GE Portuguese Journal of Gastroenterology最新文献

Introduction: Malignant melanoma of the esophagus is an uncommon cause of dysphagia and accounts for only 0.1-0.2% of esophageal neoplasms. Diagnosis is based on esophagogastroduodenoscopy (EGD) with biopsies and immunohistochemical analysis, the latter being crucial in the amelanocytic variant. Gastrointestinal melanomas are more invasive and comprise poorer prognosis than cutaneous melanomas.

Case presentation: The authors present the case of a 70-year-old woman admitted to the emergency department for progressive dysphagia with 2 months of evolution. EGD revealed the presence of an extensive, eccentric lesion, occupying approximately half of the luminal circumference at the level of the distal esophagus with circumferential involvement of the esophagogastric junction and cardia. Thoracoabdominopelvic computed tomography and positron emission tomography showed signs of advanced disease. The initial endoscopic biopsies were inconclusive, and EGD was repeated with multiple biopsies directed at the most infiltrative areas, whose histopathological analysis with immunohistochemistry revealed neoplastic cells with marked nuclear positivity for SOX10 and cytoplasmic positivity for vimentin, Melan-A, and HMB45 with absence of melanin pigment, findings suggestive of esophagocardiac amelanocytic malignant melanoma. In a multidisciplinary team meeting, the neoplasm was deemed unresectable, and the proposal was for esophageal stent placement and palliative hormone therapy.

Discussion: Primary amelanocytic malignant melanoma is an exceptionally rare neoplasm and an extremely uncommon cause of dysphagia. In this context, we present a compelling case study that underscores the rarity of this histological type, the importance of directing biopsies to the most suspicious areas of the lesion to increase diagnostic yield, the need for a high clinical suspicion, and the atypical endoscopic presentation associated with the amelanocytic subtype.

A 64-year-old male was admitted with fever, abdominal pain, and jaundice. Medical history was relevant for colorectal adenocarcinoma 11 years before and right hepatectomy due to liver metastasis. MRCP revealed left hepatic duct stenosis without liver nodules. ERCP was performed for biliary drainage with plastic stents. After inconclusive brush cytology, cholangioscopy (SpyGlass™ DS2) was performed showing villous mucosa surrounded by irregular vessels suggestive of tumor neovascularization. SpyBite™ biopsies confirmed biliary metastasis of colorectal origin. The patient started palliative chemotherapy being readmitted 6 months later with acute cholangitis. Diffuse infiltrating intrabiliary lesion with 120 mm was detected in control MRCP. Given its intraductal extension and gastric compression by the hypertrophied liver leading to duodenoscope mispositioning, transpapilar stents could not be deployed. Multiorgan dysfunction developed despite broad-spectrum antibiotics, and EUS-guided biliary drainage was proposed. Although EUS access was limited by gastric bulging, puncture of a dilated intrahepatic duct was accomplished with a 19G needle. PCSEMS (GIOBOR™ 8 × 100 mm) placement was only possible above the gastroesophageal junction with the proximal flare being incidentally deployed in a 3-cm intraparietal esophageal tract. The misplaced stent was immediately recanalized, and a stent-in-stent FCSEMS (WallFlex™ 80 × 10 mm) allowed the hepaticoesophagostomy creation. Since the stent opening was orally oriented in esophageal lumen, parenteral nutrition was started to avoid contamination. Sepsis recovering and liver test normalization were observed. Before hospital discharge, stent reposition was planned to resume oral feeding. After placement of a third stent-in-stent NCSEMS (WallFlex™ 120 × 10 mm) in the hepaticoesophagostomy to prevent migration, the proximal flare was oriented to the stomach gently pushing with the endoscope aiding by an inflated biliary balloon. The patient resumed chemotherapy but died 8 months after due to disease progression. Isolated bile duct metastasis is an uncommon complication of colorectal cancer. EUS-guided hepaticoesophagostomy is feasible when puncture through the esophagus was inevitable, especially in patients with liver hypertrophy.

Introduction: Refractory ascites (RA) is the most common complication of end-stage liver disease (ESLD) with a significant burden in terms of symptoms and overall quality of life (QoL). There are limited therapeutic options available for this population and most ultimately undergo serial large-volume paracentesis (LVP). Long-term abdominal drains (LTAD) are commonly used for malignant ascites drainage but not for ascites related to ESLD, due to concerns about kidney injury and infection.

Objectives: This review aims to describe the safety, effectiveness, and impact on the QoL of LTAD in ESLD-related ascites.

Methods: Using systematic review methodology, PubMed-MEDLINE, Embase, and Google Scholar databases were searched for studies published between January 1, 2001, to June 1, 2024, combining medical subject headings (MeSH) ([cirrhosis OR chronic liver disease] AND refractory ascites AND [permanent-tunneled peritoneal catheter OR tunneled catheter OR indwelling catheter OR long-term abdominal drains]). Inclusion and exclusion criteria were applied to the results.

