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BACKGROUND AND AIMS: The histological status of ulcerative colitis [UC] patients in clinical and endoscopic remission has gained space as an important prognostic marker and a key component of disease monitoring. Our main aims were to compare two histological indexes-the continuous Geboes score [GS] and the Robarts Histopathology index [RHI]-regarding their definitions of histological remission and response, and the ability of faecal calprotectin [FC] levels to discriminate between these statuses. METHODS: This was an analysis of three prospective cohorts including 422 patients previously enrolled in other studies. RESULTS: The two continuous scores [GS and RHI] were shown to be significantly correlated [correlation coefficient of 0.806, p < 0.001] and particularly close regarding their definition of histological response: 95% and 88% of all patients classified as having/not having [respectively] histological response according to RHI also did so according to GS. Moreover, median FC levels in patients with histological response were lower than those in patients without histological response [GS: 73.00 vs 525.00, p < 0.001; RHI: 73.50 vs 510.00, p < 0.001]; a similar trend was observed when FC levels of patients in histological remission were compared to those of patients with histological activity [GS: 76.00 vs 228.00, p < 0.001; RHI: 73.50 vs 467.00, p < 0.001]. FC levels allowed us to exclude the absence of histological remission [according to RHI] and absence of histological response [according to RHI and GS], with negative predictive values varying from 82% to 96%. However, optimization of the FC cut-off to exclude the absence of histological remission, as for the continuous GS, falls within values that resemble those of the healthy population. CONCLUSION: The continuous GS and RHI histological scores are strongly correlated in their definitions of histological response. An absence of histological remission could only be excluded at physiological levels of FC.
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Colite Ulcerativa/diagnóstico , Complexo Antígeno L1 Leucocitário/análise , Biomarcadores/análise , Colite Ulcerativa/patologia , Colo/patologia , Colo Sigmoide/patologia , Fezes/química , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reto/patologia , Indução de Remissão , Índice de Gravidade de Doença , SigmoidoscopiaRESUMO
BACKGROUND AND AIMS: Endoscopic retrograde cholangiopancreatography is the preferred strategy for the management of biliary and pancreatic duct stones. However, difficult stones occur, and electrohydraulic (EHL) and laser lithotripsy (LL) have emerged as treatment modalities for ductal clearance. Recently, single-operator cholangioscopy was introduced, permitting the routine use of these techniques. We aimed to evaluate the clinical effectiveness of cholangioscopy-guided lithotripsy using LL or EHL in patients with difficult biliary or pancreatic stones. METHODS: This is a prospective clinical study - conducted at two affiliated university hospitals - of 17 consecutive patients with difficult biliary and pancreatic stones who underwent single-operator cholangioscopy-guided lithotripsy using two techniques: holmium laser lithotripsy (HL) or bipolar EHL. We analyzed complete ductal clearance as well as the impact of the location and number of stones on clinical success and evaluated the efficacy of the two techniques used for cholangioscopy-guided lithotripsy and procedural complications. RESULTS: Twelve patients (70.6%) had stones in the common bile duct/common hepatic duct, 2 patients (17.6%) had a stone in the cystic stump, and 3 patients (17.6%) had stones in the pancreas. Sixteen patients (94.1%) were successfully managed in 1 session, and 1 patient (5.9%) achieved ductal clearance after 3 sessions including EHL, LL, and mechanical lithotripsy. Eleven patients were successfully submitted to HL in 1 session using a single laser fiber. Six patients were treated with EHL: 4 patients achieved ductal clearance in 1 session with a single fiber, 1 patient obtained successful fragmentation in 1 session using two fibers, and 1 patient did not achieve ductal clearance after using two fibers and was successfully treated with a single laser fiber in a subsequent session. Complications were mild and were encountered in 6/17 patients (35.2%), including fever (n = 3), pain (n = 1), and mild pancreatitis (n = 1). Conclusions: Cholangioscopy-guided lithotripsy using LL or EHL in patients with difficult biliary or pancreatic stones is highly effective with transient and minimal complications. There is a clear need to further compare EHL and HL in order to assess their role in the success of cholangioscopy-guided lithotripsy.
