IMPACT OF ACUTE KIDNEY INJURY STAGING ON PROGNOSIS OF PATIENTS WITH CIRRHOSIS.

BACKGROUND: Acute kidney injury (AKI) is a common and severe complication of cirrhosis. OBJECTIVE: To evaluate the impact of AKI staging on 30-day mortality of patients with cirrhosis. METHODS: We performed a retrospective cohort study of hospitalized patients with cirrhosis. Acute kidney injury (AKI) was diagnosed according to the International Club of Ascites recommendations and staged according to the European Association for the Study of the Liver guidelines. Comparisons between groups were made by one-way analysis of variance and Tukey test. Chi-square was calculated for dichotomous variables. Comparisons of renal impairment status among patients were performed using Kaplan-Meier statistics and differences between groups were analyzed using the log-rank test. A P-value <0.05 was considered to be statistically significant. RESULTS: Two hundred and thirty-two patients were included in the study. The diagnosis of AKI was performed in 98 (42.2%) of them. The overall 30-day mortality was 19.8% (46/232). Mortality increased as the degree of AKI progressed. Among patients who did not have AKI, mortality was 5.2% (7/134). When compared to patients without AKI, patients diagnosed with AKI stage 1a had mortality of 12.1% (4/33, P=0.152); patients with AKI stage 1b had mortality of 45% (18/40, P<0.001); and patients with AKI stages 2 or 3 had mortality of 68% (17/25, P<0.001). Moreover, it is noteworthy that full response to treatment was associated to a decreased mortality when compared to patients who did not show complete recovery of renal function (14.3% vs 57.9%, P<0.001). CONCLUSION: AKI stages 1b or greater, but not AKI stage 1a, are associated to higher 30-day mortality of patients with cirrhosis.

Avaliação prognóstica de lesão renal aguda em pacientes cirróticos / Impact of acute kidney injury staging on prognosis of patients with cirrhosis

ABSTRACT BACKGROUND: Acute kidney injury (AKI) is a common and severe complication of cirrhosis. OBJECTIVE: To evaluate the impact of AKI staging on 30-day mortality of patients with cirrhosis. METHODS: We performed a retrospective cohort study of hospitalized patients with cirrhosis. Acute kidney injury (AKI) was diagnosed according to the International Club of Ascites recommendations and staged according to the European Association for the Study of the Liver guidelines. Comparisons between groups were made by one-way analysis of variance and Tukey test. Chi-square was calculated for dichotomous variables. Comparisons of renal impairment status among patients were performed using Kaplan-Meier statistics and differences between groups were analyzed using the log-rank test. A P-value <0.05 was considered to be statistically significant. RESULTS: Two hundred and thirty-two patients were included in the study. The diagnosis of AKI was performed in 98 (42.2%) of them. The overall 30-day mortality was 19.8% (46/232). Mortality increased as the degree of AKI progressed. Among patients who did not have AKI, mortality was 5.2% (7/134). When compared to patients without AKI, patients diagnosed with AKI stage 1a had mortality of 12.1% (4/33, P=0.152); patients with AKI stage 1b had mortality of 45% (18/40, P<0.001); and patients with AKI stages 2 or 3 had mortality of 68% (17/25, P<0.001). Moreover, it is noteworthy that full response to treatment was associated to a decreased mortality when compared to patients who did not show complete recovery of renal function (14.3% vs 57.9%, P<0.001). CONCLUSION: AKI stages 1b or greater, but not AKI stage 1a, are associated to higher 30-day mortality of patients with cirrhosis.

