An elderly patient's pancreatobiliary puzzle: unraveling diagnosis and treatment challenges.

Pancreatobiliary fistulas associated withntraductal Papillary Mucinous Neoplasm (IPMN) are rare and present therapeutic challenges. The authors describe the clinical course of an 81-year-old woman presenting with acute cholangitis, ultimately diagnosed with IPMN involving secondary ducts with focal high-grade dysplasia. Initial manifestations included elevated inflammatory markers, cholestasis, and imaging findings of a pancreatic lesion. Endoscopic retrograde cholangiopancreatography revealed dilation of both intrahepatic and extrahepatic bile ducts, along a cystic cluster originating from the pancreas, fistulizing into the common bile duct. Despite initial endoscopic interventions, recurrent cholestasis persisted. Subsequent multidisciplinary evaluation led to a cephalic duodenopancreatectomy. This case underscores the rarity of pancreatobiliary fistulas associated with IPMNs and the subsequent therapeutic challenges. The absence of standardized treatment algorithms for such intricate cases emphasizes the importance of individualized approaches. The fluoroscopy image displaying a cystic cluster originating from the pancreas and showing fistulization into the common bile duct is a rare image presented in our report, unique to this case.

Non-invasive liver fibrosis assessment: is transient elastography mandatory?

Real-time elastography (RTE) is a conventional ultrasonography-based liver stiffness assessment technique developed in chronic viral hepatitis. Evidence of its applicability in other aetiologies is lacking. This study aims to determine RTE diagnostic accuracy for advanced fibrosis in compensated chronic liver disease (cCLD) and to compare it with the biochemical scores FIB-4 and APRI, using transient elastography (TE) as the gold standard. A single center cross-sectional study including cCLD patients was conducted. RTE with assessment of Liver Fibrosis Index and TE were performed in the same day by different operators blind to the other technique result. The scores FIB-4 and APRI were calculated. Fibrosis cut-off values were inferred from previous evidence.

Predictors for incomplete response to ursodeoxycholic acid in primary biliary cholangitis. Data from a national registry of liver disease.

BACKGROUND: The current standard of treatment in primary biliary cholangitis (PBC) is ursodeoxycholic acid (UDCA), although a considerable proportion of patients show incomplete response resulting in disease progression. OBJECTIVE: This study aimed to assess the prevalence of incomplete response to UDCA and determine associated patients' characteristics. METHODS: Patients with PBC as main diagnosis were included from a national multicentric patient registry-Liver.pt. Main endpoints included incomplete response to UDCA treatment according to Barcelona, Paris I and Paris II criteria, Globe and UK PBC scores and the association between baseline characteristics and incomplete response according to Paris II criteria. RESULTS: A total of 434 PBC patients were identified, with a mean age of 55 years and 89.2% females. Nearly half of patients were asymptomatic at diagnosis and 93.2% had positive anti-mitochondrial antibodies. Almost all patients (95.6%) had been prescribed at least one drug for PBC treatment. At the last follow-up visit, 93.3% were under treatment of which 99.8% received UDCA. Incomplete response to UDCA was observed in 30.7%, 35.3%, 53.7% and 36.4% of patients according to Barcelona, Paris I, Paris II criteria and Globe score, respectively. After adjusting for age and sex, and accordingly to Paris II criteria, the risk for incomplete biochemical response was 25% higher for patients with cirrhosis at diagnosis (odds ratio [OR] = 1.25; 95% confidence interval [95%CI]: 1.02-1.54; p = 0.033) and 35% (95%CI:1.06-1.72; p = 0.016) and 5% (OR = 1.05; 95%CI:1.01-1.10; p = 0.013) for those with elevated gamma-glutamyl transferase (GGT) and alkaline phosphatase (ALP). CONCLUSION: A considerable proportion of patients showed incomplete biochemical response to UDCA treatment according to Paris II criteria. Cirrhosis, elevated GGT and ALP at diagnosis were identified as associated risk factors for incomplete response. Early identification of patients at risk of incomplete response could improve treatment care and guide clinical decision to a more careful patient monitorization.

Variation between Pathological Measurement and Endoscopically Estimated Size of Colonic Polyps.

