Free-Floating Thrombi in the Right Atrium Causing Pulmonary Embolism

A 74-year-old man presented to our Emergency Department with acute dyspnoea. His electrocardiogram showed atrial flutter with 2:1 block and a rate of 150 bpm. Initial investigations revealed a D-dimer level of 6.01 mg/dl. Based on the patient’s complaints and the high D-dimer level, computed tomography pulmonary angiography was immediately performed. This showed no evidence of pulmonary embolism, but there were pneumatic changes in the right upper lung lobe. Antibiotics treatment was started with pipracillin/tazobactam, after which the patient’s condition improved. However, on the third day after admission he developed acute dyspnoea, diaphoresis and cardiopulmonary instability immediately after defecation. To promptly confirm our clinical suspicion of pulmonary embolism, a transthoracic echocardiography was carried out. This demonstrated a worm-like, mobile mass in the right heart. The right ventricle was enlarged, and paradoxical septal motion was present, indicating right ventricular pressure overload. The systolic tricuspid valvular gradient was 56 mmHg. The patient was treated with thrombolysis. His condition was greatly clinically improved after 3 hours. After 10 days of hospitalization, the patient was discharged.

Efeitos da simpaticotomia endoscópica sobre as artérias carótidas e vertebrais na terapêutica cirúrgica da hiperidrose primária

Analisar, em pacientes submetidos a simpaticotomia videotoracoscópica para tratamento da Hiperidrose Primária (HP), as conseqüências hemodinâmicas da desnervação vascular das artérias carótidas e vertebrais após a trans-secção cirúrgica da cadeia simpática torácica (simpaticotomia), através da mensuração de parâmetros ultra-sonográficos. Método: Vinte e quatro pacientes portadores de HP submetidos a quarenta e oito simpaticotomias torácicas endoscópicas foram avaliados através da mensuração da velocidade de pico sistólico (VPS), velocidade de pico diastólico (VPD), índice de pulsatibilidade (IP) e índice de resistência (IR) nas artérias carótidas comuns, internas e externas, além da artéria vertebral bilateralmente usando o eco-doppler duplex scan. As avaliações foram realizadas antes da intervenção cirúrgica e trinta dias após o procedimento. O teste de Wilcoxon foi usado na análise das diferenças entre as variáveis antes e depois da simpaticotomia. Resultados: A simpaticotomia no nível de T3 foi a trans-secção mais realizada (95,83%), seja isoladamente (25%) ou associada a T4 (62,50%) ou a T2 (8,33%). Houve aumento significativo no IR e no IP da artéria carótida comum bilateralmente (p<0,05). A VPD da artéria carótida interna diminuiu em ambos os lados (p<0,05). A VPS e a VPD da artéria vertebral direita também aumentaram (p<0,05). Achados assimétricos foram observados, de modo que artérias do lado direito foram as mais freqüentemente afetadas. Conclusões: Alterações hemodinâmicas foram observadas nas artérias vertebral e carótida após simpaticotomia para tratamento de HP. VPS foi o parâmetro mais freqüentemente alterado, principalmente nas artérias do lado direito, representando alterações assimétricas significantes nas artérias carótida e vertebral. Entretanto, são necessárias pesquisas subseqüentes para verificar se essas alterações são definitivas ou temporárias, uma vez que as inferências clínicas somente terão validação se as alterações forem permanentes

A Case of Chronic Mesenteric Ischemia imitating Crohn's disease

Objectives: We present an atypical case of chronic mesenteric ischemia with weight loss as only clinical manifestation and endoscopic findings imitating Crohn´s disease. Materials and Methods: A CT Angiography of abdomen confirmed the diagnosis of mesenteric ischemia after total occlusion of celiac trunk and superior mesenteric artery. Results: The patient died due to severe sepsis, as a result of extended bowel infarction. Conclusions: The diagnosis of chronic mesenteric ischemia requires a high degree of clinical suspicion and can be life-saving if early conducted.

