Endoscopic transmural resection as an alternative to colorectal surgery after high-risk (non-curative) endoscopic resection.

Endoscopic full-thickness resection (eFTR) is an emerging technique that enables effective and safe management of complex colorectal lesions. The full-thickness resection device (FTRD®, Ovesco, Germany) has primarily been used for non-exposed transmural resection of challenging subepithelial or epithelial lesions, where conventional methods may be limited. This technique represents an alternative to surgery in selected patients, and its applications are rapidly expanding. In recent years, eFTR has been described as an alternative to surgery for scars aiming to exclude residual tumors after non-curative endoscopic resection. We present a case of a 41-year-old woman with Lynch syndrome (dMLH1) with rectal adenocarcinoma at the age of 20 underwent anterior resection of the rectum and adjuvant chemoradiotherapy. At the age of 39, during endoscopic surveillance, she presented with a suspicious lesion (Paris 0-Is+IIa, NICE2, JNET2B) measuring 16mm in the hepatic angle, and underwent en bloc endoscopic mucosal resection (EMR). Histopathological analysis revealed a low-grade invasive adenocarcinoma with lymphoid stroma with deep invasion of the submucosa and resection margin involvement (vertical R1). After a multidisciplinary team discussion, complementary surgery was proposed but the patient refused, opting for close endoscopic and imaging surveillance. Two subsequent colonoscopies plus computed tomography (CT) scans showed no signs of macro or microscopic residual or recurrent tumor, even after extensive biopsies of the colonic scar. However, a CT scan 20months post-resection showed a de novo 2cm thickening of the parietal wall in the hepatic angle, consistent with the location of the previous endoscopic resection. Suspecting deep parietal tumor recurrence without superficial endoscopic findings, a transmural endoscopic resection using FTRD® of the EMR scar was performed, whose histology revealed no transparietal tumor recurrence.

Leading with dysphagia An unusual view of a common symptom.

Plummer-Vinson syndrome (PVS) is characterized by the classic triad of post-cricoid dysphagia, iron-deficiency anemia and esophageal webs. PVS is commonly found in women of middle age especially in the fourth and fifth decade of life. The prevalence of PVS has decreased due to early detection of iron deficiency and repletion of iron stores. We report a case of a 81-year-old female patient who had a classic presentation of PVS, treated successfully with endoscopic procedure. To our knowledge, the current case is the fourth case of dysphagia related to Plummer-Vinson syndrome reported in an octogenarian in the literature so far. Iron supplementation can resolve dysphagia in many patients, but dilation of esophageal webs may sometimes be required. PVS should be part of the differential diagnosis of sideropenic dysphagia, especially due the risk of pharyngeal and esophageal epidermoid neoplasia.

Unexpected cause of upper gastrointestinal bleeding: beyond the typical complications of gallstone disease.

An 88-year-old man presented with haematemesis with haemodynamic stability requiring transfusion of 5 units of blood. Physical examination was unremarkable. Upper endoscopy identified a fistulous opening in the proximal second part of the duodenum (D2) with an oozing bleed and blood clots. A computed tomography (CT)-angiogram revealed a 18mm cystic artery pseudoaneurysm next to a fistulous communication between the gallbladder and D2, allowing the passage of a large stone (Bouveret syndrome). The patient successfully underwent emergent arterial embolization guided by a clip endoscopically-placed near the duodenal fistulous orifice. There were no intercurrences or bleeding recurrence.

Foreign body impaction between diverticula: an uncommon cause of chronic abdominal pain.

A woman in her 70s with a medical history of hypertension and dyslipidemia was admitted for colonoscopy due to long-term abdominal pain. During the procedure, a sharp cylindrical foreign body was identified in the sigmoid colon, imprisoned in two diametrically opposite diverticular orifices, with purulent drainage and exuberant reactive inflammatory tissue in each diverticulum. Carefully mobilization from both diverticular orifices into the colon lumen and safety removal were performed using a rat tooth forceps, without intercurrences. The removed foreign body corresponded to a chicken bone about 3 cm in size. The plain abdominal X-ray had no evidence of pneumoperitoneum. Empirical antibiotic therapy was started with complete resolution of abdominal pain during follow-up. Most foreign bodies lodged in the colon are treated conservatively as they typically pass without intervention, however, they can cause damage to the colonic mucosa and lead to perforation or infections (namely peritonitis, peritoneal abscesses, and fistulas).

