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- Acute Pancreatitis and Posterior Reversible Encephalopathy Syndrome: A Case ReportPublication . Pereira, Vítor Magno; Correia, Luís Marote; Rodrigues, Tiago; Faria, Gorete SerrãoThe posterior reversible encephalopathy syndrome is a neurological syndrome characterized by headache, confusion, visual disturbances and seizures associated with identifiable areas of cerebral edema on imaging studies. The authors report the case of a man, 33 years-old, leukodermic with a history of chronic alcohol and tobacco consumption, who is admitted to the emergency department for epigastric pain radiating to the back and vomiting with about six hours of evolution and an intense holocranial headache for two hours. His physical examination was remarkable for a blood pressure of 190/100 mmHg and tenderness in epigastrium. His analytical results revealed emphasis on amylase 193 U/L and lipase 934 U/L. During the observation in the emergency department, he presented a generalized tonic-clonic seizure. Abdominal ultrasonography was performed and suggestive of pancreatitis without gallstones signals. Head computed tomography showed subarachnoid haemorrhage and a small right frontal cortical haemorrhage. The brain magnetic resonance imaging done one week after admission showed areas of a bilateral and symmetrical T2 / FLAIR hyperintensities in the subcortical white matter of the parietal and superior frontal regions, suggesting a diagnosis of posterior reversible encephalopathy syndrome. Abdominal computed tomography (10 days after admission) demonstrated a thickened pancreas in connection with inflammation and two small hypodense foci in the anterior part of the pancreas body, translating small foci of necrosis. The investigation of a thrombophilic defect revealed a heterozygous G20210A prothrombin gene mutation. The patient was discharged without neurological sequelae and asymptomatic. The follow-up brain magnetic resonance imaging confirmed the reversal of the lesions, confirming the diagnosis.
- A Case of Unexplained Cutaneous Lesions, Cholestatic Hepatitis, and Noncirrhotic Portal Hypertension in a Female PatientPublication . Carvão, Joana; Pereira, Vítor Magno; Jasmins, LuísQuestion: A 57-year old woman with a previous history of contrast-related anaphylaxis was referred to the gastroenterology department with worsening liver function tests. She developed recurrent abdominal pain, diarrhea, significant weight loss, pruriginous generalized skin rash, and increased abdominal volume over 1 year. Physical examination revealed generalized small reddish monomorphic macules on the trunk and thighs (Figure A), hepatosplenomegaly, peripheral lymphadenopathy, and ascites. Blood tests showed normocytic normochromic anemia (hemoglobin 9.4 g/dL), monocytosis (1.3 103/mL), thrombocytopenia (97 103/mL), slight international normalized ratio prolongation, and a marked elevation of cholestasis parameters without jaundice (aspartate aminotransferase, 60 U/L; alanine aminotransferase, 56 U/L; gamma-glutamyl transferase, 324 U/L; and alkaline phosphatase, 1277 U/L). Abdominal Doppler ultrasound examination and a computed tomography scan revealed homogeneous hepatosplenomegaly (without signs of chronic liver disease), signs of portal hypertension without thrombosis of the splenoportal axis, moderate ascites, and intra-abdominal, axillary, and inguinal lymphadenopathies. Upper endoscopy showedesophageal varices and portal hypertensive gastropathy.Laboratory studies for chronic hepatopathy, infectious agents, and angiotensin-converting enzyme were negative. Bone marrow biopsy revealed granulomatous myelitis, and both lymphadenopathy and skin biopsies showed increased mononuclear cells.
- Celiac Disease as a Rare Cause of Membranous Nephropathy: A Case ReportPublication . Pestana, Nicole; Vida, Carlota; Durães, José; Silva, Gil; Vieira, PedroMembranous nephropathy is the most common cause of nephrotic syndrome in adults. A non-negligible number of cases are associated with systemic conditions. We report a case of a 50-year-old man who presented with nephrotic syndrome six months after being diagnosed with celiac disease. Although the patient showed disappearance of circulating immunoglobulin A (IgA) anti-tissue transglutaminase antibodies following a gluten-free diet, he had a sudden onset of nephrotic syndrome presenting with severe hypoalbuminemia. Other secondary causes were promptly excluded leading to the assumption of celiac disease-associated membranous nephropathy with remission after treatment with angiotensin system blockade and a gluten-free diet. The goal of this case report is to alert the clinic towards this rare association aiming for an early diagnosis and adequate selection of long-term therapy.