An Unexpected Cause of Marked Weight Loss Associated with Vomiting in an Adult Man: Gastric Phytobeozar

Objectives: We present the case of an edentulous 47-year-old farmer referred to our Department of Internal Medicine because of postprandial vomiting, hyporexia, asthenia and weight loss. He ate a mostly vegetarian diet. Materials and methods: An oesophagogastroduodenoscopy revealed the presence of a phytobezoar at the level of the fundus and body of the stomach. Endoscopic fragmentation and removal of the phytobezoar were unsuccessful and the patient had to undergo open surgery. Results: Recovery was uneventful and free of complications. Conclusion: Phytobezoars should be taken into account in the differential diagnosis of unexplained vomiting and weight loss.

Giant Cell Arteritis Presenting with Bilateral Subdural Haematomas of Arterial Origin

Giant cell arteritis or temporal arteritis is an inflammatory condition affecting medium to large sized vessels, particularly the cranial arteries. A 76-year-old man with no significant past medical history presented to the emergency department with a 3-week history of diffuse headaches associated with fever, loss of appetite, weight loss and general malaise. A CT scan of the brain showed bilateral shallow chronic low density subdural haematomas. A complete laboratory panel was unremarkable except for a raised erythrocyte sedimentation rate and elevated C-reactive protein. A transthoracic echocardiogram and CT scan of the body were unremarkable. MRI of the brain confirmed bilateral old subdural collections and showed marked vessel wall enhancement in the frontal branches of the left superficial temporal artery. A left temporal artery biopsy confirmed giant cell temporal arteritis. We speculate that a vasculitic process in the small subdural arteries may have contributed to our patient’s spontaneous subdural haematomas.

Endoluminal calprotectin measurement in assessment of pouchitis and a new index of disease activity: a pilot study

Pouchitis is the most common complication following proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis (UC). To provide a standardized definition of pouchitis clinical, endoscopic and histological markers were grouped and weighted in the pouch disease activity index (PDAI). However, the delay in the assessment of the final score due to the time requested for histological analysis remains the main obstacle to the index implementation in clinical practice so that the use of modified-PDAI (mPDAI) with exclusion of histologic subscore has been proposed. We tested the ability of calprotectin measurement in the pouch endoluminal content to mimic the histologic score as defined in the PDAI, the index that we adopted as gold standard for pouchitis diagnosis. Calprotectin was measured by ELISA in the pouch endoluminal content collected during endoscopy in 40 consecutive patients with J-pouch. In each patient PDAI and mPDAI were calculated and 15% of patients were erroneously classified by mPDAI. ROC analysis of calprotectin values vs. acute histological subscore ≥ 3 identified different calprotectin cut-off values with corresponding sensitivity and specificity allowing the definition and scoring of different range of calprotectin subscores. We incorporated the calprotectin score in the mPDAI obtaining a new score that shows the same specificity as PDAI for diagnosis of pouchitis and higher sensitivity when compared with mPDAI. The use of the proposed new score, once validated in a larger series of patients, might be useful in the early management of patients with symptoms of pouchitis.

Prevalence of Barrett Esophagus in Adolescents and Young Adults With Esophageal Atresia

International audience

Screening of esophageal varices by esophageal capsule endoscopy: results of a French multicenter prospective study

International audience

Imagiologia dos Tumores malignos do pâncreas

As neoplasias malignas do pâncreas englobam vários tipos histologicos com características ima giológicas e comportamentos que permitem distingui-los entre si numa boa percentagem de situações. Contudo, nem sempre a sua diferenciação se toma possível sem o recurso às técnicas anátomo-patoló gicas, constituindo um grande desafio à imagiologia o diagnóstico diferencial com lesões benignas, com referencia particular às massas inflamatórias. O adenocarcinoma constitui cerca de 95% das neo plasias pancreáticas e é uma das grandes causas de morte por cancro nos países desenvolvidos. As técnicas de imagem aplicadas no diagnóstico e no estadiamento dos principais tumores do pâncreas são muito diversificadas, englobando meios inócuos, como a ecografia, métodos invasivos utilizando técnicas angiográficas ou recurso aos meios endoscópicos para acesso endocavitário. A utilidade de cada uma destas variedades técnicas depende essencialmente do tipo de tumor a estudar, tomando-se fundamental o correcto e o completo conhecimento das possibilidades e limitações de cada uma, com vista à aplicação racional dos meios na imagiologia do pâncreas.