RESUMO CONTEXTO: A lesão renal aguda (LRA) é uma complicação comum e grave na cirrose. OBJETIVO: Avaliar o impacto dos estágios da LRA na mortalidade em 30 dias de pacientes com cirrose. MÉTODOS: Realizou-se um estudo de coorte retrospectivo com pacientes com cirrose hospitalizados. LRA foi diagnosticada de acordo com as recomendações do International Club of Ascites e o estadiamento foi feito de acordo com as recomendações da European Association for the Study of the Liver. Comparações entre os grupos foram feitas por análise de variância unidirecional e teste de Tukey. O teste do qui-quadrado foi calculado para variáveis categóricas. Comparações quanto à lesão renal entre os pacientes foram realizadas com estatísticas de Kaplan-Meier, e diferenças entre os grupos foram analisadas pelo teste de log-rank. Um P-valor <0,05 foi considerado estatisticamente significativo. RESULTADOS: Duzentos e trinta e dois pacientes foram incluídos no estudo. O diagnóstico de LRA foi realizado em 98 (42,2%) deles. A mortalidade geral em 30 dias foi de 19,8% (46/232). A mortalidade aumentou de acordo com a progressão dos estágios de LRA. Entre pacientes sem LRA, a mortalidade foi de 5,2% (7/134). Quando comparados aos pacientes sem LRA, pacientes diagnosticados com LRA estágio 1a tiveram mortalidade de 12,1% (4/33, P=0,152); pacientes com LRA estágio 1b tiveram mortalidade de 45% (18/40, P<0,001); e pacientes com LRA estágios 2 ou 3 tiveram mortalidade de 68% (17/25, P<0,001). Além disso, é importante ressaltar que a resposta completa ao tratamento associou-se à menor mortalidade quando comparada à ausência de recuperação completa da função renal (14,3% vs 57,9%, P<0,001). CONCLUSÃO: LRA estágios 1b ou superior, mas não estágio 1a, estão associadas à maior mortalidade em 30 dias de pacientes com cirrose.

Hepcidin serum levels in HCV chronically mono-infected naïve patients, compared to healthy individuals

Introduction: Metabolism of iron is altered in patients infected with chronically Hepatitis C. The aim of this study is to compare compare the hepcidin levels in between individuais chronically infected with HCV and uninfected individuals. The aim of this study is to compare the hepcidin serum levels between individuals chronically infected with HCV and uninfected individuals. Methods: A cross-sectional study evaluating hepcidin serum levels of mono-infected HCV (n=29), naive, non-diabetic, non-cirrhotic and non-obese patients by means of ELISA, compared to uninfected patients (n=9) with the same characteristics. The degree of liver fibrosis, according to the METAVIR scale on liver biopsies, the lipid profile, the resistance insulin level, as calculated on HOMA-IR (homeostatic model assessment for insulin resistance), the interleukin-6 (IL-6) and the ferritin serum levels were also measured. Results: The levels of hepcidin were significantly lower in HCV patients compared to controls (8.4 pg/mL (±4.94) vs. 19.51 pg/mL (±5.51)) with p<0.001. The levels of ferritin and hepcidin did not show any relation. There was no difference between hepcidin levels in relation to viral genotype, viral load, IL-6 and degrees of fibrosis within HCV infected individuals. Conclusion: It is possible that hepatic iron overload in this population is explained by suppressed levels of hepcidin in patients with HCV. (AU)

Transaminases elevadas em um paciente assintomático: o que fazer? / Elevated transaminases in an asymptomatic patient: what to do?

Objetivos: Enzimas hepáticas elevadas são um cenário comum encontrado pelos médicos na prática clínica. O objetivo desse estudo é auxiliar os profissionais de saúde na condução desses casos, revisando possíveis causas tanto hepáticas, quanto extra-hepáticas para este achado e como prosseguir com a avaliação diagnóstica frente ao mesmo. Métodos: As buscas foram realizadas nas bases de dados MEDLINE e LILACS. A estratégia de busca foi desenvolvida utilizando-se os seguintes termos de pesquisa: "transaminases" OR "alanina transaminase" OR "aspartato transaminase". Os critérios de elegibilidade foram: estudos realizados em humanos, adultos, maiores de 19 anos, estudos com texto disponível, publicados em português, espanhol ou inglês a partir de 2012. Resultados: De um total de 1219 artigos que foram encontrados nas bases de dados, 20 foram incluídos nessa revisão. Foram selecionados 11 artigos com base na relevância clínica e fator de impacto das revistas. Conclusões: A alteração dos níveis das enzimas hepáticas em um paciente assintomático é um problema comum encontrado no cenário médico. A anamnese, exame físico e avaliação laboratorial são fundamentais para o diagnóstico. Dessa forma, uma abordagem sistemática pode auxiliar na condução ao correto diagnóstico, sendo necessário, por vezes, o auxílio de um especialista.

