Gastrointestinal obstruction caused by solidification and coagulation of enteral nutrition: pathogenetic mechanisms and potential risk factors.

Enteral nutrition (EN) is preferred in order to provide nutrition and reduce catabolism in critically ill patients. Recent studies suggest that the use of EN is successful and complications are rare. However, an underestimated mechanical complication of tube feedings seen in critically ill patients is the coagulation and solidification of the EN causing gastrointestinal obstruction. This report describes two clinical cases (1.23% of all cases seen at our clinic) of obstruction and perforation of the small bowel secondary to the solidification of EN. The understanding and early recognition of this potential complication are essential for the prevention and successful treatment of this condition.

Sevalamer Hydrochloride, Sevelamer Carbonate and Lanthanum Carbonate: In Vitro and In Vivo Effects on Gastric Environment.

Hyperphosphatemia is common in patients with chronic renal failure. Phosphate binders are associated with gastric intolerance, representing the main reason of drug discontinuation. The aim of this study was to compare the effects in vitro and in vivo of sevelamer hydrochloride (SH), sevelamer carbonate (SC) and lanthanum carbonate (LC) on gastric microenvironment. We have also evaluated the efficacy and tolerability of these drugs in hemodialysis (HD) patients. In vitro analysis: Dissolution time, ability to uptake phosphorus, changes in pH starting from gastric milieu and the amount of carbon dioxide (CO(2)) produced were the variables analyzed. In vivo analysis: 24-h esophago-gastric pH measurement was evaluated in 24 HD patients treated with phosphate binders and proton pump inhibitor (PPI). In vitro: LC dissolved over a longer time compared with SC (58 ± 2.4 vs. 12 ± 0.6 min; P < 0.001) and SH (58 ± 2.4 vs. 10.3 ± 0.8 min; P < 0.001), determining the most alkaline pH. SC had the highest chelation power, binding 4.00 × 10(-9) mol/L of phosphoric acid. CO2 volume released was increased in LC solution (53.2 ± 7.8) compared to SC (33.9 ± 6.2; P < 0.001) and SH (2.3 ± 1.8; P < 0.001). In vivo: gastric pH increased after administration of phosphate binder. The most alkaline pH was recorded in patients treated with SC. The alkalinization of the gastric environment was not prevented by PPI therapy. 424 episodes of esophageal reflux were registered, 74% of them were alkaline. The LC group was characterized by the highest number of episodes. Sevelamer carbonate had a greater capacity and rapidity to chelate phosphorus, with a mild tolerability, due to its low CO(2) production. Sevelamer HCl was the most tolerated chelator because it did not produce CO(2), while lanthanum carbonate was the least soluble.

Laparoscopic cyst fenestration in the treatment of polycystic liver disease.

INTRODUCTION: The PLD, included in the group of malformative lesions of ductal plate, is characterized by progressive development of multiple parenchymal cysts. Different surgical treatments have been proposed for symptomatic patients with PLD: percutaneus aspiration, fenestration, hepatic resection and liver transplantation. The aim of this report is to outline the treatment of polycystic liver disease with laparoscopic fenestration. MATERIALS AND METHODS: Of thirteen patients with PLD, in all cases associated with polycystic kidney disease, 7 patients underwent to laparoscopic treatment of cysts fenestration, and 6, asymptomatic and not amenable to surgical treatment, underwent to clinical follow-up. Of the 7 patients, 5 have symptoms related to "effect mass" 1-2-3 of hepatic cysts while in the 2 asymptomatics the fenestration of the cysts was performed during the procedure of laparoscopic cholecystectomy for cholelithiasis. DISCUSSION: The best indication for laparoscopic fenestration are those cases of PLD characterized by a relatively limited number of large cysts, preferably situated in the anterior segments of the liver and in the left lobe; in this patients, laparoscopic fenestration reduces significantly the volume of the liver and relieves symptoms. The laparoscopic fenestration of hepatic cyst, in carefully selected patients, is an effective technique in terms of morbidity, mortality, conversion rate and recurrence rates; while in patients with cyst diffuse in liver parenchyma is indicated the hepatic resection or liver transplantation. The optimal surgical approach is still evolving, the type of approach is related to extent and distribution of the cysts, and vascular anatomy of normal segment of the liver. KEY WORDS: Laparoscopic fenestration, Policystic liver.