Interventions for dysphagia in acute stroke (Review)

Background It is unclear how dysphagic patients should be fed and treated after acute stroke. Objectives The objective of this review was to assess the effect of different management strategies for dysphagic stroke patients, in particular how and when to feed, whether to supplement nutritional intake, and how and whether to treat dysphagia. Search strategy We searched the Cochrane Stroke Group trials register, Medline, Embase, ISI, and existing review articles.We contacted researchers in the field and equipment manufacturers. Date of the most recent searches: March 1999. Selection criteria Unconfounded truly or quasi randomised controlled trials in dysphagic patients with acute/subacute (within 3 months) stroke. Data collection and analysis Three reviewers independently applied the trial inclusion criteria. Two reviewers assessed trial quality and extracted the data. Main results Percutaneous endoscopic gastrostomy (PEG) versus nasogastric tube (NGT) feeding: two trials (49 patients) suggest that PEG reduces end-of-trial case fatality (Peto Odds Ratio, OR 0.28, 95% CI 0.09 to 0.89) and treatment failures (OR 0.10, 95% CI 0.02 to 0.52), and improves nutritional status, assessed as weight (Weighted Men Difference, WMD +4.1 kg, 95% CI -4.3 to +12.5), mid-arm circumference (WMD +2.2 cm, 95% CI -0.5 to +4.9) or serum albumin (WMD + 7.0 g/l, 95% CI +4.9 to +9.1) as compared with NGT feeding; two larger studies are ongoing. Timing of feeding: no completed trials; one large study is ongoing. Swallowing therapy for dysphagia: two trials (85 patients) suggest that formal swallowing therapy does not significantly reduce end-of-trial dysphagia rates (OR 0.55, 95%CI 0.18 to 1.66). Drug therapy for dysphagia: one trial (17 patients); nifedipine did not alter end-of-trial case fatality or the frequency of dysphagia. Nutritional supplementation: one trial (42 patients) found a non-significant trend to a lower case fatality, and significantly increased energy and protein intake; one large trial is ongoing and data is awaited from two other studies. Fluid supplementation: one trial (20 patients) found that supplementation did not alter the time to resolution of dysphagia. Authors’ conclusions Too few studies have been performed, and these have involved too few patients. PEG feeding may improve outcome and nutrition as compared with NGT feeding. Further research is required to assess how and when patients are fed, and the effect of swallowing or drug therapy on dysphagia.

Parâmetros morfológicos de ativação dos eosinófilos do sangue periférico : uma nova ferramenta para triagem de pacientes portadores de esofagite eosinofílica

Tese (doutorado)—Universidade de Brasília, Faculdade de Medicina, Programa de Pós-Graduação em Patologia Molecular, 2015.

Safety and risk factors for difficult endoscopist-directed ERCP sedation in daily practice: a hospital-based case-control study

Background: There are limited data concerning endoscopist-directed endoscopic retrograde cholangiopancreatography deep sedation. The aim of this study was to establish the safety and risk factors for difficult sedation in daily practice. Patients and methods: Hospital-based, frequency matched case-control study. All patients were identified from a database of 1,008 patients between 2014 and 2015. The cases were those with difficult sedations. This concept was defined based on the combination of the receipt of high-doses of midazolam or propofol, poor tolerance, use of reversal agents or sedation-related adverse events. The presence of different factors was evaluated to determine whether they predicted difficult sedation. Results: One-hundred and eighty-nine patients (63 cases, 126 controls) were included. Cases were classified in terms of high-dose requirements (n = 35, 55.56%), sedation-related adverse events (n = 14, 22.22%), the use of reversal agents (n = 13, 20.63%) and agitation/discomfort (n = 8, 12.7%). Concerning adverse events, the total rate was 1.39%, including clinically relevant hypoxemia (n = 11), severe hypotension (n = 2) and paradoxical reactions to midazolam (n = 1). The rate of hypoxemia was higher in patients under propofol combined with midazolam than in patients with propofol alone (2.56% vs. 0.8%, p < 0.001). Alcohol consumption (OR: 2.674 [CI 95%: 1.098-6.515], p = 0.030), opioid consumption (OR: 2.713 [CI 95%: 1.096-6.716], p = 0.031) and the consumption of other psychoactive drugs (OR: 2.015 [CI 95%: 1.017-3.991], p = 0.045) were confirmed to be independent risk factors for difficult sedation. Conclusions: Endoscopist-directed deep sedation during endoscopic retrograde cholangiopancreatography is safe. The presence of certain factors should be assessed before the procedure to identify patients who are high-risk for difficult sedation.