Aims: Elevated liver enzymes are a common scenario found by doctors in clinical practice. The aim of this study is to assist health care professionals in the conduct of these cases, reviewing possible causes so much liver as liver extra for this found and how to proceed with the diagnostic evaluation it. Methods: The searches were performed in the MEDLINE and LILACS databases. The search strategy was developed using the following search terms: "transaminases" OR "alanine transaminase" OR "aspartate transaminase". The eligibility criteria were: studies in humans, adults over 19 years, studies with available text, published in Portuguese, Spanish or English from 2012 up. Results: Of a total of 1219 articles that were found in the databases, 20 were included in this review. Based on 11 articles based on the clinical relevance and impact factor of the journals. Conclusions: Changing liver enzyme levels in an asymptomatic patient is a common problem found in the medical setting. Anamnesis, physical examination and laboratory evaluation are fundamental for diagnosis. In this way, a systematic approach can help in conducting the correct diagnosis, sometimes requiring the assistance of a specialist.

Tratamento antissecretor da doença do refluxo gastroesofágico pediátrica - uma revisão sistemática / Antisecretory treatment for pediatric gastroesophageal reflux disease - a systematic review

ABSTRACT BACKGROUND: Proton pump inhibitors and histamine H2 receptor antagonists are two of the most commonly prescribed drug classes for pediatric gastroesophageal reflux disease, but their efficacy is controversial. Many patients are treated with these drugs for atypical manifestations attributed to gastroesophageal reflux, even that causal relation is not proven. OBJECTIVE: To evaluate the use of proton pump inhibitors and histamine H2 receptor antagonists in pediatric gastroesophageal reflux disease through a systematic review. METHODS: A systematic review was performed, using MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials databases. The search was limited to studies published in English, Portuguese or Spanish. There was no limitation regarding date of publication. Studies were considered eligible if they were randomized-controlled trials, evaluating proton pump inhibitors and/or histamine H2 receptor antagonists for the treatment of pediatric gastroesophageal reflux disease. Studies published only as abstracts, studies evaluating only non-clinical outcomes and studies exclusively comparing different doses of the same drug were excluded. Data extraction was performed by independent investigators. The study protocol was registered at PROSPERO platform (CRD42016040156). RESULTS: After analyzing 735 retrieved references, 23 studies (1598 randomized patients) were included in the systematic review. Eight studies demonstrated that both proton pump inhibitors and histamine H2 receptor antagonists were effective against typical manifestations of gastroesophageal reflux disease, and that there was no evidence of benefit in combining the latter to the former or in routinely prescribing long-term maintenance treatments. Three studies evaluated the effect of treatments on children with asthma, and neither proton pump inhibitors nor histamine H2 receptor antagonists proved to be significantly better than placebo. One study compared different combinations of omeprazole, bethanechol and placebo for the treatment of children with cough, and there is no clear definition on the best strategy. Another study demonstrated that omeprazole performed better than ranitidine for the treatment of extraesophageal reflux manifestations. Ten studies failed to demonstrate significant benefits of proton pump inhibitors or histamine H2 receptor antagonists for the treatment of unspecific manifestations attributed to gastroesophageal reflux in infants. CONCLUSION: Proton pump inhibitors or histamine H2 receptor antagonists may be used to treat children with gastroesophageal reflux disease, but not to treat asthma or unspecific symptoms.