Iron pill-induced gastritis: an unrecognized side effect of iron-deficiency anemia.

Iron-deficiency anemia is a prevalent condition usually treated with iron supplementation. Iron pill-induced gastritis is an under-recognized, albeit serious potential complication of iron pill ingestion in the upper gastrointestinal tract. This entity must be identified by healthcare providers who prescribe iron. The diagnosis of this unusual drug-induced disease is based on endoscopic findings and histopathological examination, because the clinical symptoms are vague and non-specific. Herein we report a case of a 79-year-old woman with iron-deficiency anemia taking oral ferrous sulfate with multiple congestive and eroded polypoid lesions. Histology showed an H. pylori-negative erosive gastritis with iron deposition, confirming the diagnosis of iron pill-induced gastritis. The aim of this report is to highlight that iron pill-induced gastritis is an under-diagnosed entity that must be kept in mind when patients undergo chronic iron-pill therapy because it can lead to serious complications of the upper gastrointestinal tract.

Cast the bait in human fishing: an expected esophageal foreign body.

An 82-year-old woman with a medical history of dementia was admitted to the emergency department with a line under tension by lead weights through her mouth, suspecting inadvertent swallowing of a fishhook. The chest X-ray was normal. An emergent endoscopy revealed the hook imprisoned in the middle esophagus. The sharped end of the hook was carefully detached into the esophageal lumen using a rat tooth forceps and safely removed with an esophageal overtube. The esophageal defect at the impaction site was closed with the placement of two 11-mm through-the-scope metal clips, without intercurrences. Ingestion of foreign bodies is relatively rare in adults and typically pass without intervention. Their extraction is a therapeutic challenge dependent on the type and location of the object, the time since ingestion, and the probability of associated complications, such as obstruction or perforation. Endoscopic management is the first choice in the treatment of esophageal foreign bodies as a safe, effective, and minimally invasive technique, as it allows to maintain control of the object during extraction and minimize the risk of additional damage. This case report represents a successful retrieval of an unusual foreign body specially designed in a sharped shape to be ingested by fish during fishing with an esophageal overtube avoiding surgery with significant morbidity and mortality.

Successful Endoscopic Closure of Esophageal Perforation in Boerhaave Syndrome Using the Over-the-Scope Clip.

Boerhaave syndrome (BS) is a rare but potentially fatal condition. Although surgery is considered the standard treatment, endoscopic therapy has acquired an important role as a minimally invasive management approach. The authors describe 2 cases of middle-aged male patients, presenting with spontaneous esophageal perforation after severe straining and vomiting. In the first case, the patient presented with a bone impaction in the upper esophagus successfully removed by rigid esophagoscopy. After the procedure, a chest X-ray/cervicothoracic computerized tomography scan (CT) showed a left hydropneumothorax and pneumomediastinum with oral contrast leak at the lower esophagus. In the second case, the patient presented to the Emergency Department with severe chest pain after an episode of vomiting. The CT showed a massive pneumomediastinum, subcutaneous emphysema, and an oral contrast leak compatible with BS. The patient was initially submitted to surgical suture, but contrast extravasation persisted after 12 days. After multidisciplinary team discussion of both patients, an upper gastrointestinal endoscopy was performed, which revealed pericentimetric wall defects at the distal esophagus. These were successfully closed using an over-the-scope clip (OTSC). After at least a 9-month follow-up, patients have remained clinically well with no relapse. The authors highlight the severity of these clinical cases and the endoscopic option that proved to be decisive in addressing BS. The favorable outcomes suggest a role for the OTSC approach in closing spontaneous esophageal perforation both as first-line and as rescue therapy after a surgical failure.

