesions with positive horizontal resection margins (R-ESD study).

BACKGROUND : During endoscopic submucosal dissection (ESD), the normal mucosa is cut under constant optical control. We studied whether a positive horizontal resection margin after a complete en bloc ESD predicts local recurrence. METHODS: In this European multicenter cohort study, patients with a complete en bloc colorectal ESD were selected from prospective registries. Cases were defined by a horizontal resection margin that was positive or indeterminate for dysplasia (HM1), whereas controls had a free resection margin (HM0). Low risk lesions with submucosal invasion (T1) and margins free of carcinoma were analyzed separately. The main outcome was local recurrence. RESULTS: From 928 consecutive ESDs (2011-2020), 354 patients (40 % female; mean age 67 years, median follow-up 23.6 months), with 308 noninvasive lesions and 46 T1 lesions, were included. The recurrence rate for noninvasive lesions was 1/212 (0.5 %; 95 %CI 0.02 %-2.6 %) for HM0 vs. 2/96 (2.1 %; 95 %CI 0.57 %-7.3 %) for HM1. The recurrence rate for T1 lesions was 1/38 (2.6 %; 95 %CI 0.14 %-13.5 %) for HM0 vs. 2/8 (25 %; 95 %CI 7.2 %-59.1 %) for HM1. CONCLUSION: A positive horizontal resection margin after an en bloc ESD for noninvasive lesions is associated with a marginal nonsignificant increase in the local recurrence rate, equal to an ESD with clear horizontal margins. This could not be confirmed for T1 lesions.