Immuno-mediated colitis induced by nivolumab that mimics endoscopically and histologically an ulcerative colitis.

Immunotherapy has revolutionized the management of oncological pathology, demonstrating effectiveness in treating various cancers by stimulating the immune system against tumor cells. Among the immunotherapy drugs are programmed cell death protein 1 (PD-1) inhibitors, such as Nivolumab, which, by blocking this receptor on the surface of T lymphocytes, enhance the immune response. Despite their significant benefits, these agents present specific adverse effects on healthy tissues that need to be understood. One of these effects is immune-mediated colitis, a potentially serious gastrointestinal disorder that may require the permanent discontinuation of the drug. Although it can occur with various immunotherapy regimens, it occurs more frequently with anti-CTLA4 agents like Ipilimumab, with its incidence much lower with anti-PD1 agents. We present the case of a 62-year-old male diagnosed with metastatic clear cell renal carcinoma treated with radical nephrectomy and subsequent palliative systemic treatment with Nivolumab. After the third cycle of immunotherapy, he developed abdominal pain and diarrhea. Colonoscopy revealed continuous mucosal inflammation up to the cecum, erosions, exudates, and loss of the vascular pattern. Biopsies showed signs of active colitis, cryptic abscesses, and focal cryptitis, all consistent with a case of immuno-mediated colitis induced by Nivolumab that mimics, both endoscopically and histologically, the findings found in ulcerative colitis.

Torsade de pointes secondary to long QT syndrome after intragastric balloon placement. A rare but severe complication.

The obesity pandemic is becoming one of the most prevalent diseases nowadays. There is a wide spectrum of treatment, ranging from hygienic-dietary measures to bariatric surgery. Endoscopic intragastric balloon placement is becoming increasingly more frequent, due to its technical simplicity, safety and short-term success(1). Although complications are rare some can be severe, so pre-endoscopic evaluation must be carried out carefully. A 43-year-old woman with a history of grade I obesity (BMI 32.7) had an Orbera® intragastric balloon implanted successfully. After the procedure she presented frequent nausea and vomiting, partially controlled with antiemetics. She attended the Emergency Department(ED) with a persistent emetic syndrome - oral intolerance and short-term loss of consciousness(syncope), for which she was admitted. Lab tests showed metabolic alkalosis with severe hypokalemia(K+ 1.8mmol/L), so fluid therapy was initiated for hydroelectrolytic replacement. During the patient's stay in the ED, two episodes of polymorphic ventricular tachychardia "Torsades de Pointes" (PVT-TDP) occurred, leading to cardiac arrest and requiring electrical cardioversion to restore sinus rhythm, in addition to a temporary pacemaker placement. Telemetry showed a corrected QT interval of >500ms, compatible with Long QT Syndrome(LQTS). Once the patient was hemodynamically stabilized a gastroscopy was performed. The intragastric balloon located in the fundus was removed using an extraction kit, puncturing and aspirating 500ml of saline solution, and extracting the collapsed balloon without any complications. The patient achieved an adequate oral intake afterwards, and no recurrence of emetic episodes were noticed. Previous ECGs revealed a prolonged QT interval and a genetic study confirmed a congenital type 1 LQTS. Treatment was initiated with beta-blockers and a bicameral automatic defibrillator was implanted in order to prevent recurrences. Intragastric balloon placement is generally a safe procedure, serious complications present in 0.70% of cases(2). It is essential to have a proper pre-endoscopic evaluation, including patient's medical history and comorbidities. Episodes of PVT-TDP may present precipitated by certain medications (eg. metoclopramide) or hydroelectrolytic imbalances (eg, hypokalemia)(3). A standardized evaluation of ECG before intragastric balloon placement may be useful to prevent these rare but serious complications.

Torsade de pointes secondary to long QT syndrome after intragastric balloon placement. A rare but severe complication

