Strongyloides stercoralis Gastric Ulcer: A Rare Cause of Upper Gastrointestinal Bleeding.

Strongyloidiasis is an infection caused by Strongyloides stercoralis. Gastrointestinal manifestations typically include duodenitis, chronic enterocolitis, and malabsorption, while gastric involvement is very rare. In this case report, the -authors present a case of upper gastrointestinal bleeding caused by a gastric ulcer with a challenging etiological diagnosis. In Portugal, there have been reports in the past century of autochthonous cases of S. stercoralis infection suggesting endemic zones, but with the current sanitation infrastructure strongyloidiasis is thought to be rare. A 56-year-old Caucasian male smoker with a history of significant weight loss presented to the emergency department with hema-temesis and abdominal pain. Upper endoscopy revealed a giant gastric ulcer with a macroscopic appearance suggestive of malignancy. Further investigation with CT scan highlighted gastric wall thickness and a spiculated lung lesion in the upper right lobe without lymph node involvement or metastatic disease. Bronchoscopy with bronchial brushing was performed. Histological examination identified squamous cell carcinoma of the lung and the patient was referred to Oncological Pneumology. Gastric ulcer biopsies ruled out malignancy and identified fragments of nematodes with inflammatory infiltrates and fibrinogranulocytic exudate, suggestive of S. stercoralis. Accordingly, the diagnosis of strongyloidiasis was made and further confirmed with molecular methods and serology. The giant gastric ulcer was affirmed to be caused by S. stercoralis infection and the patient was treated with ivermectin with improvement of epigastric pain. On reevaluation 6 weeks later the patient was asymptomatic, had gained weight, parasitological stool examinations were negative, and upper endoscopy showed complete ulcer healing. Further tests were done targeting risk factors for strongyloidiasis, and in addition to the presence of malignancy, other underlying causes for immunosuppression were ruled out. In this case report strongyloidiasis was manifested by gastric involvement with upper gastrointestinal bleeding in a patient who was subsequently diagnosed with squamous cell carcinoma of the lung.

A estrongiloidíase é uma infecção causada por Strongyloides stercoralis. As manifestações gastrointestinais tipicamente incluem duodenite, enterocolite crónica e má absorção, sendo o envolvimento gástrico muito raro. Neste caso clínico, os autores apresentam um caso de hemorragia digestiva alta causada por uma úlcera gástrica com um diagnóstico etiológico desafiante. Em Portugal no século passado existiram casos autóctones de infecção a S. stercoralis sugerindo zonas endémicas, mas com a actual infraestrutura de saneamento a estrongiloidíase é rara. Homem de 56 anos de idade, caucasiano, fumador, com história de perda ponderal significativa, admitido no Serviço de Urgência por hematemeses e dor abdominal. A endoscopia digestiva alta realizada revelou uma úlcera gástrica gigante com aparência macroscópica sugestiva de malignidade. A investigação subsequente com tomografia computadorizada (TC) destacou a presença de espessamento gástrico e uma lesão pulmonar espiculada no lobo superior direito, sem envolvimento ganglionar ou doença metastática. Foi realizada broncofibroscopia com escovado brônquico tendo o exame histológico identificado carcinoma pavimento celular do pulmão, pelo que o doente foi referenciado para a Pneumologia Oncológica. As biópsias da úlcera gástrica descartaram malignidade e identificaram fragmentos de nemátodes com infiltrados inflamatórios e exsudado fibrino-granulocítico, sugestivo de Strongyloides stercoralis. Consequentemente, foi feito o diagnóstico de estrongiloidíase, confirmado com métodos moleculares e sorologia. Admitiu-se que a úlcera gástrica gigante terá sido causada pela infecção por Strongyloides stercoralis e o doente foi tratado com ivermectina com melhoria da dor epigástrica. Em reavaliação, seis semanas depois, o doente estava assintomático, com ganho ponderal, os exames parasitológicos das fezes estavam negativos e a endoscopia digestiva alta mostrou cicatrização completa da úlcera. Foram realizados exames adicionais para investigação de factores de risco para estrongiloidíase, tendo sido excluídas outras causas de imunossupressão subjacente para além da presença de malignidade. Neste caso clínico, a estrongiloidíase manifestou-se por envolvimento gástrico com hemorragia digestiva alta num doente que foi posteriormente diagnosticado com carcinoma pavimento celular do pulmão.

