Rescue Therapy of Delayed Gastric Perforation Caused by an External Drainage Using an Over-the-Scope Clip.

This case reports a iatrogenic gastric fistula due to external draining successfully closed by using an over- the-scope clip. A 50-year old patient with a history of acute pancreatitis, segmental portal hypertension and splenectomy for splenic rupture, with long-term external drainage for a low volume pancreatic fistula, was referred to our hospital. The patient noticed the occurrence of a sudden increase of the drain flow and the immediate drainage of ingested liquid, with no fever or pain. An upper gastrointestinal endoscopy evidenced the gastric fistula with the presence of the drain inside the stomach near a gastric varix. The surgical approach was inappropriate due to bleeding risk. An over-the-scop clip was placed succeeding to stop the gastric flow. The external fistula closed one week later.

Predictors of variceal or nonvariceal source of upper gastrointestinal bleeding. An etiology predictive score established and validated in a tertiary referral center.

BACKGROUND & AIMS. For upper gastrointestinal bleeding (UGIB), guidelines recommend pharmacological treatment before endoscopy. Therefore, it is important to establish an early diagnosis of the variceal or non-variceal source of bleeding. This study aims to analyze the clinical and laboratory parameters which are predictors of the UGIB etiology, and to develop a score for predicting variceal or non-variceal bleeding. METHODS. This study comprised patients presenting to the emergency department of a tertiary care center with UGIB, throughout a 1-year period. Clinical, ultrasound data and laboratory parameters were noted. RESULTS. Of the 517 patients with UGIB, 29.8% had variceal and 70.2% non-variceal bleeding. Six factors were associated with variceal hemorrhage: cirrhosis (OR=10.74, 95% CI: 3.50-32.94, p<0.001), history of variceal hemorrhage (OR=13.11, 95%CI: 3.09-55.57, p<0.001), ascites (OR=4.41, 95% CI: 1.74-11.16, p=0.002), thrombocytopenia (OR=2.77, 95% CI: 1.18-6.50, p=0.01), elevated INR (OR=4.77, 95% CI:1.47-15.42, p=0.009) and elevated bilirubin levels (OR=2.43, 95% CI:1.01-5.84, p=0.04). Two factors were associated with non-variceal bleeding: the use of NSAIDs (OR=0.32, 95%CI: 0.13-0.83, p=0.01) and of anticoagulants (OR=0.04, 95%CI: 0.00-0.89, p=0.04). A prediction score for UGIB etiology was designed based on this model. We calculated a cutoff value of 0.968, higher values being predictive of variceal bleeding. Positive predictive value (PPV) and negative predictive value (NPV) were: 82.7% and 97%, respectively. The score was validated prospectively in another group of 162 patients: PPV and NPV were 72.7% and 95.3%, respectively. CONCLUSIONS. Several factors were identified as predictors for the etiology of UGIB. Due to its high PPV and NPV, our UGIB etiology score might be useful in predicting variceal bleeding and could assist in the selection of pharmacological therapy before endoscopy.

Prevalence, histology, endoscopic treatment and long-term follow-up of large colonic polyps and laterally spreading tumors. The Romanian experience.

AIMS: We report the prevalence, histological aspect, endoscopic treatment and follow-up of colonic polyps of 2 cm or larger and of laterally spreading tumors (LSTs) in an eastern European country. METHODS: All consecutive colonoscopies carried out over a 1-year period (3,856) in the Endoscopy Department of the 3rd Medical Clinic Cluj-Napoca were evaluated. Fifty-two polyps and 12 LSTs of >=2cm diameter were found. Size, location and histological aspect of large colonic polyps and LSTs were assessed. Endoscopic or surgical resection was recorded. An extensive endoscopic and histological follow-up was performed. RESULTS: Median size of polyps was 32mm and of LSTs 41mm. Invasive carcinoma was found in 7 polyps (20.6%) and in 4 LSTs (28.6%). Thirty-six polyps were endoscopically resected (69.2%). A complete endoscopic excision was performed in 35 polyps (98.6%). Histological complete resection was achieved in 30 polyps (83.3%). Thirteen polyps were surgically resected (25%). Eight LSTs were endoscopically resected (64.3%) using endoscopic piecemeal resection (EPMR). A complete endoscopic excision was performed in three LSTs (37.5%). Three LSTs were surgically resected (21.5%). In the polyp group, one patient presented endoscopic recurrence (16.6%) at 6 months follow-up. In the LST group, two invasive recurrences were present at 3 and 30 months of follow-up. CONCLUSIONS: A complete resection can be performed in the majority of large polyps. LSTs larger than 50mm, incomplete resection and superficial invasive carcinoma were correlated with endoscopic recurrence. EPMR might be a curative method for LSTs but an accurate endoscopic diagnosis and long-term endoscopic follow-up are mandatory.

Acute pancreatitis in a pregnant woman with acute fatty liver dystrophy. A case report.

Acute fatty liver and acute pancreatitis rarely complicate pregnancy. Acute pancreatitis may appear isolated but when it is subsequent to acute fatty liver of pregnancy the evolution is in many cases fatal. We report the case of a 26-year-old primigravida, at 25 weeks' gestation, who developed acute fatty liver of pregnancy and acute pancreatitis after an acute viral upper respiratory tract infection, with an unfavorable evolution to death. Establishing the diagnosis was very difficult and it was confirmed only at laparotomy.

Eosinophilic ascites in a patient with toxocara canis infection. A case report.

We report the case of a young female patient, admitted for a recent ascites of unknown origin. The acute onset was with colicky abdominal pain and peritoneal effusion, which led to the suspicion of perforated ulcer. A diagnostic laparoscopy was performed which showed free peritoneal fluid and normal abdominal viscera. At upper gastro-intestinal endoscopy, performed a few days later, patchy erythema in the antral region and duodenal edema were revealed. Duodenal biopsies showed marked eosinophilic infiltration. The ascitic fluid was straw coloured, sterile with 90% eosinophils. Eosinophilic gastroenteritis was suspected, but differential diagnosis required the exclusion of migrant parasites. The stool exams were negative but serology for Toxocara antibodies was positive. The treatment with albendazole (Zentel 400 mg twice a day for 5 days) led to the disappearance of signs and symptoms. The eosinophilic infiltrate of the gut was absent in duodenal biopsies taken two months later.

Education and management of patients with familial adenomatous polyposis. Are we making progress? A case report.

A 25-year-old male patient was admitted to our clinic for abdominal pain, diarrhea, intermittent rectal bleeding and weight loss. The family history revealed two deaths due to colorectal cancer (maternal grandmother and patient's mother). The colonoscopy showed hundreds of polyps throughout the colon, and an ulcerative rectosigmoidian tumor. The diagnosis was Familial Adenomatous Polyposis (FAP). Colectomy with ileorectal anastomosis was performed. Histopathological diagnosis revealed moderately differentiated adenocarcinoma. Adjuvant chemotherapy was carried out. The patient had three brothers, without clinical symptoms. They had a colonoscopic examination for screening. Two of them were diagnosed with adenomatous polyposis - the first with classic FAP and the other one with the attenuated type (AFAP). The diagnosis of FAP can be made on the basis of either clinical or genetic criteria. When the family history, clinical features, and pathological findings are classic, the diagnosis is straightforward. Screening and prophylactic surgery are effective to prevent colorectal cancer in patients with FAP. Lifelong regular surveillance is necessary to detect and manage extracolonic lesions.