RESUMO CONTEXTO: Inibidores de bomba de prótons e antagonistas dos receptores H2 da histamina são duas das mais comumente prescritas classes de medicações para a doença do refluxo gastroesofágico pediátrica, mas sua eficácia é controversa. Muitos pacientes são tratados com essas drogas por manifestações atípicas atribuídas ao refluxo gastroesofágico, mesmo que uma relação causal não esteja comprovada. OBJETIVO: Avaliar os inibidores da bomba de prótons e os antagonistas dos receptores H2 da histamina na doença do refluxo gastroesofágico pediátrica através de uma revisão sistemática. MÉTODOS: Realizou-se uma revisão sistemática, utilizando as bases de dados MEDLINE, EMBASE e Cochrane Central Register of Controlled Trials. A pesquisa foi limitada a estudos publicados em inglês, português e espanhol. Não houve limitação quanto à data de publicação. Os estudos foram considerados elegíveis se fossem ensaios controlados randomizados que avaliassem inibidores da bomba de prótons e/ou antagonistas dos receptores H2 da histamina para o tratamento da doença do refluxo gastroesofágico pediátrica. Estudos publicados apenas como resumos, estudos que não avaliassem desfechos clinicamente relevantes e estudos que comparassem exclusivamente diferentes doses do mesmo fármaco foram excluídos. A extração de dados foi realizada por pesquisadores independentes. O protocolo do estudo foi registrado na plataforma PROSPERO (CRD42016040156). RESULTADOS: Após a análise das 735 referências identificadas, 23 estudos (1598 pacientes randomizados) foram incluídos na revisão sistemática. Oito estudos demonstraram que tanto os inibidores da bomba de prótons como os antagonistas dos receptores H2 da histamina eram eficazes contra as manifestações típicas da doença de refluxo gastroesofágico e que não havia evidências de benefício na combinação dessas classes de drogas ou na prescrição rotineira de tratamentos de manutenção de longo prazo. Três estudos avaliaram o efeito dos tratamentos em crianças com asma e, nem os inibidores da bomba de prótons, nem os antagonistas dos receptores H2 da histamina se mostraram significativamente melhores do que o placebo. Um estudo comparou diferentes combinações de omeprazol, betanecol e placebo para o tratamento de crianças com tosse, e não há uma definição clara sobre a melhor estratégia terapêutica. Outro estudo demonstrou que o omeprazol apresentou melhor desempenho do que a ranitidina para o tratamento de manifestações extraesofágicas da doença do refluxo gastroesofágico. Dez estudos não tiveram sucesso em demonstrar benefícios significativos dos inibidores da bomba de prótons ou dos antagonistas dos receptores H2 da histamina para o tratamento de manifestações inespecíficas atribuídas ao refluxo gastroesofágico em crianças menores de 1 ano de idade. CONCLUSÃO: Inibidores da bomba de prótons ou antagonistas dos receptores H2 da histamina podem ser utilizados para tratar crianças com doença de refluxo gastroesofágico, mas não para tratar asma ou sintomas inespecíficos.

ANTISECRETORY TREATMENT FOR PEDIATRIC GASTROESOPHAGEAL REFLUX DISEASE - A SYSTEMATIC REVIEW.