BACKGROUND AND AIMS: Accurate determination of colonic polyp size is vital to an appropriate surveillance. The main aim of this study was to evaluate variation between the polyp size reported by the endoscopist and its pathological measurement. METHODS: A retrospective analysis of all colonic adenomatous polyps resected in a 12-month period was performed at our center. Endoscopic and pathological size for each polyp were compared, and overestimation rates, underestimation rates, and endoscopic-pathological variation (EPV) were calculated. RESULTS: Among the 573 polyps that were included, the mean endoscopic and pathological sizes were 8.00 and 6.66 mm, respectively. The most frequent error, in 62.1%, was overestimation by the colonoscopist. Overestimation and EPV were associated with resection technique (higher in endoscopic mucosal resection and smaller with biopsy forceps) and colonoscopist. They were not associated with years of experience in colonoscopy. Overestimation was more frequent in larger polyps. CONCLUSIONS: Our study shows significant discordance between endoscopic and pathological size of colonic polyps with a clear tendency for endoscopic overestimation. Larger polyps are more difficult to accurately assess than smaller ones. This propensity for error was not related to colonoscopist's years of experience and seems to be an individual tendency.

INTRODUÇÃO E OBJETIVOS: A precisão na determinação do tamanho de pólipos do cólon é vital para uma vigilância adequada. O objetivo deste trabalho foi avaliar a variação entre o tamanho reportado pelo endoscopista e pelo anatomo-patologista. MÉTODOS: Foi realizada uma análise retrospetiva de todos os pólipos adenomatosos ressecados, num período de 12 meses, no nosso centro. O tamanho endoscópico e patológico de cada pólipo foi comparado e foram calculadas as taxas de sobrestimativa, subestimativa e a variação endoscópica-patológica (VEP). RESULTADOS: Foram incluídos 573 pólipos, tamanho endoscópico e patológico médio de 8,00 e 6,66 milímetros, respetivamente. O erro mais frequente, em 62.1% foi a sobrestimativa pelo endoscopista. A sobrestimativa e a VEP associaram-se à técnica de resseção (maior na resseção endoscópica da mucosa e mais pequena na pinça de biópsias) e ao colonoscopista. Não se associaram aos anos de experiáncia em colonoscopia. A sobrestimativa foi mais frequente nos pólipos maiores. CONCLUSÕES: O nosso trabalho mostrou uma discordância significativa entre o tamanho endoscópico e patológico de pólipos do cólon com uma clara tendáncia para a sobrestimativa. Os pólipos maiores são mais difíceis de avaliar com precisão do que os mais pequenos. Esta propensão para o erro não se relacionou com os anos de experiáncia em colonoscopia e parece ser uma tendáncia individual.

Dysphagia lusoria: a little-known cause of dysphagia

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Dysphagia lusoria: a little-known cause of dysphagia.

It is referred the case report of an 82-year-old female was referred for the evaluation of progressive esophageal dysphagia of a six month duration, with a recent weight loss of 10% of the normal corporal weight over a six month period. The patient reported solid food dysphagia that required liquids to facilitate food progression and denied food impaction.

A Case Series of Anal Carcinoma Misdiagnosed as Idiopathic Chronic Anal Fissure.

Chronic anal fissure is a linear ulcer in the anal canal that has not cicatrized for more than 8-12 weeks of treatment. Most anal fissures are idiopathic and are located in the posterior midline. Squamous cell carcinoma of the anus commonly presents as bleeding and anal pain. It may also present as a mass, nonhealing ulcer, itching, discharge, fecal incontinence and fistulae. Not uncommonly, small and early cancers are misdiagnosed as benign anorectal disorders like anal fissures or hemorrhoids. The clinical suspicion of squamous cell carcinoma of the anus is of paramount importance in patients with nonhealing anal fissures, fissures in atypical positions or with indurated or ulcerated anal tags and in patients with risk factors for the development of anal squamous intraepithelial lesions that are precursors of invasive anal squamous cell carcinoma. The authors present 3 cases of squamous cell carcinoma of the anus initially misdiagnosed as benign chronic anal fissure.

A fissura anal crónica é uma úlcera linear presente no canal anal que não cicatriza após 8 a 12 semanas de tratamento. A maioria das fissuras anais são idiopáticas e localizadas na linha média posterior. O carcinoma epidermoide do canal anal apresenta-se frequentemente com proctalgia e hemorragia, podendo também manifestar-se como uma úlcera que não cicatriza, corrimento anal, incontinência fecal e fístula. Não raramente, os carcinomas pequenos e em estádios precoces podem ser diagnosticados incorretamente como patologia anorrectal benigna, como fissuras ou hemorróidas. A suspeição clínica de carcinoma epidermoide do canal anal é de enorme importância em fissuras anais que não cicatrizam, localizadas em posições atípicas, com marisca anal ulcerada ou endurecida e em doentes com fatores de risco para lesões escamosas intraepiteliais anais que são percursoras do carcinoma epidermoide anal. Os autores apresentam três casos de carcinoma epidermoide do canal anal inicialmente diagnosticados incorretamente como fissuras anais benignas.