- Chronic gastritis (Clinical case)Publication . Sousa, Bruno; Tavares, NelsonA 42-year-old heavy-duty driver (from 9 am to 5 pm) with a part-time as a cook (7 pm to 11:30 pm), who has complaints of dyspepsia. He was sent to the Nutrition Consultation by his General Practitioner with Sucralfate, Diazepan and Esomeprazole and diagnosed with chronic gastritis.
- Clube Português do Pâncreas Recommendations for Chronic Pancreatitis: Etiology, Natural History, and Diagnosis (Part I)Publication . Rodrigues-Pinto, Eduardo; Caldeira, Ana; Soares, João Bruno; Antunes, Teresa; Carvalho, Joana Rita; Costa-Maia, José; Oliveira, Pedro; Azevedo, Richard; Liberal, Rodrigo; Bouça Machado, Tiago; Pereira, Vitor; Moutinho-Ribeiro, PedroChronic pancreatitis (CP) is a heterogeneous disease, with different causes and often a long delay between onset and full classic presentation. Clinical presentation depends on the stage of the disease. In earlier stages, recurrent episodes of acute pancreatitis are the major signs dominating clinical presentation. As the inflammatory process goes on, less acute episodes occur, and pain adopts different aspects or may even disappear. After 10-15 years from onset, functional insufficiency occurs. Then, a classic presentation with pain and pancreatic exocrine and endocrine insufficiency appears. Diagnosis remains challenging in the early stages of the disease, as its initial presentation is usually ill-defined and overlaps with other digestive disorders. Computed tomography and magnetic resonance cholangiopancreatography should be the first choice in patients with suspected CP. If the results are normal or equivocal but still there is a high suspicion of CP, the next option should be endoscopic ultrasound. Endoscopic retrograde cholangiopancreatography is mainly a therapeutic technique, and for the diagnostic purpose should only be used when all other imaging modalities and pancreatic function tests have been exhausted. Indirect tests are used to quantify the degree of insufficiency in already-established late CP. Recommendations on CP were developed by Clube Português do Pâncreas (CPP), based on literature review to answer predefined topics, subsequently discussed and approved by all members of CPP. Recommendations are separated in two parts: "chronic pancreatitis etiology, natural history, and diagnosis," and "chronic pancreatitis medical, endoscopic, and surgical treatment." This abstract pertains to part I.
- Clube Português do Pâncreas Recommendations for Chronic Pancreatitis: Medical, Endoscopic, and Surgical Treatment (Part II)Publication . Rodrigues-Pinto, Eduardo; Caldeira, Ana; Soares, João Bruno; Antunes, Teresa; Carvalho, Joana Rita; Costa-Maia, José; Oliveira, Pedro; Azevedo, Richard; Liberal, Rodrigo; Bouça Machado, Tiago; Magno-Pereira, Vitor; Moutinho-Ribeiro, PedroChronic pancreatitis (CP) is a complex disease that should be treated by experienced teams of gastroenterologists, radiologists, surgeons, and nutritionists in a multidisciplinary environment. Medical treatment includes lifestyle modification, nutrition, exocrine and endocrine pancreatic insufficiency correction, and pain management. Up to 60% of patients will ultimately require some type of endoscopic or surgical intervention for treatment. However, regardless of the modality, they are often ineffective unless smoking and alcohol cessation is achieved. Surgery retains a major role in the treatment of CP patients with intractable chronic pain or suspected pancreatic mass. For other complications like biliary or gastroduodenal obstruction, pseudocyst drainage can be performed endoscopically. The recommendations for CP were developed by Clube Português do Pâncreas (CPP), based on literature review to answer predefined topics, subsequently discussed and approved by all members of CPP. Recommendations are separated in two parts: "chronic pancreatitis etiology, natural history, and diagnosis," and "chronic pancreatitis medical, endoscopic, and surgical treatment." This abstract pertains to part II.