BACKGROUND: Proton pump inhibitors and histamine H2 receptor antagonists are two of the most commonly prescribed drug classes for pediatric gastroesophageal reflux disease, but their efficacy is controversial. Many patients are treated with these drugs for atypical manifestations attributed to gastroesophageal reflux, even that causal relation is not proven. OBJECTIVE: To evaluate the use of proton pump inhibitors and histamine H2 receptor antagonists in pediatric gastroesophageal reflux disease through a systematic review. METHODS: A systematic review was performed, using MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials databases. The search was limited to studies published in English, Portuguese or Spanish. There was no limitation regarding date of publication. Studies were considered eligible if they were randomized-controlled trials, evaluating proton pump inhibitors and/or histamine H2 receptor antagonists for the treatment of pediatric gastroesophageal reflux disease. Studies published only as abstracts, studies evaluating only non-clinical outcomes and studies exclusively comparing different doses of the same drug were excluded. Data extraction was performed by independent investigators. The study protocol was registered at PROSPERO platform (CRD42016040156). RESULTS: After analyzing 735 retrieved references, 23 studies (1598 randomized patients) were included in the systematic review. Eight studies demonstrated that both proton pump inhibitors and histamine H2 receptor antagonists were effective against typical manifestations of gastroesophageal reflux disease, and that there was no evidence of benefit in combining the latter to the former or in routinely prescribing long-term maintenance treatments. Three studies evaluated the effect of treatments on children with asthma, and neither proton pump inhibitors nor histamine H2 receptor antagonists proved to be significantly better than placebo. One study compared different combinations of omeprazole, bethanechol and placebo for the treatment of children with cough, and there is no clear definition on the best strategy. Another study demonstrated that omeprazole performed better than ranitidine for the treatment of extraesophageal reflux manifestations. Ten studies failed to demonstrate significant benefits of proton pump inhibitors or histamine H2 receptor antagonists for the treatment of unspecific manifestations attributed to gastroesophageal reflux in infants. CONCLUSION: Proton pump inhibitors or histamine H2 receptor antagonists may be used to treat children with gastroesophageal reflux disease, but not to treat asthma or unspecific symptoms.

Pancreatite aguda / Acute pancreatitis

Os autores fazem uma revisão atualizada da abordagem clínica da pancreatite aguda, com ênfase nas medidas a serem aplicadas na emergência.

The authors disclose an updated review of clinical management of acute pancreatitis, focusing on measures to be applied in emergency.

Abordagem inicial à insuficiência hepática aguda / Initial approach to acute hepatic insufficiency

A insuficiência hepática aguda é uma entidade clínica rara cujo reconhecimento precoce é crucial para a instituição de medidas e transferência do paciente para centro de transplante hepático emergencial. O objetivo deste artigo é revisar tópicos diagnósticos e o tratamento inicial da insuficiência hepática aguda.

Acute liver failure is a rare critical illness whose early recognition is crucial for the establishment of management measures and to proceed the patient transference to a center with active emergency liver transplantation program. The purpose of this article is to review basic topics of diagnosis and initial treatment of acute liver failure.

Hemorragia digestiva alta / High digestive bleeding

A hemorragia digestiva é uma das emergências médicas mais comuns e uma complicação séria em pacientes internados gravemente enfermos. A úlcera péptica é uma das suas principais causas. A maioria dos pacientes para espontaneamente de sangrar, mas em cerca de 20% dos casos é necessária uma endoscopia digestiva alta (EDA) de urgência terapêutica após estabilização hemodinâmica.

Gastrointestinal bleeding is one of the most common medical emergencies and serious complication in hospitalized critically ill patients. A peptic ulcer is one of its main causes. Most patients stop spontaneous bleeding, but about 20% of the cases an upper endoscopy (UE) after the therapeutic urgency hemodynamic stabilization is required.

Ascite: diagnóstico diferencial e manejo / Ascites: differential diagnosis and management

Os autores realizaram uma prática e objetiva revisão sobre ascite, destacando aspectos como definição, etiologia, diagnóstico, paracentese, análise do líquido ascítico e manejo. O objetivo é auxiliar o profissional da saúde na rápida identificação da patologia relacionada à ascite e definir o tratamento mais adequado dos pacientes, principalmente cirróticos.

The authors conducted a quickly and practice review about ascites, targeting aspects such as definition, etiology, diagnosis, paracentesis, ascitic fluid analysis and management. The goal is to assist healthcare professionals in the early identification of disease and appropriate treatment of patients with ascites, especially cirrhosis.