A síndrome de Boerhaave (SB) é uma entidade rara, mas potencialmente fatal. Embora a cirurgia seja o tratamento padrão, o tratamento endoscópico tem adquirido um papel importante como opção minimamente invasiva. Os autores descrevem dois casos de doentes do sexo masculino de meia-idade, que apresentaram perfuração esofágica espontânea após esforço emético intenso e vómitos. No primeiro caso, o doente apresentou impactação de um osso no esófago superior, que foi removido com sucesso por esofagoscopia rígida. Após o procedimento, o doente realizou radiografia de tórax e tomografia computorizada (TC) cervico-torácica que evidenciou hidropneumotórax esquerdo e pneumomediastino com extravasamento de contraste oral ao nível do esófago inferior. No segundo caso, o doente apresentou-se no Serviço de Urgência com toracalgia intensa após episódio de vómito. A TC mostrou pneumomediastino exuberante, com enfisema subcutâneo e extravasamento de contraste oral compatível com SB. O doente foi inicialmente submetido a rafia cirúrgica, mas o esofagograma ao 12º dia mostrou persistência de extravasamento do contraste. Após discussão em reunião multidisciplinar, ambos os doentes realizaram endoscopia digestiva alta, com visualização de orifícios pericentimétricos no esófago distal, encerrados com sucesso com a aplicação de clip overthe- scope (OTSC). Após seguimento de pelo menos 9 meses, os doentes permaneceram clinicamente bem, sem evidência de recidiva. Os autores destacam a gravidade desses casos clínicos, bem como a opção endoscópica que se mostrou decisiva no tratamento da SB. Os resultados favoráveis sugerem um papel para a abordagem com OTSC no tratamento da perfuração esofágica espontânea, tanto como tratamento de primeira linha, como terapêutica de resgate após falência do tratamento cirúrgico.

Lymphogranuloma Venereum-Associated Proctitis Mimicking a Malignant Rectal Neoplasia: Searching for Diagnosis.

Background: Chlamydia trachomatis-lymphogranuloma venereum (LGV) is a sexually transmitted infection (STI) and an uncommon cause of proctitis. The diagnosis requires a high index of clinical suspicion, since the clinical, imaging, endoscopic, and histological findings can mimic multiple benign or malignant conditions like inflammatory bowel disease and rectal neoplasms. Case Presentation: We present the case of a 48-year-old Caucasian male with no significant previous medical history who was admitted due to the suspicion of a rectal neoplasia. He underwent an abdominopelvic computed tomography (CT) scan and pelvic magnetic resonance imaging (MRI) before admission due to complaints of anorectal pain, hematochezia, and constipation over the previous 2 weeks. The examination revealed a circumferential rectal wall thickening, infiltration of the perirectal fat and invasion of the mesorectal fascia, associated with perirectal fat lymphadenopathy. A radiological diagnosis of a rectal malignant neoplasia staged as T4N2MX was stated. Digital rectal examination identified a circumferential rectal tumor. Rectosigmoidoscopy showed an extensive and circumferential ulceration of the rectal mucosa, with elevated geographical borders, exudate, and aphthoid erosions at the proximal limit of the endoscopic mucosal ulceration. Biopsy specimens revealed acute ulcerative proctitis with lymphoplasmocytic inflammatory infiltrate but no evidence of dysplasia or malignancy. A STI screening was positive for HIV-1 (CD4+ 251/mm3; N = 700-1,100) and C. trachomatis, with an elevated IgA-specific antibody titer (52.000; N < 5.0), suggesting LGV disease. The diagnosis was confirmed by the identification of C. trachomatis DNA on rectal swab. Other infectious causes of acute proctitis were excluded. When faced with these results, the patient ended up mentioning that he had unprotected anal sex with men. He started treatment with doxycycline 100 mg twice a day for 21 days, with a drastic improvement. Rectosigmoidoscopy was repeated and showed clear signs of progressive resolution of the ulcerative proctitis. Discussion: LGV-associated proctitis, often undervalued, is a reemerging disease which should always be considered a benign cause of rectal mass, in order to avoid delay in diagnosis and development of complications. Diagnosis becomes more challenging in patients with unknown HIV status. A detailed clinical history, including sexual behaviors, is a vital step to achieve the final diagnosis.