INTRODUÇÃO: A CPRE é o exame preferencial para a remoção de cálculos biliares e pancreáticos. Em situações de cálculos difíceis foram propostas novas modalidades terapêuticas como a litotrícia electro-hidráulica (LEH) e a litotrícia por laser (LL). Recentemente a disponibilidade da colongioscopia de operador-único tornaram estas técnicas mais acessíveis e fáceis de realizar. Procuramos avaliar a eficácia clínica de litotrícia guiada por colangioscopia recorrendo á LEH ou á LL em doentes com cálculos biliares e pancreáticos difíceis. MÉTODOS: Estudo prospetivo, conduzido em 2 Hospitais associados á Universidade e englobando 17 doentes consecutivos com cálculos difíceis biliares e pancreáticos, estes doentes foram tratados com litotrícia guiada por colangioscopia recorrendo a LEH ou LL. Analisamos a limpeza completa dos ductos, bem como o impato do número de pedras e localização no sucesso clínico, associada á avaliação das 2 técnicas de litotrícia e complicações desta abordagem terapêutica. RESULTADOS: Doze doentes (70.6%) tinham cálculos no colédoco/hepático comum, 2 doentes (17.6%) tinham um cálculo único no coto do cístico e 3 doentes (17.6%) apresentavam cálculos pancreáticos. Dezasseis (94.1%) doentes foram tratados com sucesso numa única sessão e o restante (5.9%) doente necessitou de 3 sessões incluído LEH, LL e litotrícia mecânica para obter limpeza dos ductos. Onze doentes foram tratados com LL e obtiveram sucesso clínico numa única sessão com uma fibra única de laser. Seis doentes foram tratados com LEH: 4 doentes obtiveram sucesso clínico numa única sessão com 1 fibra; 1 doente necessitou de 2 fibras para obter limpeza ductal numa sessão única. O último doente falhou a limpeza dos ductos com duas fibras de LEH e necessitou de sessão adicional com Laser (uma fibra) para obter fragmentação adequada dos cálculos. As complicações foram ligeiras em 6/17 (35.2%) doentes e incluíram febre (n = 4), dor (n = 1) e pancreatite ligeira (n = 1). Conclusões: A litotrícia guiada por colangioscopia com recurso a LEH ou LL em doentes com cálculos difíceis biliares e pancreáticos é muito eficaz e está associada a complicações transitórias e ligeiras. Existe clara necessidade de realizar estudos comparativos entre LEH e LL.
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OBJECTIVE: Histological remission is being increasingly acknowledged as a therapeutic endpoint in patients with UC. The work hereafter described aimed to evaluate the concordance between three histological classification systems-Geboes Score (GS), Nancy Index (NI) and RobartsHistopathologyIndex (RHI), as well as to evaluate their association with the endoscopic outcomes and the faecal calprotectin (FC) levels. DESIGN: Biopsy samples from 377 patients with UC were blindly evaluated using GS, NI and RHI. The results were compared with the patients' Mayo Endoscopic Score and FC levels. RESULT: GS, NI and RHI have a good concordance concerning the distinction between patients in histological remission or activity. RHI was particularly close to NI, with 100% of all patients classified as being in remission with NI being identified as such with RHI and 100% of all patients classified as having activity with RHI being identified as such with NI. These scores could also predict the Mayo Endoscopic Score and the FC levels, with their sensitivity and specificity levels depending on the chosen cut-offs. Moreover, higher FC levels were statistically associated with the presence of neutrophils in the epithelium, as well as with ulceration or erosion of the intestinal mucosa. CONCLUSIONS: GS, NI and RHI histopathological scoring systems are comparable in what concerns patients' stratification into histological remission/activity. Additionally, FC levels are increased when neutrophils are present in the epithelium and the intestinal mucosa has erosions or ulcers. The presence of neutrophils in the epithelium is, indeed, the main marker of histological activity.