Hemorragia digestiva alta: diagnóstico diferencial e abordagem / High digestive hemorrhage: differential diagnosis and approach

O objetivo desta publicação é realizar uma breve revisão sobre hemorragia digestiva alta. Além de citar as principais causas desta síndrome, será enfatizada a abordagem na emergência de um paciente nesse contexto: avaliação da estabilidade hemodinâmica e as primeiras medidas a serem realizadas com o intuito de diminuir a morbi-mortalidade. Por fim, serão citadas algumas formas de tratamento "curativo" das principais patologias que podem causar o sangramento digestivo alto.

The purpose of this publication is to conduct a brief review of upper gastrointestinal bleeding. In addition to citing the major causes of this syndrome is the approach emphasized in the emergence of a patient in this context: assessment of hemodynamic stability and the first approaches to be undertaken in order to decrease the morbidity and mortality. Finally, some will be mentioned treatment modalities "healing" of the main diseases that can cause upper gastrointestinal bleeding.

Investigação de icterícia / Investigation of jaudice

Este trabalho é uma revisão da literatura sobre como investigar a icterícia no paciente adulto. Para isso, é imprescindível entender o metabolismo da bilirrubina, a fisiopatologia da hiperbilirrubinema e reconhecer os principais diagnósticos diferenciais de icterícia no adulto.

This article is a literature review on jaundice investigation in adult patients. Therefore, it is necessary for the understanding, knowing about the metabolism of bilirubin and the pathophysiology of hyperbilirrubinemia as well as recognizing the main differential diagnoses of jaundice in adults.

Diverticulite do intestino delgado, uma causa incomum deabdome agudo inflamatório / Diverticulitis of the small bowel, an unusual cause of inflamatory acute abdomen

Objetivos: Descrever a apresentação clínica, o diagnóstico diferencial e o tratamento de um caso de diverticulite do intestino delgado.Descrição do caso: Um homem de 58 anos de idade apresentou quadro clínico de dor e distensão abdominal, com exames de imagem demonstrando espessamento de alça de intestino delgado. Foi realizado exame videolaparoscópico do abdome e diagnosticada diverticulite do intestino delgado, a qual recebeu tratamento cirúrgico. O paciente teve boa evolução no pós operatório.Conclusões: A localização da doença diverticular no intestino delgado é pouco comum, e sua apresentação com complicações como perfuração, obstrução e hemorragia a tornam de grande importância clínica, pela dificuldade de se estabelecer o diagnóstico diferencial com outras moléstias abdominais.

Aims: To describe the clinical presentation, differential diagnosis and treatment of a case of diverticulitis of the small intestine.Case description: A man of fifty-eight years of age presented a clinical picture of abdominal pain and distension, with imaging demonstrating thickened loop of small intestine. Direct laparoscopic examination of the abdomen diagnoseddiverticulitis of the small intestine, which received surgical treatment. The patient progressed well postoperatively.Conclusion: Small bowel is an uncommon site of diverticular disease, and its great clinical importance lies in its presentation with problems such as perforation, obstruction and bleeding, which makes it difficult to establish a differential diagnosis with other abdominal diseases.

Effect of bariatric surgery on liver fibrosis.

BACKGROUND: Although bariatric surgery has been shown to improve hepatic steatosis in morbidly obese patients, the effect of weight loss on hepatic fibrosis has not been determined. Since the prognosis of patients with nonalcoholic fatty liver disease is closely related to the development of hepatic fibrosis, it is important to determine the hepatic histology of these patients after weight loss. We therefore evaluated the prevalence of hepatic fibrosis in morbidly obese patients undergoing bariatric surgery and assessed the correlation of histologic changes with weight loss. METHODS: We retrospectively evaluated 78 morbidly obese patients who underwent gastric bypass. Liver biopsies were taken during surgery and after weight loss, and the correlations between histologic findings and hepatic fibrosis were determined. RESULTS: Of the 78 patients, 35 (44.8%) had fibrosis at first biopsy, and 24 (30.8%) had hepatic fibrosis after weight loss, including 19 of the 35 patients (54.3%) with fibrosis at first biopsy and 5 of the 43 (11.6%) without hepatic fibrosis at first biopsy (P = 0.027). CONCLUSIONS: Weight loss in morbidly obese patients was associated with a reduction in the prevalence of hepatic fibrosis.