Introdução: A infeção por Chlamydia trachomatis-linfogranuloma venéreo (LGV) é uma doença sexualmente transmissível (DST), sendo uma causa incomum de proctite. O diagnóstico exige um elevado grau de suspeição, dado que os achados clínicos, radiológicos, endoscópicos e histológicos podem mimetizar múltiplas condições benignas ou malignas, como a doença inflamatória intestinal e as neoplasias retais. Caso clínico: Apresentamos o caso de um homem de 48 anos, caucasiano, sem antecedentes relevantes, admitido por suspeita de neoplasia retal. Por queixas de dor anorretal, hematoquézias e obstipação com 2 semanas de evolução, realizou uma tomografia computadorizada abdominopélvica e uma ressonância magnética pélvica, que revelaram espessamento retal circunferencial, infiltração da gordura periretal e invasão da fáscia mesoretal, associados a linfadenopatias locais, sugestivos de malignidade retal (T4N2MX). O toque retal identificou uma tumoração retal circunferencial.A retosigmoidoscopia mostrou mucosa retal com ulceração extensa e circunferencial, bordos geográficos elevados, exsudado e erosões aftóides no limite proximal da ulceração mucosa. As biópsias revelaram proctite ulcerada aguda com infiltrado linfoplasmocitário difuso, sem displasia ou neoplasia. O screening de DST foi positivo para VIH-1 (CD4+ 251/mm3; N: 700­1100) e título elevado de IgA para C. trachomatis (52 000; N< 5), sugerindo LGV. O diagnóstico foi confirmado pela identificação do DNA de C. trachomatis em zaragatoa retal. Outras causas infecciosas de proctite aguda foram excluídas. Perante estes resultados, o doente acabou por mencionar que tinha tido relações homossexuais anais desprotegidas. Iniciou doxiciclina (100 mg duas vezes por dia, por 21 dias) com melhoria sintomática drástica. Repetiu retosigmoidoscopia, com sinais de proctite ulcerada em resolução. Discussão: A proctite por LGV, frequentemente desvalorizada, é uma doença re-emergente, que deve ser sempre equacionada como causa benigna de massa retal, de modo a evitar o atraso diagnóstico e o desenvolvimento de complicações. O diagnóstico torna-se mais desafiante em doentes com status VIH desconhecido. A história clínica detalhada, incluindo comportamentos sexuais de risco, é fundamental para o diagnóstico.

Role of Intestinal Ultrasound in the Evaluation of Postsurgical Recurrence in Crohn's Disease: Correlation with Endoscopic Findings.

Introduction: Endoscopy remains the exam of choice in the evaluation of activity in Crohn's disease (CD) after surgery (ACD-AS). However, intestinal ultrasound (IUS) may represent a noninvasive alternative. The objective of this study is to determine the diagnostic accuracy of this modality compared to endoscopy. Material and Methods: This is a cross-sectional study, comprising a period of 14 months, carried out in patients with established CD and ileocecal resection due to the disease. IUS (HI-VISION Avius®, Tokyo, Japan) was performed with linear probe B-mode/Doppler prior to ileocolonoscopy. IUS and ileocolonoscopy were performed on the same day by 2 specialists in Gastroenterology dedicated to ultrasound and inflammatory bowel disease, in a double-blind mode. Collected demographic and clinical data (Harvey-Bradshaw Index [HBI]; remission ≤4), serological/fecal inflammatory parameters (leukocytes [4-10 × 109 cells/L], C-reactive protein [≤0.5 mg/dL], and fecal calprotectin [<50 mg/kg]), endoscopy (Rutgeerts score: remission 3 mm and/or Limberg score >1) was abnormal in 61.5% (n = 24) of the cases. Endoscopic remission (Rutgeerts score