The obesity pandemic is becoming one of the most prevalent diseases nowadays. There is a wide spectrum of treatment, ranging from hygienic-dietary measures to bariatric surgery. Endoscopic intragastric balloon placement is becoming increasingly more frequent, due to its technical simplicity, safety and short-term success(1). Although complications are rare some can be severe, so pre-endoscopic evaluation must be carried out carefully. A 43-year-old woman with a history of grade I obesity (BMI 32.7) had an Orbera® intragastric balloon implanted successfully. After the procedure she presented frequent nausea and vomiting, partially controlled with antiemetics. She attended the Emergency Department(ED) with a persistent emetic syndrome - oral intolerance and short-term loss of consciousness(syncope), for which she was admitted. Lab tests showed metabolic alkalosis with severe hypokalemia(K+ 1.8mmol/L), so fluid therapy was initiated for hydroelectrolytic replacement. During the patient’s stay in the ED, two episodes of polymorphic ventricular tachychardia “Torsades de Pointes” (PVT-TDP) occurred, leading to cardiac arrest and requiring electrical cardioversion to restore sinus rhythm, in addition to a temporary pacemaker placement. Telemetry showed a corrected QT interval of >500ms, compatible with Long QT Syndrome(LQTS). Once the patient was hemodynamically stabilized a gastroscopy was performed. The intragastric balloon located in the fundus was removed using an extraction kit, puncturing and aspirating 500ml of saline solution, and extracting the collapsed balloon without any complications. The patient achieved an adequate oral intake afterwards, and no recurrence of emetic episodes were noticed. Previous ECGs revealed a prolonged QT interval and a genetic study confirmed a congenital type 1 LQTS. Treatment was initiated with beta-blockers and a bicameral automatic defibrillator was implanted in order to prevent recurrences. ... (AU)

Intestinal stenosis developed after a complete response to chemotherapy in a patient with Crohn´s disease and lymphoma of the jejunum.

An increased risk of hematologic malignancies secondary to long-term immunomodulators and biologics has been described in patients with inflammatory bowel disease1. Here, we present a case of jejunal stricture after chemotherapy treatment in a patient with ileal Crohn´s disease (CD) and jejunal lymphoma. The patient was a 32-year-old male with ileal CD in remission presenting with abdominal pain and distension. Abdominal computed tomography (CT) showed a poorly defined mass in the proximal jejunum, and positron emission tomography (PET) - CT showed hypermetabolic activity at that level. An upper endoscopy evidenced an indurated, friable circumferential mass causing a significant reduction of the intestinal lumen. Histological and cytometry findings led to a diagnosis of large B cell lymphoma, for which the patient received standard treatment (R-CHOP and IPI), achieving complete response. Eight months later, the patient reported abdominal pain and distention. Abdominal CT showed a thickening of a short segment of the proximal jejunum. An upper endoscopy showed a punctiform stenosis, while multiple biopsies showed neither histological recurrence of lymphoma nor signs of IBD. The patient was diagnosed with a post-chemotherapy stricture and underwent progressive endoscopic balloon dilatation. He finally was scheduled for laparoscopic small bowel resection. An histological analysis of the surgical piece revealed a granulomatous reaction with multinucleated foreign body-like giant cells, without evidence of malignancy (recurrence of lymphoma) nor inflammatory infiltrate suggesting CD. The patient currently remains asymptomatic with no new episodes of abdominal pain.

Prevalencia y patrón de consumo de alcohol en pacientes con carcinoma hepatocelular / Prevalence and pattern of alcohol consumption in patients with hepatocellular carcinoma

Objetivo Estudio transversal prospectivo realizado para conocer la prevalencia y el patrón de consumo de alcohol (CA) de los pacientes con carcinoma hepatocelular (CHC) y evaluar la utilidad del AUDIT en estos. Métodos Se incluyeron 102 pacientes consecutivos atendidos en consulta entre febrero y marzo de 2022; se excluyeron aquellos con encefalopatía hepática en el momento de la entrevista, pacientes en lista de espera para trasplante por esta indicación y aquellos en seguimiento postrasplante. Resultados La prevalencia del CA en pacientes con diagnóstico de CHC es del 35%, si bien menos del 10% consume más de 100g de etanol a la semana. El CA fue más frecuente en varones, ambiente urbano, con diagnóstico de CHC hace más de un año y en pacientes en estadio inicial/muy inicial del BCLC. La puntuación AUDIT mayor o igual a 3 (AUROC 0,849) predice cualquier CA con una sensibilidad del 75% (IC 95%: 59,47-90,53%) y con una especificidad del 84% (IC 95%: 74,70-94,05%). Conclusiones A pesar del diagnóstico de CHC, más de un tercio de los pacientes consume alcohol. La puntuación AUDIT igual o mayor de 3 discrimina cualquier CA con una sensibilidad del 75% y una especificidad del 84% en esta población (AU)