[Gastrointestinal stromal tumour: our experience]. / I tumori stromali gastrointestinali (GIST): nostra esperienza.

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract. These tumours originate in Cajal interstitial cells and the majority are located in the stomach and small intestine. They frequently develop in males aged 50-60 years. The symptoms of GIST are non-specific and depend on the size and location of the lesion. Imaging difficulties impede an early diagnosis; sometimes these tumours represent an unexpected intraoperative finding or an emergency abdominal picture. GISTs are classified as tumours with low- and high-risk of malignancy, depending on tumour size and mitotic count. Tumour site and acute onset are also significant parameters for prognostic purposes. Fifteen patients with GIST - gastric in 7 cases, ileal in 6, jejunal in 1 and colonic in 1 - were treated surgically and, in 9 cases, with adjuvant therapy (chemotherapy in 4 patients and imatinib mesylate in 5). The mean follow-up was 38 months. No postoperative mortality was recorded, and the morbidity was 13.3%. Histological examinations documented 6 benign tumours and 9 malignancies. Two patients, one with gastric and one with colonic GIST, were lost to follow-up. One patient, with two synchronous gastric neoplasms (GIST + adenocarcinoma) died after 16 months, while the other 5 patients with gastric GIST are still alive; two patients with ileal GIST, treated with chemotherapy, died after 15 and 18 months, respectively. The mean survival of patients treated with imatinib mesylate was 36 months. Surgical management and the use of imatinib constitute the therapeutic gold standard for GIST. The use of imatinib mesylate is recommended today in the treatment of advanced GIST, especially in cases with liver and peritoneal metastases.

[Acute abdomen for perforated gastrointestinal stromal tumor (GIST). A case report]. / Addome acuto da GIST perforato del digiuno. Contributo clinico.

The authors report on a case of voluminous perforated gastrointestinal stromal tumor (GIST) of small intestine and make a review to the light of most recent clinicopathologic advancements. The first clinical manifestation as acute abdomen due to their perforation extremely rare. Gastrointestinal stromal tumor (GIST) represent a rare group of multiform tumors with various biological behaviour. Were identified in the past as leiomyomas, leiomyosarcomas or leiomyoblastomas, has been reclassified on immunochemical features, with a positive expression of Kit (CD117 antigen). Traditionally the prognostic factors of these tumour are: mitotic rate, tumor size and anatomic site. The complete surgical resection and use of imatinib mesylate (Gleevec) are the best available approach.

Volvulus due to a giant sigmoid diverticulum: a rare cause of intestinal occlusion.

The case of a giant sigmoid diverticulum complicated by a volvulus of the bowel is reported. After an exhaustive literature review, the Authors analyse the aetiopathogenetic, physiopathological and clinical aspects of this rare condition, considering its diagnostic and therapeutic implications. The Authors describe surgical problems and therapeutic management, pointing out that without an accurate study by radiological imaging, it is very difficult to diagnose the condition, particularly when no specific symptoms have been observed.

Epithelioid hemangioendothelioma of the stomach: clinical-pathological features, nosologic setting, and surgical therapy. Report of a case.

Vascular tumors of the stomach represent 0.9%-3.3% of all gastric neoplasms. A 41-year-old man was admitted to our department with a 3-month history of early postprandial epigastric pain, sluggish digestion, nausea, asthenia, and occasional alimentary emesis. Preoperative staging detected a submucosal neoformation in the prepyloric zone, which narrowed the lumen, without any infiltrative features; a wedge gastric resection was performed and the definitive diagnosis was an epithelioid hemangioendothelioma of stomach. An 8-month follow up did not show any relapse of the disease. The term hemangioendothelioma is controversial because of disagreements regarding the nosologic setting and treatment. As a result, the latest WHO classification calls such neoplasms "borderline." The correct diagnosis depends on the histological findings supported by immunohistochemistry. Surgery represents the treatment of choice; however, a conservative approach is preferred whenever possible. However, due to the borderline biological behavior of this neoplasm, it is important that detailed clinical evaluations be carried out for such patients along with a thorough follow-up.