Diagnostic and therapeutic ERCP in symptomatic choledocholithiasis, via laparoscopic transgastric access, after roux-en-y gastric bypass / CPER diagnóstica e terapêutica na coledocolitíase sintomática, via acesso transgástrico por videolaparoscopia, após bypass gástrico em y-de-roux

Treatment of choledocholithiasis is a challenge in patients previously submitted to gastric bypass and especially in those already cholecystectomized. We describe here the details of a technique that was shown to be safe, minimally invasive and effective in the treatment of a patient with a calculus of 1.8cm in the middle third of the common bile duct with various associated problems.

O tratamento da coledocolitíase é um desafio em pacientes previamente submetidos a bypass gástrico e especialmente naqueles que já colecistectomizados. Descrevemos aqui os detalhes de uma técnica que se mostrou segura, minimamente invasiva e eficaz no tratamento de um paciente com um cálculo de 1,8cm no terço médio do ducto biliar comum, com várias comorbidades associadas.

Diagnóstico, tratamento e acompanhamento do carcinoma hepatocelular variante fibrolamelar / Diagnosis, treatment and monitoring of hepatocellular carcinoma variant fibrolamellar

Objetivos: descrever um caso de carcinoma hepatocelular variante fibrolamelar, uma patologia pouco comum e com tratamento de escolha ainda controverso. Descrição do caso: aqui relatamos o caso de um paciente masculino de 45 anos, com diagnóstico de carcinoma hepatocelular variante fibrolamelar que foi submetido à hepatectomia parcial com ressecção tumoral, e encontra-se momentaneamente livre de doença após o seguimento de um ano. Conclusão: a variante fibrolamelar do carcinoma hepatocelular acomete geralmente em pacientes jovens, com fígado não-cirrótico, apresentando crescimento tumoral indolente e com melhores taxas de cura em comparação à forma clássica do carcinoma hepatocelular.

Aim: to describe a case of hepatocellular carcinoma fibrolamellar variant, an unusual pathology and treatment of choice remains controversial. Case description: here we report the case of a male patient of 45 years diagnosed with hepatocellular carcinoma variant fibrolamellar who underwent hepatectomy with tumor resection and is momentarily free of disease after one year follow up. Conclusion: fibrolamellar variant of hepatocellular carcinoma usually affects young patients with non-cirrhotic liver and has indolent tumor growth and better cure rates in comparison to the classic form of hepatocellular carcinoma.

Carcinoma de vesícula biliar mascarado por Síndrome de Mirizzi: relato de caso e revisão da literatura / Carcinoma of the gallbladder masked by Mirizzi Syndrome: case report andliterature review

Objetivos: este relato de caso visa descrever uma forma pouco comum de apresentação de câncer de vesícula biliar, mascarado pela Síndrome de Mirizzi.Descrição do caso: uma mulher consultou por náuseas, acolia e colúria, que haviam iniciado dois meses antes, e icterícia, de início recente. A ecografia abdominal evidenciou dilatação da via biliar com coledocolitíase e colelitíase. Uma colangiopancreatografia endoscópica retrógrada mostrou obstrução no terço médio do ducto hepático comum, não sendo visualizado cálculo. A suspeita diagnóstica inicial foi de Síndrome de Mirizzi. Foi inserida uma endoprótese na via biliar principal, com plano de cirurgia. Durante o procedimento cirúrgico foram encontradas lesões macroscópicas em peritônio e vesícula biliar, que indicaram interrupção da cirurgia e coleta de material para biópsia. O exame anatomopatológico evidenciou adenocarcinoma. A paciente teve alta hospitalar com acompanhamento oncológico e plano de quimioterapia.Conclusões: a concomitância da Síndrome de Mirizzi com carcinoma de vesícula é extremante rara, pois são doenças pouco frequentes. Para o diagnóstico definitivo do tumor de vesícula biliar é sempre imperativo o estudo anatomopatológico de todas as peças cirúrgicas.