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Biomarcadores/análise , Colite Ulcerativa/patologia , Fezes/química , Complexo Antígeno L1 Leucocitário/análise , Sigmoidoscopia , Adulto , Idoso , Biópsia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Indução de RemissãoRESUMO
INTRODUCTION: Endoscopic retrograde cholangiopancreatography is the method of choice for biliary drainage, although in some cases standard biliary access is difficult or even impossible. Endoscopic ultrasound (EUS)-guided endoluminal procedures are an alternative in these cases, although experience with these techniques is still limited. CLINICAL CASE: We present two cases of successful EUS-guided biliary drainage. In the first case, a hepaticogastrostomy was performed in a patient with stage IV gastric adenocarcinoma with obstructive jaundice due to compression of the hilum, where malignant gastric stenosis and previous palliative gastrojejunostomy precluded access to the second part of the duodenum. In the second case, a patient with a pancreatic head adenocarcinoma with duodenal invasion that precluded major papillae identification was submitted to a choledochoduodenostomy. Both procedures occurred without immediate or delayed adverse events, with technical and clinical success. DISCUSSION: Although experience with EUS-guided biliary drainage is still limited, its efficacy and safety is favorable when compared with percutaneous and surgical drainage, and should be considered an alternative to these techniques where sufficient expertise exists.
INTRODUÇÃO: A colangiopancreatografia retrógrada endoscópica é o procedimento de escolha para a drenagem biliar, embora em alguns casos o acesso biliar convencional é difícil ou até impossível. As técnicas de drenagem guiadas por ecoendoscopia são uma alternativa nestes casos, embora a experiência seja ainda limitada. CASO: Apresentamos dois casos de drenagem biliar eficaz guiada por ecoendoscopia. No primeiro caso foi realizada hepaticogastrostomia numa doente com adenocarcinoma gástrico estadio IV, com icterícia obstrutiva devido a compressão hilar pela neoplasia, na qual o acesso à segunda porção duodenal se revelou impossível devido à neoplasia gástrica estenosante e a antecedentes de gastrojejunostomia paliativa. No segundo caso, uma doente com adenocarcinoma cefalo-pancreático com invasão duodenal que impedia a identificação da papila foi submetida a coledocoduodenostomia. Em ambos os procedimentos foi conseguida drenagem biliar eficaz e não ocorreram eventos adversos imediatos ou tardios. Discussão: Apesar de a experiência com técnicas de drenagem biliar guiadas por ecoendoscopia ser limitada, o seu perfil de eficácia e segurança parece ser favorável quando comparada com as alternativas (drenagem percutânea ou cirúrgica), pelo que devem ser consideradas quando exista equipamento e experiência necessária.