- Demystifying endoscopic retrograde cholangiopancreatography (ERCP)Publication . Magno Pereira, Vítor; Moutinho-Ribeiro, Pedro; Macedo, GuilhermeBackground: For many years, ERCP was avoided in pregnancy given the concerns regarding the adverse effects that, with special focus on radiation, could occur in the developing fetus. However, the postponement or rejection of ERCP in pregnant women, may lead to a higher risk for mother and fetus, especially when the indication is unequivocal, namely cholangitis, biliary pancreatitis and symptomatic choledocholithiasis. Summary and key messages: This review aims to summarize the scarce literature on the subject in order to plan ERCP in pregnancy with the highest safety. The use of techniques that reduce radiation and increase the protection of pregnant women allow radiation levels far below the safety limits. We also discuss the various alternatives of ERCP without radiation. EUS can eliminate the need for ERCP with doubtful choledocholithiasis and plan the best approach in those with previous evidence. The possibility of performing “ERCP” with a linear echoendoscope uniquely under ultrasound control has been described. Conversely, the two-step strategy (initial sphincterotomy with stent placement without fluoroscopy and after delivery, ERCP with lithiasis extraction) proved to be safe obviating fluoroscopy. In conclusion, ERCP can be performed in pregnancy safely and effectively with minimal radiation or even no-radiation at all.
- Dysphagia in a young female patient: it’s not always that simplePublication . Carvão, Joana; Peixoto, Armando; Rios, Elisabete; Macedo, GuilhermeA 42-year- old female patient was referred to our gastroenterology department with a 4-month history of weekly symptoms of dysphagia for solids and liquids. The patient also reported occasional symptoms of food impaction and heartburn. She denied nausea, vomiting, weight loss or a recent change in bowel habits. The patient was not under any medication. Medical or surgical history was unremarkable. There was no family history of gastrointestinal cancer. Physical examination was normal, and laboratory tests did not reveal anaemia or other abnormalities. She underwent an oesophagogastroduodenoscopy, and the oesophagus is shown in figure 1. Biopsies were performed in the upper and lower parts of the oesophagus and the result is shown in figure 2. Macroscopically and histologically, the stomach was normal. On the same day, the patient underwent a high-resolution manometry (HRM) (Medtronic 36-channel solid-state catheter) with 10 supine liquid swallows (5 mL water each) with the following findings (figure 3).
- Esophageal and Gastroduodenal Hemorrhagic Necrosis: A Unique Finding in the Setting of Septic Shock and Vasopressor UsePublication . Carvão, Joana; Faria, Maria Gorete; Magno Pereira, Vitor; Sousa Andrade, Carla; Fernandes, Nicodemos; Nóbrega, José Júlio; Jasmins, LuísEsophageal and gastroduodenal necrosis are rare conditions with poor prognosis. We describe a case that was diagnosed with upper endoscopy in the setting of severe septic shock. To our knowledge, this is the first case in which esophageal and gastroduodenal necrosis occurred simultaneously in this setting. We discuss the pathophysiology, diagnostic approach, and treatment options of this rare entity.
- Hepatosplenic T-Cell Lymphoma: A Rare Complication of Monotherapy with Thiopurines in Crohn’s DiseasePublication . Carvão, Joana; Magno Pereira, Vítor; Jacinto, Fernando; Sousa Andrade, Carla; Jasmins, LuísHepatosplenic T-cell lymphoma (HSTCL) is an extremely rare and aggressive form of non-Hodgkin lymphoma associated with poor response to treatment and high mortality. There is an increased incidence among patients with inflammatory bowel disease, especially young male patients under 35 years old and on combination therapy (thiopurine and anti-TNF-α). We describe a case of HSTCL in a young male patient with stenosing ileal Crohn's disease on azathioprine monotherapy for 4.8 years admitted to our hospital with intra- abdominal sepsis. Despite chemotherapy, the patient eventually died 1 month after the diagnosis. Through a literature review, we identified 18 additional cases of HSTCL in Crohn's disease patients that had only been treated with thiopurine monotherapy. The authors intend to highlight the rarity of this diagnosis especially with azathioprine monotherapy and the diagnostic challenge in a case that presented with intra-abdominal sepsis.