Aims: This case report aims to describe an unusual presentation of gallbladder cancer, masked by Mirizzi Syndrome.Case description: a woman complained of nausea, dark urine and acholic stools started two months earlier, and jaundice started later. An abdominal ultrasound showed dilatation of the bile duct with choledocholithiasis and cholelithiasis. A cholangiopancreatography showed obstruction in the middle third of the common bile duct, without visualization of gallstones. The initial diagnosis was Mirizzi Syndrome. A stent was inserted in the main bile duct, to plan surgery. During surgery macroscopic lesions were found in gallbladder and peritoneum, which indicated interruption of the surgery and sample collection for biopsy. Pathological examination revealed adenocarcinoma. The patient was discharged with oncological follow-up plan and chemotherapy.Conclusions: The coexistence of Mirizzi Syndrome with carcinoma of the gallbladder is extremely rare, because both diseases are uncommon. Anatomopathological examination of all surgical specimens is always imperative for the definitive diagnosis of gallbladder tumor.

Divertículo gigante do cólon: uma doença rara com localização atípica / Giant colonic diverticulum, a rare disease with atypical localization

O divertículo gigante do cólon é uma rara patologia com menos de 150 casos descritos na literatura inglesa, sendo a primeira referência feita pelos franceses Bonvin e Bonte em 1946. Em 90% dos casos, esta patologia localiza-se no cólon sigmoide e a sua apresentação pode variar desde a forma assintomática até o abdômen agudo. O caso descrito ocorreu em um paciente masculino, com 55 anos, e apresentou-se insidiosamente, com quadro clínico infeccioso e diagnóstico realizado por ressonância nuclear magnética e enema opaco. A localização do divertículo é atípica no cólon transverso, e o tratamento realizado foi cirúrgico com diverticulectomia, apresentando pós-operatório sem complicações.

Giant colonic diverticulum is a rare disease with fewer than 150 cases reported in English literature, the first reference made by the French Bonvin and Bonte in 1946. In 90% of cases the pathology is located in the sigmoid colon and the presentation of this disease can vary from asymptomatic to the acute abdomen. The case described occurred in a male patient aged 55 years and presented insidiously with clinical infection and diagnosis by MRI and barium enema. The location of divertículo is atypical in the transverse colon, and the patient was treated with surgical diverticulectomy, with no postoperative complications.

Síndrome Sump: um relato de caso / Sump Syndrome: a case report

Objetivos: descrever o diagnóstico e tratamento de um caso de Síndrome Sump. Descrição do Caso: uma mulher de 33 anos vinha apresentando episódios recorrentes de dor abdominal, acompanhados de febre e calafrios. A paciente havia sido submetida previamente à cirurgia de vias biliares, sendo realizado o diagnóstico atual de Síndrome Sump. Optou-se pelo tratamento cirúrgico, diante da impossibilidade de tratamento endoscópico. Conclusões: a Síndrome Sump, entidade rara na atualidade, consiste em uma complicação da coledocoduodenoanastomose, causada pelo contato de resíduos gástricos com o colédoco distal, levando à sua obstrução. Deve ser lembrada como causa de colangite de repetição.

Aims: To describe the diagnosis and treatment of a case of Sump Syndrome. Case Description: A 33 years old woman presented recurrent episodes of abdominal pain accompanied by fever and chills. The patient had previously undergone surgery of the biliary tract, and the current diagnosis of Sump Syndrome was performed. A surgical treatment was indicated given the impossibility of endoscopic treatment. Conclusions: The Sump Syndrome, rare nowadays, consists of a complication of choledocoduodenoanastomosis caused by contact of gastric residues with the distal common bile duct, causing obstruction. It should be considered as a cause of recurrent cholangitis.