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Ressecção Endoscópica de Mucosa/métodos , Endossonografia/métodos , Lipoma , Neoplasias Retais , Prolapso Retal , Idoso , Feminino , Humanos , Lipoma/complicações , Lipoma/patologia , Lipoma/fisiopatologia , Lipoma/cirurgia , Neoplasias Retais/complicações , Neoplasias Retais/patologia , Neoplasias Retais/fisiopatologia , Neoplasias Retais/cirurgia , Prolapso Retal/diagnóstico , Prolapso Retal/etiologia , Prolapso Retal/cirurgia , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento , Carga TumoralRESUMO
BACKGROUND AND AIMS: Mucosal healing and histological remission are different targets for patients with ulcerative colitis, but both rely on an invasive endoscopic procedure. This study aimed to assess faecal calprotectin and neutrophil gelatinase B-associated lipocalin as biomarkers for disease activity in asymptomatic ulcerative colitis patients. METHODS: This was a multicentric cross-sectional study including 371 patients, who were classified according to their endoscopic and histological scores. These results were evaluated alongside the faecal levels of both biomarkers. RESULTS: Macroscopic lesions [i.e. endoscopic Mayo score ≥1] were present in 28% of the patients, and 9% had active disease according to fht Ulcerative Colitis Endoscopic Index of Severity. Moreover, 21% presented with histological inflammation according to the Geboes index, whereas 15% and 5% presented with focal and diffuse basal plasmacytosis, respectively. The faecal levels of calprotectin and neutrophil gelatinase B-associated lipocalin were statistically higher for patients with endoscopic lesions and histological activity. A receiver operating characteristic-based analysis revealed that both biomarkers were able to indicate mucosal healing and histological remission with an acceptable probability, and cut-off levels of 150-250 µg/g for faecal calprotectin and 12 µg/g for neutrophil gelatinase B-associated lipocalin were proposed. CONCLUSIONS: Faecal calprotectin and neutrophil gelatinase B-associated lipocalin levels are a valuable addition for assessment of disease activity in asymptomatic ulcerative colitis patients. Biological levels of the analysed biomarkers below the proposed thresholds can rule out the presence of macroscopic and microscopic lesions with a probability of 75-93%. However, caution should be applied whenever interpreting positive results, as these biomarkers present consistently low positive predictive values.
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Colite Ulcerativa/patologia , Fezes/química , Complexo Antígeno L1 Leucocitário/análise , Lipocalina-2/análise , Neutrófilos/química , Adulto , Colite Ulcerativa/metabolismo , Colo/patologia , Feminino , Humanos , Complexo Antígeno L1 Leucocitário/metabolismo , Lipocalina-2/metabolismo , Masculino , Pessoa de Meia-Idade , Neutrófilos/metabolismoRESUMO
Breast cancer is the most common tumor in women and the first cause of death for malignancy in the female. Bile ducts are not among the common sites of metastasis from breast cancer. Few cases of obstructive jaundice due to metastatic breast cancer have been described in the literature and they mostly resulted from widespread liver metastases that eventually involved the bile ducts. We report an exceptional case of ampullary metastasis in the absence of liver metastases. Sporadic reports have been published about the involvement of the ampulla by breast cancer metastasis. This case emphasizes the need to consider this diagnosis in women presenting with obstructive jaundice, especially when there is a clinical possibility of breast cancer.
O cancro da mama é o tumor mais comum em mulheres e a principal causa de morte por neoplasia nesta população. A via biliar não é um local comum de metastização desta neoplasia. Poucos casos de icterícia obstrutiva devido a metástases mamárias têm sido descritos na literatura e ocorrem principalmente devido a metástases hepáticas que comprimem a via biliar. Relatamos um caso excepcional de metástase ampular na ausência de metástases hepáticas.Existem apenas relatos esporádicos do envolvimento da ampola por metástase mamárias. Este caso enfatiza a necessidade de considerar este diagnóstico perante um quadro de icterícia obstrutiva, especialmente em doentes com possível neoplasia mamária.
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Hepatitis B virus (HBV) reactivation is a well-recognized complication that occurs in lymphoma patients who undergo chemotherapy. Only very few cases of HBV reactivation in patients with isolated antibody against hepatitis B surface antigen (anti-HBs) have been reported. We present a case of a 78-year-old woman diagnosed with diffuse large B cell non-Hodgkin's lymphoma who only displayed a positive anti-HBs, as the single possible marker of occult HBV infection, before starting therapy. She was treated with several chemotherapeutic regimens (including rituximab) for disease relapses during 3 years. Forty days after the last cycle of chemotherapy, she presented with jaundice, markedly elevated serum aminotransferase levels, and coagulopathy. HBV serology showed positivity for HBsAg, anti-HBc and anti-HBs. HBV DNA was positive. Antiviral treatment with entecavir was promptly initiated, but the patient died from liver failure. A review of the literature of HBV reactivation in patients with detectable anti-HBs levels is discussed.