Results: One hundred thirty-nine studies were identified, with 16 deemed eligible for final analysis, including three randomized clinical trials. The studies varied in design, included different types of LTAD, and were generally of low quality, with many lacking statistical power due to small sample sizes. In terms of effectiveness, technical success was 100%, and as long as LTAD remains in situ, no need for additional LVP is required. Overall, the catheters remained in situ for periods ranging from 3 to 436 days. In terms of safety, kidney injury occurred in 17-50% of patients, but only if >1.5 L/day were drained. Infections, including cellulitis and peritonitis, occurred in 7-58% of patients and were generally resolved with antibiotic therapy and/or device removal. LTAD do not appear to have a negative impact on mortality. Regarding QoL, the data are contradictory with most studies reporting an overall neutral effect.

Conclusion: LTAD should be considered as an option in RA from ESLD in the future but more quality studies are needed to confirm their safety and benefits in controlling symptoms. This could be an important step in terms of improving the palliative needs of this population.

Introduction: Peritoneal mesothelioma (PeM) is a rare cancer of the peritoneal lining. Unlike pleural mesothelioma, PeM is less frequently linked to asbestos exposure. Chronic serosal inflammation, as seen in Crohn's disease (CD), has been proposed as a contributing factor in its carcinogenesis.

Case presentation: A male with a long-standing history of ileal CD presented with recurrent episodes of intestinal subocclusion. Imaging showed complex active ileal CD, new-onset ascites, and peritoneal densification. Intraoperatively, a small bowel mass adherent to the sigmoid colon and millimetric nodules of the peritoneum were identified. Histology of the resected segment showed CD-related changes and multiple areas of epithelioid mesothelioma, despite no asbestos exposure. He received cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, with no signs of recurrence after 15 months.

Discussion/conclusion: We present a rare case of non-asbestos-related PeM in a patient with long-standing active CD, highlighting the diagnostic challenges and possible link between chronic serosal inflammation and PeM.

Background and aims: Cardiopulmonary arrest is a rare but possible complication of endoscopic procedures, particularly when performed under sedation and/or analgesia. Hospitalized patients, and probably those with a Do-Not-Resuscitate (DNR) order, present a higher risk of severe cardiopulmonary complications during endoscopy. The request for endoscopic examination, particularly urgent procedures, is becoming increasingly more frequent in patients with DNR orders. In this study, we aimed to assess current practices, concepts, and guideline awareness of nationally surveyed Portuguese gastroenterologists regarding the approach to code status for DNR patients in the periendoscopic period.

Methods: Online anonymous and self-administered survey was adapted to the Portuguese reality and was conducted to assess gastroenterologists and gastroenterology trainees' basic demographics data and details about current practice, personal opinions, and knowledge of existing guidelines concerning the reversal of periprocedural DNR orders.

Results: One hundred forty-five gastroenterologists, including 26 trainees (17.9%), responded to the survey. In patients with a DNR order, code status is rarely discussed (<25% of cases) with the patient/legal representative (66.9%, n = 97) or hospitalist (58.6%, n = 85), and the DNR order is also rarely reversed (reversal in all [100% of cases] or most cases [75-99% of cases] in 8.3%, n = 12). Most respondents were unaware of the procedures necessary for DNR prescription in Portugal (81.3%, n = 118), as well as existing guidelines on DNR reversal (96.5%, n = 140). Regarding personal beliefs, the majority considered that in these patients, the DNR order should be reversed to an intermediate option that includes limited resuscitation maneuvers (62.1%, n = 90) and that the urgency of a procedure should not influence the decision to reverse the DNR order (n = 89, 61.4%). There was consensus on the need for recommendations on this topic for gastroenterologists (97.9%, n = 142).

Conclusion: Portuguese gastroenterologists usually do not revisit the DNR order before endoscopic procedures as a matter of course and consequently do not reverse it. Furthermore, we found significant variation in practices and beliefs among Portuguese gastroenterologists in their approach to the patient with a DNR order, probably due to the unawareness and lack of specific existing guidelines.

Introduction: HHV-6 infection is usually asymptomatic or self-limited, although in certain populations, particularly in immunocompromised patients, it can cause serious infections. Hepatic involvement, previously described in immunocompromised and occasionally in immunocompetent adults, can lead to acute liver failure (ALF).

Case presentation: We report a case of a 20-year-old female with no known liver disease, who presented with a 4-day history of diffuse abdominal pain, vomiting, and fever on the first day. She reported an influenza-like syndrome the previous week and undetermined weight loss over the last 2 months, associated with a behavior compatible with a purging eating disorder. She had a binge drinking pattern of alcohol consumption, followed by paracetamol intake for veisalgia, and occasional cannabinoid use. The patient denied other exposures. She developed grade 1 hepatic encephalopathy and was diagnosed with ALF. Further workup for underlying etiology detected HHV-6B, both in peripheral blood and liver tissue.