Introdução: A endoscopia permanece o exame de eleição na avaliação da atividade da Doença de Crohn (DC) póscirurgia (ADC-PC). No entanto, a ecografia dirigida à parede digestiva (Eco-PD) pode representar uma alternativa não-invasiva. O objetivo do trabalho é determinar a acurácia diagnóstica e concordância desta modalidade comparativamente à endoscopia. Materiais e métodos: Estudo transversal, compreendendo um período de 14 meses, efetuado a doentes com DC estabelecida e resseção ileocecal pela doença. Realizada Eco-PD (HI-VISION Avius®, Tokyo, Japan) com sonda linear em modo-B/Doppler previamente à ileocolonoscopia. A Eco-PD e ileocolonoscopia foram realizadas no mesmo dia por 2 especialistas dedicados a ecografia e doença inflamatória intestinal, de forma duplamente cega. Recolhidos dados demográficos, clínicos (índice Harvey-Bradshaw [HBI; remissão: ≤4]), parâmetros inflamatórios serológicos/fecais (leucócitos [4 < N < 10 × 109 células/L], proteína C reativa [≤0,5 mg/dL], calprotectina fecal [N <50 mg/kg]), endoscópicos (score Rutgeerts: remissão < i2) e ecográficos (espessamento [N ≤ 3mm] e vascularização da parede digestiva pelo score semi-quantitativo de Limberg [ausente = 0; escassa = 1; moderada = 2; marcada = 3]). Resultados: Incluídos 39 doentes (sexo feminino: 64,1%, idade média: 43,5 ± 15,3 anos). Seguimento mediano pós-cirurgia de 9 anos (IQR 9). Classificação Montreal: L1 61,5% (n = 24), L3 38,5% (n = 15), B1 e B2 28,2% (n = 11) e B3 43,6% (n = 17).A maioria estava em remissão clínica (87,2%; n = 34) com HBI médio de 2,1 ± 2,2. Vinte e dois doentes (56,4%) tinham marcadores inflamatórios dentro de parâmetros normais. A Eco-PD (espessamento parede intestinal >3 mm e/ou Limberg >1) foi anormal em 61,5% (n = 24). Remissão endoscópica (Rutgeerts < i2) em 53,8% (n = 21). Comparativamente à endoscopia, a Eco-PD (AUROC 0,75; p = 0,007) mostrou acuidade diagnóstica superior aos parâmetros inflamatórios (AUROC 0,66; p = 0,083) e clínica (AUROC 0,64; p = 0,139). A ecografia mostrou uma moderada concordância com a endoscopia (ĸ = 0,5; p = 0,001), superior aos parâmetros inflamatórios (ĸ = 0,33, p = 0,041) ou clínica (ĸ = 0,29, p = 0,01). Conclusões: A avaliação ecográfica da parede digestiva é uma técnica não invasiva que mostrou uma boa acuidade diagnóstica e uma concordância moderada com a endoscopia, superior à clínica e parâmetros inflamatórios serológicos/fecais.

Duodenal variceal bleeding as a presentation of hepatocellular carcinoma.

A 79-year-old man with alcoholic liver cirrhosis without regular medical follow-up, presented at the emergency room with hematemesis. An upper endoscopy revealed a varix at the anterior wall of bulb with a red wale sign, indicating recent bleeding. An injection N-butyl-2 cyanoacrylate plus metacryloxisulfolane was successfully performed. The abdominal computed tomography angiography scan revealed a 29x26-mm nodule consistent with hepatocellular carcinoma (HCC), tumoral portal vein thrombosis (and communicating collateral from the superior mesenteric vein feeding the duodenal varix with no splenorenal shunt. After endoscopic therapy, the patient remained asymptomatic without rebleeding. Given HCC stage D (Barcelona Clinic Liver Cancer), after multidisciplinary discussion, the patient was evaluated for best supportive care. Ectopic varices are clinically challenging causes of portal hypertensive bleeding associated with significant mortality, requiring a high index of suspicion and multimodal diagnostic and therapeutic approaches. The management includes endoscopic therapy, interventional radiology techniques (TIPS with variceal embolization, balloon occluded retrograde transvenous obliteration and percutaneous transhepatic obliteration) or surgery. The best endoscopic treatment modality remains unclear because there are no studies directly comparing the different endoscopic techniques. In setting of ectopic varices, abdominal imaging is mandatory to exclude splanchnic vein thrombosis, HCC and to map portosystemic collaterals to guide further treatments.

An Atypical Presentation of a Colonic Lipoma: Avoiding Surgery with a Deeper Endoscopic Look.