Clube Português do Pâncreas Recommendations for Chronic Pancreatitis: Medical, Endoscopic, and Surgical Treatment (Part II).

Chronic pancreatitis (CP) is a complex disease that should be treated by experienced teams of gastroenterologists, radiologists, surgeons, and nutritionists in a multidisciplinary environment. Medical treatment includes lifestyle modification, nutrition, exocrine and endocrine pancreatic insufficiency correction, and pain management. Up to 60% of patients will ultimately require some type of endoscopic or surgical intervention for treatment. However, regardless of the modality, they are often ineffective unless smoking and alcohol cessation is achieved. Surgery retains a major role in the treatment of CP patients with intractable chronic pain or suspected pancreatic mass. For other complications like biliary or gastroduodenal obstruction, pseudocyst drainage can be performed endoscopically. The recommendations for CP were developed by Clube Português do Pâncreas (CPP), based on literature review to answer predefined topics, subsequently discussed and approved by all members of CPP. Recommendations are separated in two parts: "chronic pancreatitis etiology, natural history, and diagnosis," and "chronic pancreatitis medical, endoscopic, and surgical treatment." This abstract pertains to part II.

Endoscopic band ligation - A valid option in colonic diverticular bleeding / Ligadura con bandas elásticas - una opción válida en el sangrado diverticular

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Clube Português do Pâncreas Recommendations for Chronic Pancreatitis: Etiology, Natural History, and Diagnosis (Part I).

Chronic pancreatitis (CP) is a heterogeneous disease, with different causes and often a long delay between onset and full classic presentation. Clinical presentation depends on the stage of the disease. In earlier stages, recurrent episodes of acute pancreatitis are the major signs dominating clinical presentation. As the inflammatory process goes on, less acute episodes occur, and pain adopts different aspects or may even disappear. After 10-15 years from onset, functional insufficiency occurs. Then, a classic presentation with pain and pancreatic exocrine and endocrine insufficiency appears. Diagnosis remains challenging in the early stages of the disease, as its initial presentation is usually ill-defined and overlaps with other digestive disorders. Computed tomography and magnetic resonance cholangiopancreatography should be the first choice in patients with suspected CP. If the results are normal or equivocal but still there is a high suspicion of CP, the next option should be endoscopic ultrasound. Endoscopic retrograde cholangiopancreatography is mainly a therapeutic technique, and for the diagnostic purpose should only be used when all other imaging modalities and pancreatic function tests have been exhausted. Indirect tests are used to quantify the degree of insufficiency in already-established late CP. Recommendations on CP were developed by Clube Português do Pâncreas (CPP), based on literature review to answer predefined topics, subsequently discussed and approved by all members of CPP. Recommendations are separated in two parts: "chronic pancreatitis etiology, natural history, and diagnosis," and "chronic pancreatitis medical, endoscopic, and surgical treatment." This abstract pertains to part I.

A pancreatite crónica (PC) é uma doença heterogénea, com diferentes etiologias, muitas vezes, com um longo período entre o início de sintomatologia e a apresentação clínica clássica. A clínica depende do estadio da doença, sendo que nos estadios iniciais, predominam episódios recorrentes de pancreatite aguda; com a progressão da doença, os episódios agudos tornam-se menos frequentes, e a dor adota padrões diferentes, podendo inclusive desaparecer; a insuficiência funcional desenvolve-se 10 a 15 anos após o início, assumindo-se então, a apresentação clássica com dor, insuficiência pancreática exócrina e endócrina. O diagnóstico pode ser desafiador nos estadios iniciais da doença, já que a apresentação inicial é geralmente mal definida e se sobrepõe a outros patologias gastrointestinais. A TAC e CPRM devem ser os primeiros métodos de imagem em doentes com suspeita de PC. Se os resultados forem normais ou ambíguos, a próxima opção deve ser a ecoendoscopia. A CPRE é uma técnica principalmente terapêutica, sendo que para fins de diagnóstico, deve ser reservada para quando todas os outros exames de imagem/testes de função pancreática forem inconclusivos. Testes indiretos de função pancreática devem ser usados para quantificação do grau de insuficiência pancreática em doentes com PC já estabelecida. As recomendações sobre PC foram desenvolvidas pelo Clube Português do Pâncreas (CPP), com base numa revisão da literatura para responder a questões predefinidas, posteriormente discutidos e aprovados por todos os membros do CPP. As recomendações encontram-se separadas em duas partes: "etiologia da pancreatite crónica, história natural e diagnóstico" e "tratamento médico, endoscópico e cirúrgico da pancreatite crónica." Este resumo corresponde à parte I.