Aim Prospective cross-sectional study conducted to determine the prevalence and pattern of alcohol consumption (AC) in patients with hepatocellular carcinoma (HCC) and to assess the utility of the AUDIT in HCC patients. Methods One hundred and two consecutive patients form our HCC monographic outpatient clinic visited between February and March 2022 were included. Patients with hepatic encephalopathy at the time of the interview, on the waiting list for liver transplantation and those undergoing post-transplant follow-up were excluded. Results The prevalence of AC in patients diagnosed with HCC is 35%, although less than 10% consume more than 100g per week. AC was more frequent in males, in an urban environment, with a diagnosis of HCC more than a year ago, and in patients in early/very early stages of BCLC. AUDIT score greater than or equal to 3 (AUROC 0.849) predicts any AC with a sensitivity of 75% (95% CI: 59.47-90.53%) and a specificity of 84% (95% CI: 74.70-94.05%). Conclusions Despite the diagnosis of HCC, more than a third of the patients consume alcohol. An AUDIT score equal to or greater than 3 discriminates any AC with a sensitivity of 75% and a specificity of 84% in this population (AU)

[Prevalence and pattern of alcohol consumption in patients with hepatocellular carcinoma]. / Prevalencia y patrón de consumo de alcohol en pacientes con carcinoma hepatocelular.

AIM: Prospective cross-sectional study conducted to determine the prevalence and pattern of alcohol consumption (AC) in patients with hepatocellular carcinoma (HCC) and to assess the utility of the AUDIT in HCC patients. METHODS: One hundred and two consecutive patients form our HCC monographic outpatient clinic visited between February and March 2022 were included. Patients with hepatic encephalopathy at the time of the interview, on the waiting list for liver transplantation and those undergoing post-transplant follow-up were excluded. RESULTS: The prevalence of AC in patients diagnosed with HCC is 35%, although less than 10% consume more than 100g per week. AC was more frequent in males, in an urban environment, with a diagnosis of HCC more than a year ago, and in patients in early/very early stages of BCLC. AUDIT score greater than or equal to 3 (AUROC 0.849) predicts any AC with a sensitivity of 75% (95% CI: 59.47-90.53%) and a specificity of 84% (95% CI: 74.70-94.05%). CONCLUSIONS: Despite the diagnosis of HCC, more than a third of the patients consume alcohol. An AUDIT score equal to or greater than 3 discriminates any AC with a sensitivity of 75% and a specificity of 84% in this population.

Sigmoid volvulus management, only endoscopic devolvulation?

Intestinal obstruction due to sigmoid volvulus (SV) represents a relevant percentage of abdominal diseases presenting at the emergency department. Treatment is based on early endoscopic devolvulation (ED), followed by elective surgery as definitive treatment. A 78-year-old man institutionalized with Lewy body dementia presents with abdominal pain, distention, and absence of stool in 72 hours. Coffee bean sign was seen in abdominal x-ray. Previously, he had been admitted three times last year with recurrent SV, managed with ED succesfully. Despite the recurrence, no surgical treatment was indicated after resolution of the acute situation and recovery of intestinal transit. This time, urgent colonoscopy was performed and a 20 cm length of purplish-black (isquemic) sigmoid mucosa was observed. With these findings of stablished intestinal ischemia urgent surgical intervention was performed (sigmoidectomy and terminal "Hartmann" colostomy). Histologically, necrosis, severe ulceration and mixed inflammation was noticed in the surgical piece. The patient develops favorably during a postoperative period without incidents. Therefore, he is discharged to his center. At the moment he is asymptomatic one year after the intervention with no new episodes. Recurrency of SV after ED is up to 86% of cases. In every episode, the incidence of complications such as intestinal ischemia or perforation increases significantly, as well as urgent surgery and mortality. Definitive treatment must be surgical, sigmoidectomy and terminal anastomosis is the choice technique.

Recurrent abdominal pain as the only clinical manifestation of hereditary angioedema type II.

Recurrent abdominal pain is a common reason for consultation in Gastroenterology. The differential diagnosis includes hereditary angioedema (HAE), a rare disorder characterized by recurrent episodes of angioedema, without urticaria or pruritus, which most often affects the skin, but also mucosal tissues of the gastrointestinal tract, triggered by diverse factors such as infections, trauma, surgery, drugs, or stress. It is a disease with a difficult diagnosis due to its heterogeneous and transitory clinical features, so having a clinical suspicion in the appropriate context would allow the administration of a specific treatment and avoid unnecessary examinations. We present the case of a 19-year-old male followed-up for recurrent abdominal pain that, after numerous microbiological, endoscopic, and radiological examinations, complement tests were requested, obtaining low levels of C4 with increased levels of C1 inhibitor and reduced functional activity, being diagnosed with HAE type II.