Therapeutic failure with thalidomide in patients with recurrent intestinal bleeding due to angiodysplasias

Angiodysplasias are one of the reasons of gastrointestinal bleeding, whose origin is usually due to vascular malformations. There are different types of therapies for angiodysplasia such as endoscopic, angiographic and pharmacological techniques. Among the last ones, there is little variety of effective drugs to treat the disease. We describe the therapeutic failure with thalidomide in a male with recurrent gastrointestinal bleeding due to angiodysplasias. A thorough diagnostic work-up, including gastroscopy, enteroscopy, angiography and capsule endoscopy were performed. Despite treatment with high-dose somatostatin analogues and oral iron, the patient continued bleeding. The patient was administered then thalidomide for three months with no clinical response. Thalidomide had to be withdrawn owing to adverse effects.

Influence of delayed cholecystectomy after acute gallstone pancreatitis on recurrence: consequences of lack of resources

Introduction: Acute pancreatitis is often a relapsing condition, particularly when its triggering factor persists. Our goal is to determine the recurrence rate of acute biliary pancreatitis after an initial episode, and the time to relapse, as well as to identify the risk factors for recurrence. Material and method: We included all patients admitted for a first acute gallstone pancreatitis event during four years. Primary endpoints included readmission for recurrence and time to relapse. Results: We included 296 patients admitted on a total of 386 occasions. The incidence of acute biliary pancreatitis in our setting is 17.5/100,000 population/year. In all, 19.6% of pancreatitis were severe (22.6% of severe acute pancreatitis for first episodes versus 3.6% for recurring pancreatitis), with an overall mortality of 4.4%. Overall recurrence rate was 15.5%, with a median time to relapse of 82 days. In total, 14.2% of patients relapsed after an acute pancreatitis event without cholecystectomy or endoscopic retrograde cholangio-pancreatography. Severe acute pancreatitis recur in 7.2% of patients, whereas mild cases do so in 16.3%, this being the only risk factor for recurrence thus far identified. Conclusions: Patients admitted for pancreatitis should undergo cholecystectomy as soon as possible or be guaranteed priority on the waiting list. Otherwise, endoscopic retrograde cholangio-pancreatography with sphincterotomy may be an alternative to surgery for selected patients.

Self-expanding metal stents in postoperative esophageal leaks

Background: Postoperative esophageal leaks have a high morbidity and mortality. Self-expanding metal stents (SEMS) have been used as an alternative to re-operation. Aim: Evaluating predictors of success of SEMS in postoperative esophageal leaks. Methods: Retrospective study of patients with postoperative esophageal leaks referred for SEMS placement in a reference center during a period of 3 years. Technical success was defined as closure of the leak in barium swallow at 15 days. Clinical success was considered as endoscopic and/or radiographic confirmation of closure after stent removal. Results: Thirteen patients placed SEMS. Median follow-up was 58 days. Leaks had a median size of 20 mm. Time between surgery and SEMS placement was 20 days. One patient died 2 days after SEMS placement and one had worsening of the fistula after SEMS expansion. Time till stent migration was 9 days. Technical success was achieved in 9 of 11 patients, with clinical success without recurrence in 5 patients. All leaks with less than 20 mm were solved endoscopically. Technical and clinical success was higher when time between surgery and SEMS placement was lower, even though without statistical significance (respectively, p = 0.228 and 0.374). In the 8 patients who died during follow-up, median survival was 59 days. Conclusions: Technical success of SEMS was higher than 80%; however, due to high morbidity and mortality, only 45% of patients had their stent removed. Lower time from diagnosis to SEMS placement and leak size less than 20 mm may be associated with better results.