A surprising "gastric" biopsy / Biopsia gástrica inesperada

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Major duodenal diverticular bleeding / Hemorragia de divertículo duodenal

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Primary adenocarcinoma arising in esophageal colon interposition for corrosive esophageal injury: a case report and review of the literature.

Background and study aims Colon interposition for benign strictures is associated with significant perioperative complications that carry high morbidity and mortality. Although rarely reported in the literature, adenocarcinoma can occur as a late complication in an interposed colonic segment. We report a case of a late-stage adenocarcinoma in a colonic interposition performed for benign esophageal stricture.

Gastritis cystica profunda mimicking a GIST - A diagnostic challenge / Gastritis cystica profunda simulando GIST - un caso de desafío diagnóstico

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Lipids, glucose and iron metabolic alterations in chronic hepatitis C after viral eradication - comparison of the new direct-acting antiviral agents with the old regimens.

BACKGROUND: Hepatitis C virus (HCV) is a unique virus which interacts with cholesterol, iron and insulin metabolism. There is limited data on the effects of direct-acting antiviral agents (DAAs) on metabolic profiles. We aimed at evaluating the behavior of metabolic risk factors of chronically HCV-infected patients after sustained virologic response (SVR), comparing the outcomes with the new DAAs versus the old treatment regimen Peg-interferon ± ribavirin. METHODS: A total of 178 patients who achieved SVR and completed one year of follow-up were prospectively included in this study: group 1 with 105 patients treated with DAAs and group 2 with 73 patients treated with old regimens. Outcomes included lipid, glucose and iron metabolism variation after SVR. RESULTS: There was a significant increase in total cholesterol in both groups (group 1: p < .001, 95% CI: 0.41-0.78; group 2: p < .001, 95% CI: 0.24-0.69). Triglyceride levels significantly decreased (p = .015, 95% CI: -0.33-0.04) in group 1 and increased (p = .014, 95% CI: 0.07-0.59) in group 2. LDL levels increased in group 1 (p = .029, 95% CI: 0.05-0.88), but no significant variation was found in group 2. No significant variation in HDL, fast glucose and iron was seen in both groups. There was a significant increase of HOMA (p = .002, 95% CI: 0.17592-0.72317) only in group 2. Ferritin serum levels significantly decreased (p < .001, 95% CI:-138.3-74.4) in group 1 but no significant variation was found in group 2. CONCLUSION: Patients who have achieved SVR may have increased risk of cardiovascular outcomes due to development of hyperlipidemia and insulin resistance.

Identifying palliative care needs in a Portuguese liver unit.

BACKGROUND & AIMS: Chronic liver disease is a major worldwide cause of morbidity and mortality. Palliative care policies are not clearly established in chronic liver disease. The NECPAL CCOMS-ICO© (NECesidades PALiativas/Palliative Needs) is a tool to identify palliative care needs, including a section for liver disease. AIM: The aim of this study was to identify palliative care needs in liver patients hospitalised in a tertiary referral Liver Unit. METHODS: Single-centre prospective observational study. One hundred and twenty patients with cirrhosis were included and NECPAL questionnaire was applied to all patients in a 7-month period. RESULTS: 84.2% of patients were considered as requiring palliative intervention; however, clinicians identified those needs only in 65.8% of the cases and caregivers in 6.7% of the cases; less than 8% of the patients were referred for palliative care consultation. An excessive use of healthcare resources (positive answer to question 3) was strongly associated with a positive need for palliative care (positive NECPAL): OR 7.305, CI 95% 2.54-20.995, P < .001). An excessive use of healthcare facilities has a sensitivity of 84.2% and a specificity of 42.1% for prediction of a positive NECPAL result (AUC 0.710, 95% CI 0.570-0.850, P = .004). CONCLUSIONS: The NECPAL CCOMS-ICO© represents a feasible and easy-to-use tool to identify palliative care needs in patients with chronic liver disease.