Common Variable Immunodeficiency with Several Gastrointestinal Manifestations.

Common variable immunodeficiency (CVID) is an immunodeficiency disorder with a high incidence of gastrointestinal (GI) manifestations and an increased risk of gastric malignancy. We report a case of a CVID with mild anemia presenting with multiple GI manifestations: gastric low-grade dysplasia (LGD), enteropathy with villous atrophy, refractory Giardia infection, nodular lymphoid hyperplasia, and inflammatory bowel-like disease. The differential diagnosis with celiac sprue could be challenging because of CVID enteropathy with villous flattening. Gastric LGD in a patient with an increased risk for gastric malignancy makes the appropriate surveillance of gastric cancer in CVID challenging.

Portal air embolism after endoscopic retrograde cholangiopancreatography.

The authors present an uncommon case of portal venous gas and contrast opacification that occured during endoscopic retrograde cholangiopancreatography. This report demonstrates that portal vein cannulation may be a source of confusion because the guided wire trajectory inside the portal vein may be similar to that of the biliary, and a contrast washout/opacified portal vein may be misinterpreted as an incompletely filled bile duct.

Portal air embolism after endoscopic retrograde cholangiopancreatography

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Long-term outcomes of Botulinum toxin in the treatment of chronic anal fissure: 5 years of follow-up.

BACKGROUND: Chronic anal fissure is a frequent and disabling disease, often affecting young adults. Botulinum toxin and lateral internal sphincterotomy are the main therapeutic options for refractory cases. Botulinum toxin is minimally invasive and safer compared with surgery, which carries a difficult post-operative recovery and fecal incontinence risk. The long-term efficacy of Botulinum toxin is not well known. OBJECTIVE: The aim of this study was to evaluate the long-term efficacy and safety of Botulinum toxin in the treatment of chronic anal fissure. METHODS: This was a retrospective study at a single center, including patients treated with Botulinum toxin from 2005 to 2010, followed over at least a period of 5 years. All patients were treated with injection of 25U of Botulinum toxin in the intersphincteric groove. The response was registered as complete, partial, refractory and relapse. RESULTS: Botulinum toxin was administered to 126 patients, 69.8% (n = 88) were followed over a period of 5 years. After 3 months, 46.6% (n = 41) had complete response, 23.9% (n = 21) had partial response and 29.5% (n = 26) were refractory. Relapse was observed in 1.2% (n = 1) at 6 months, 11.4% (n = 10) at 1 year, 2.3% (n = 2) at 3 years; no relapse at 5 years. The overall success rate was 64.8% at 5 years of follow-up. Botulinum toxin was well tolerated by all patients and there were no complications. CONCLUSION: The use of Botulinum toxin to treat patients with chronic anal fissure was safe and effective in long-term follow-up.

Black Anal Canal: Acute Necrosis.

Acute ischemia of the rectum or anal canal resulting in necrosis is extremely uncommon because both the rectum and the anal canal have excellent blood supplies. We present a case with spontaneous necrosis of the anal canal without rectal involvement. Surgical debridement was accomplished, and the recovery was uneventful. The patient was elderly, with probable atherosclerotic arterial disease, and presented with hypotension. Due to the lack of other precipitating factors, the hypoperfusion hypothesis seems to be the most suitable in this case. To the best of our knowledge, no similar cases have been reported in the literature on this subject.

Schwannoma-A Rare Subepithelial Lesion of the Colon.

Schwannoma is a benign tumor arising from Schwann cells that form the neural sheath. Primary schwannoma of the colon is rare and a few cases have been reported. We report a case of schwannoma of the colon and present the differential diagnosis that must be considered in the evaluation of colonic subepithelial lesions.

O schwannoma é um tumor benigno com origem nas células de Schwann que formam as bainhas nervosas. O schwannoma primário do cólon é uma lesão rara e poucos casos foram descritos. Apresenta-se o caso de um schwannoma do cólon e faz-se referência aos diagnósticos diferenciais que devem ser considerados na avaliação das lesões subepiteliais do cólon.