INTRODUCTION: Colonic lipomas are common mesenchymal tumours. They are usually asymptomatic and incidentally diagnosed during endoscopic or radiological examinations. Taking into account their typical endoscopic and radiological features and benign nature, tissue sampling, resection or follow-up are generally not required. CASE REPORT: A 61-year-old woman with poor surgical fitness presented with colonic subocclusion and lower gastrointestinal bleeding. A colonoscopy performed 1 month earlier showed a large polypoid lesion with necrotic and ulcerated areas occupying the lumen of the proximal ascending colon with inconclusive histology. An abdominopelvic computed tomography scan with intravenous contrast was done revealing a cecal-colonic intussusception of a heterogeneous mass. The patient was successfully managed conservatively. A delayed revision colonoscopy showed a significantly smaller atypical subepithelial lesion with no necrosis or ulceration. A single, large and deep incision with a pre-cut needle-knife® allowed the direct collection of lesion tissue using standard biopsy forceps through the so-called single-incision needle-knife® (SINK) biopsy technique. Histological examination was compatible with submucosal lipoma. After 18 months of follow-up, the patient remains asymptomatic. DISCUSSION/CONCLUSION: Colonic lipoma complications are rare and can lead to misdiagnosis; in general, they are surgically managed. A conservative approach and a minimally invasive endoscopic procedure allowed a definite diagnosis avoiding the morbidity and mortality of a major surgical intervention in a high-risk patient.

INTRODUÇÃO: Os lipomas do cólon são tumores mesenquimatosos comuns. Frequentemente são assintomáticos e diagnosticados, incidentalmente, em exames endoscópicos e imagiológicos. O diagnóstico histológico, resseção e vigilância não costumam ser necessários devido aos achados endoscópicos e imagiológicos típicos e à sua natureza benigna. CASO CLÍNICO: Uma mulher de 61 anos com contraindicação relativa para cirurgia abdominal recorreu ao serviço de urgência por quadro clínico de suboclusão intestinal e hemorragia digestiva baixa. A colonoscopia, realizada um mês antes, demonstrava uma lesão polipoide com área de necrose e ulceração a ocupar o lúmen do cólon ascendente proximal, com estudo histológico inconclusivo. Foi efetuada uma tomografia computorizada abdominopélvica com contraste intravenoso que revelou uma invaginação ceco-cólica de uma massa heterogénea.Optou-se por uma abordagem conservadora com remissão clínica. A colonoscopia de revisão diferida mostrou, na mesma localização, uma lesão subepitelial de menores dimensões, atípica, sem ulceração ou necrose. Com uma faca-agulha de pré-corte foi efetuada uma incisão única e profunda que permitiu a colheita direta de material usando uma pinça de biopsias standard através da técnica denominada biopsia por faca-agulha de précorte de incisão única. A análise histológica foi compatível com lipoma submucoso. Cerca de 18 meses após o episódio a doente permanece assintomática. DISCUSSÃO/CONCLUSÃO: As complicações do lipoma do cólon são raras e podem levar a um diagnóstico erróneo, geralmente tratado cirurgicamente. Uma abordagem conservadora inicial e um procedimento endoscópico minimamente invasivo permitiram o diagnóstico definitivo, evitando a morbilidade e mortalidade associadas a uma intervenção cirúrgica major numa doente de alto risco.

Dead-end stomach: a giant and pedunculated gastric pyloric gland adenoma conditioning gastric outlet obstruction and anemia.

We present the case of a 69-year-old female undergoing esophagogastroduodenoscopy for iron-deficiency anemia investigation. She reported intermittent bloating, nausea and vomiting. A pedunculated polyp was identified arising from the greater curvature of the middle gastric body, with a long fibroelastic stalk (30mm) and a 60mm congestive head that prolapsed towards the pyloric ring, causing a complete gastric outlet obstruction (GOO). An en-block polypectomy was performed. An intraprocedural oozing bleeding from a large visible vessel at the residual stalk was managed using endoloop®. Histo-immunohistochemistry showed a R0-resection of a mixed-type gastric pyloric gland adenoma (PGA) positive for MUC-5AC and MUC-6 mucins, in a surrounding H. pylori-negative non-atrophic chronic gastritis. She became asymptomatic with anemia resolution. Adenomas account for up to 10% of gastric polyps. Histologically, they are categorized into intestinal, foveolar, pyloric and oxyntic types (1). PGA is a rare subtype, accounting for less than 3% of all gastric polyps (2). PGAs are usually solitary at gastric body, and occur in association with autoimmune gastritis, H. pylori and chemical gastritis (2). A normal background gastric mucosa has also been described (35.8%) (3). PGAs are devoid of apical mucin cap and label by both MUC-5AC and MUC-6 (2). Choi et al. (3) defined three PGA immunohistochemical phenotypes: pure pyloric-type (25.4%), with strong MUC-6 expression; predominant foveolar-type (3%), with MUC-5AC diffuse expression but ≤10% of MUC-6 expression and no foveolar differentiation; and mixed-type (61.2%), with variable MUC-5AC/MUC-6 expression. Most PGAs are asymptomatic, but clinically significant because of their potential for malignant transformation (12-47%) and complications, including gastrointestinal bleeding and obstruction (1, 3). GOO is rare, causing intermittent symptoms by polyp intussusception (ball-valve-syndrome) (4, 5). PGA management is challenging, depending on size, morphology and location. This case illustrates a successful endoscopic resection as a minimally invasive procedure of a doubly complicated PGA.