The use of a segmental endoscopic score may improve the prediction of clinical outcomes in acute severe ulcerative colitis

Background: Acute severe colitis (ASC) remains a challenging complication of ulcerative colitis. The early identification of patients who will not respond to optimal therapy is warranted. Increasing evidence suggests that endoscopy may play a role in predicting important outcomes in acute severe colitis. Methods: The endoscopic activity of consecutive patients with acute severe colitis was evaluated using the Mayo endoscopic sub-score (Mayo) and the ulcerative colitis endoscopic index of severity (UCEIS). Two segmental indexes were also produced by summing the scores of the rectum and sigmoid (seg-Mayo and seg-UCEIS, respectively). Endpoints included the need for salvage therapy with infliximab or cyclosporine, refractoriness to corticosteroids, and colectomy. Results: Of one hundred and eight patients enrolled in the study, 60 (55.6%) were male; with a median age of 34.5 years (range 15-80). All patients received intravenous steroids. Fifty-nine patients (55.6%) showed an incomplete or absent response to steroids, 35 patients (34.3%) received salvage therapy with infliximab or cyclosporine and 38 patients (33.3%) were colectomized during the ndex hospitalization or within the first year of follow-up. All scores were able to predict the need for surgery, but only the seg-UCEIS significantly predicted refractoriness to steroids. Conclusions: There was a strong correlation between endoscopic severity and unfavorable outcomes. The UCEIS outperformed the Mayo endoscopic sub-score in all important outcomes. Segmental scoring further improved the performance of the UCEIS (AU)

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The use of a segmental endoscopic score may improve the prediction of clinical outcomes in acute severe ulcerative colitis.

BACKGROUND: Acute severe colitis (ASC) remains a challenging complication of ulcerative colitis. The early identification of patients who will not respond to optimal therapy is warranted. Increasing evidence suggests that endoscopy may play a role in predicting important outcomes in acute severe colitis. METHODS: The endoscopic activity of consecutive patients with acute severe colitis was evaluated using the Mayo endoscopic sub-score (Mayo) and the ulcerative colitis endoscopic index of severity (UCEIS). Two segmental indexes were also produced by summing the scores of the rectum and sigmoid (seg-Mayo and seg-UCEIS, respectively). Endpoints included the need for salvage therapy with infliximab or cyclosporine, refractoriness to corticosteroids, and colectomy. RESULTS: Of one hundred and eight patients enrolled in the study, 60 (55.6%) were male; with a median age of 34.5 years (range 15-80). All patients received intravenous steroids. Fifty-nine patients (55.6%) showed an incomplete or absent response to steroids, 35 patients (34.3%) received salvage therapy with infliximab or cyclosporine and 38 patients (33.3%) were colectomized during the index hospitalization or within the first year of follow-up. All scores were able to predict the need for surgery, but only the seg-UCEIS significantly predicted refractoriness to steroids. CONCLUSIONS: There was a strong correlation between endoscopic severity and unfavorable outcomes. The UCEIS outperformed the Mayo endoscopic sub-score in all important outcomes. Segmental scoring further improved the performance of the UCEIS.

A rare case of Burkitt's lymphoma of the duodenal bulb.

Gastrointestinal tract involvement in immunodeficiency-related Burkitt's lymphoma is not common and the duodenal involvement is very rare. We report the case of a 35-year-old man admitted because of abdominal pain, vomiting and weight loss. Human immunodeficiency virus infection was diagnosed and upper digestive tract endoscopy showed marked edema and hyperemia of the duodenal bulb with some violaceous areas. Immunohistochemical study of the bulbar tissue samples confirmed the diagnosis of Burkitt's lymphoma. To our knowledge, duodenal Burkitt's lymphoma affecting only the bulb has not been previously reported in the medical literature. In patients with human immunodeficiency virus infection who present with upper gastrointestinal symptoms, upper endoscopy may be diagnostic of malignancy and biopsies should be obtained from abnormal areas.