Discussion: This ALF has a viral cause due to a possible reactivation of HHV-6 in the context of immunoparesis secondary to malnutrition and binge drinking, though we cannot exclude a contribution from a toxic cause due to paracetamol overuse, facilitated by these same susceptibility factors. HHV-6 should be included in the differential diagnosis of ALF of undetermined cause, particularly in immunocompromised and seriously ill patients.

Introduction: Hepatocellular carcinoma (HCC) holds high cancer mortality worldwide. Immunotherapy-based combination therapy, currently the first-line (1L) standard of care in advanced HCC, has shifted the treatment paradigm concerning both efficacy and safety outcomes. Data on immune-related adverse event surrogacy for efficacy outcomes are mixed.

Case report: We report the case of a 58-year-old male with chronic hepatitis C virus infection who presented with a voluminous shoulder HCC metastasis. Albeit an initial significant biochemical response with 1L sorafenib, progressive disease after 3 months plus a bleeding complication led to treatment discontinuation. Second-line nivolumab, although yielding a rapid clinical and biochemical response, was permanently ceased after 12 weeks due to a grade 3 immune-related hepatitis. Notably, 5 years post-treatment, the patient sustains a major biochemical and radiographic response.

Discussion: This case highlights an unusual and sustained response to nivolumab treatment in HCC, following early treatment discontinuation due to severe hepatotoxicity.

Background: Angiotensin receptor blockers are a pharmacological class widely used as antihypertensive therapy. Recently, a relationship between these agents and gastrointestinal disease has been described, namely, enteropathy, gastropathy, and microscopic colitis. The mechanism is unknown, but it is thought that a cell-mediated immune reaction is involved and does not appear to be a class effect. Treatment consists of stopping the drug and rechallenge can confirm the diagnosis.

Case presentation: An 85-year-old man with a history of hypertension treated with olmesartan/hydrochlorothiazide for 12 years presented to the emergency department with months of epigastric pain, without vomiting, blood loss, diarrhea, or weight loss. A recent upper gastrointestinal endoscopy (UGE) showed congested mucosa, irregular erosions, and friability in the distal body, notch, and antrum. Histology revealed moderate chronic gastritis, severe inflammatory activity, abundant eosinophils, intestinal metaplasia with low-grade dysplasia, and marked atrophy, with no signs of malignancy or Helicobacter pylori (Hp). The patient had previously been treated by his family doctor with lansoprazole and sucralfate, without improvement, and was subsequently discharged on esomeprazole with a referral for a gastroenterology consultation. Three months later, a follow-up UGE showed persistent erosions despite good adherence to esomeprazole. Hp serology was positive, and the patient was started on bismuth-based quadruple therapy. A post-treatment urea breath test confirmed Hp eradication. Six months later, UGE still showed multiple ulcers in the distal body and antrum. Olmesartan was switched to lisinopril, and after another 6 months, a follow-up UGE showed no ulcers or erosions. Biopsies revealed reduced inflammation and no dysplasia, indicating histological improvement. Olmesartan-induced gastropathy was diagnosed.

Conclusions: This case report illustrates olmesartan-induced gastropathy, an important diagnosis to consider in cases of non-Hp gastritis and refractory peptic ulcer disease.

Introduction: As Portugal exhibits some of the highest gastric cancer rates in Europe, optimizing the Helicobacter pylori eradication rate is imperative. We aimed to describe H. pylori treatment regimens in Portugal, within a real clinical practice setting.

Methods: This is a prospective cohort study of the Portuguese patients diagnosed with H. pylori between May 2013 and December 2022, within the European Registry on Helicobacter pylori Management (Hp-EuReg). The demographic and clinical data, diagnostic methods, treatment regimens, and prescription trends with their effectiveness were analysed by modified intention-to-treat (mITT) and per-protocol (PP) analyses.

Results: Overall, 700 cases, mainly from 2 centres (98% of cases), were included, with 59% females, with a mean age of 54 ± 15 years. Treatment-naïve patients encompassed 81% of cases. Overall compliance (>90% drug intake) was reported in 99% of cases. Overall effectiveness was 87%, by both mITT and PP analyses. The triple PPI-clarithromycin-amoxicillin therapy decreased from 29% in 2013 to 0% in 2022. Conversely, both quadruple concomitant PPI-clarithromycin-amoxicillin-metronidazole and PPI-bismuth-metronidazole-tetracycline therapies were predominantly used from 2016 onwards, with PPI-bismuth-metronidazole-tetracycline representing 76% of all prescriptions in 2022, achieving an overall mITT effectiveness of 92% and 91%, respectively.

Conclusion: In Portugal, concomitant quadruple therapy with PPI-clarithromycin-amoxicillin-metronidazole and bismuth quadruple with PPI-bismuth-metronidazole-tetracycline provided both optimal (>90%) effectiveness, in line with results of other Southern European countries.