Gastrointestinal tract involvement in hepatocellular carcinoma: two cases illustrating duodenal and oesophageal invasion.

We present here two hepatocellular carcinoma (HCC) patients with gastrointestinal tract involvement (GITI). Hemorrhage due to duodenal involvement was the inaugural event of the HCC for the first patient. Dysphagia due to HCC recurrence in the oesophagus four years after left hepatectomy was the call symptom for the second. As incidence of HCC increases, and overall survival improves, incidence of GITI in HCC patients is expected to increase.

Is early enteral nutrition dangerous in acute non surgical complicated diverticulitis? About 25 patients fed with oral fiber free energetic liquid diet.

BACKGROUND AND STUDY AIMS: Complicated Acute Colonic Diverticulitis (ACD) is usually treated by parenteral way thus keeping the bowel at rest. To date there are no clear recommendations regarding the route of nutrition administration. We study the safety of early feeding by oral energetic fiber-free liquid diet in non-surgical complicated ACD patients. PATIENTS AND METHODS: From February 2008 to October 2011, 25 patients were admitted with complicated ACD and took part in this prospective study. Surgical and medical assessments were performed at admission. Initial treatment was given with perfusion, intravenous antibiotics and hydric diet. Within 72 hours of admission, antibiotic therapy was switched to oral administration for 5 up to 15 days depending on the progression of the disease. At the same time the patient received oral liquid fiber-free feeding. Solid but fiber-free diet was introduced 24h hours before discharge. RESULTS: 25 cases of ACD were complicated with covered perforation and/or abscess. Mean hospitalisation time was 10A.4 days. 23 cases had good recovery and discharged, while 1 case progressed to colonic stenosis during hospitalisation, requiring a sigmoidectomy with a one-time anastomosis with good recovery. One patient relapsed his abscess during hospitalisation despite CT guided drainage and required sigmoidectomy with transient ileostomy. The mean daily treatment and nutrition cost for the non-surgical 23 patients was 30 euros. CONCLUSIONS: Early enteral nutrition in complicated ACD is feasible, not harmful, and reduce both, mean hospitalization time and treatment cost. Further studies comparing enteral with parenteral nutrition are necessary to confirm our hypothesis.

The rationale for using ursodeoxycholic acid in chronic liver disease.

The authors make a review of the literature and of their personal experience about the possible mechanisms of action and the beneficial therapeutic effects of ursodeoxycholic acid in primary biliary cirrhosis. They postulate that owing to its hydrophilic properties, ursodeoxycholic acid is more efficiently absorbed by the ileum than the other bile acids, so replacing the other bile acids in the bile acid pool, and that ursodeoxycholic acid is less toxic for hepatocytes than the other bile acids accumulating in the plasma and is also a choleretic.

Endoscopic treatment of biliary tract fistulas.

Endoscopic therapy was attempted in 24 patients with spontaneous or postoperative persistent biliary fistulas. Endoscopic retrograde cholangiography demonstrated the site of the fistula in 22 cases. Sphincterotomy or biliary stent placement resulted in rapid resolution of the fistula in 16 of 24 patients. Failures were attributed to exclusion of the injured intrahepatic bile duct in two cases, insufficient dilation of a bile duct stricture in one, the large size of the bile duct defect in two, and associated lesions in three (cirrhosis, arterial trauma, subhepatic abscess). Endoscopic management of biliary fistulae requires: (1) visualization of the location of the fistula by retrograde cholangiography especially in case of an intrahepatic lesion, (2) prior percutaneous drainage of associated subhepatic or subphrenic abscesses, and (3) appropriate relief of distal biliary obstruction in order to reduce the intraductal biliary pressure. The outcome is uncertain when endoprostheses are used to bridge large bile duct defects.

Esophageal adenocarcinoma following Heller myotomy for achalasia.

We describe a patient who developed an esophageal adenocarcinoma 25 years after esophagomyotomy for achalasia. The tumor arose in a Barrett's esophagus, suggesting gastroesophageal acid reflux following the Heller procedure.