Lymphoma presented as dysphagia: a diagnosis hard to swallow.

An 18-year-old woman presented with progressive oesophageal dysphagia, weight loss and night sweats over a 6-month period. Oesophagogastroduodenoscopy revealed a diffuse luminal narrowing with normal mucosa, whose biopsies were inconclusive. A cervical and thoracic CT scan showed a thickening of the upper oesophagus, densification of the mediastinal fat, several adenopathies and a 4.3×2.4 cm mass with infiltrative appearance and heterogeneous enhancement in right cervical paravertebral location. Positron emission tomography-CT showed marked increased fluorodeoxyglucose uptake in supradiaphragmatic lymph nodes, pleuropulmonary tissue, paraspinal musculature and bone marrow. Imaging-guided and surgical incisional biopsies of the paravertebral mass were inconclusive. During hospitalisation, she developed right cervicobrachial paraesthesia. Only excisional biopsy of the mass allowed the diagnosis of high-grade B-cell lymphoma not otherwise specified, Ann Arbor stage IV-B. The patient underwent chemotherapy with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone), followed by R-EPOCH (rituximab, etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin hydrochloride). Follow-up at 12 months revealed complete response.

Lysosomal Acid Lipase: Can it be a New Non-Invasive Serum Biomarker of Cryptogenic Liver Fibrosis and Cirrhosis?

INTRODUCTION AND AIM: The association between lysosomal acid lipase (LAL) activity and liver steatosis or fibrosis is poorly studied. The aim of our study was to determine the predictive power of LAL for cryptogenic liver steatosis and cryptogenic significant fibrosis/cirrhosis. MATERIAL AND METHODS: Cross-sectional observational study of 101 adult patients with unexplained elevated liver enzymes/hepatomegaly with or without dyslipidemia submitted to the determination of LAL activity and LIPA gene (E8SJM-C.894G^A) mutation. Seventy-one patients underwent liver biopsy or FibroScan®. Patients with an identifiable liver dysfunction cause and well-stablished NAFLD/NASH risk factors were excluded. Predictors for liver steatosis, significant fibrosis (> F2) or cirrhosis (F4) were evaluated. RESULTS: Liver steatosis and fibrosis were mainly assessed by liver biopsy (74.6%; n = 53). Steatosis was present in 62.0% (n = 44), significant fibrosis in 47.9% (n = 34) and cirrhosis in 39.4% (n = 28). The median LAL was 0.36 (0.21-0.46)nmol/spot/h (vs. 0.29 (0.20-0.47); p = 0.558) for liver steatosis, 0.22 (0.11-0.29) nmol/spot/h (vs. 0.40 (0.34-0.51); p <0.001) for significant fibrosis and 0.21 (0.11-0.27) nmol/spot/h (vs. 0.40 (0.32-0.52); p < 0.001) for cirrhosis. No LIPA gene mutations were found. LAL activity was the strongest predictor of significant fibrosis (AUROC: 0.833; p < 0.001) with a cut-off of 0.265 (sensitivity: 85.9%; specificity: 75.0%) and cirrhosis (AUROC: 0.859; p < 0.001) with a cut-off of 0.235 (sensitivity: 86.2%; specificity: 75.0%), being higher than FIB4, GUCI or APRI. However, LAL activity was not associated with liver steatosis (AUROC: 0.536; p =0.558). CONCLUSION: LAL activity can be considered a non-invasive new marker of cryptogenic liver fibrosis with higher accuracy than other known biomarkers. LAL activity < 0.265 nmol/spot/h was strongly associated with cryptogenic significant fibrosis and <0.235 nmol/spot/h with cryptogenic cirrhosis. LAL activity was not associated with cryptogenic liver steatosis.