Editor-in-Chief, Deputy Editor 2017-2019

 

Editor-in-Chief:

Tom MOREELS

 

Deputy Editor:

Nicolas LANTHIER

 

Letters



A rare cause of hematemesis: Esophageal haematoma as a complication of subclavian puncture


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A 52-year-old female patient with chronic renal failure was admitted to the emergency unit with hematemesis and hypotension. She’s been on haemodialysis for three years and a catheter insertion via the subclavian vein had been attempted without success some hours before admission. The patient had subcutaneous haematoma on the right side of the neck and chest wall (Figure 1), hypotension and tachycardia. Haemoglobin level was 7.5 g/dl, platelets and coagulation parameters were within normal range. Oesophagogastroduodenoscopy revealed that nearly the whole oesophageal lumen was filled with intramural haematoma and there was blood in stomach (Figure 1). Haematoma was on the right wall and extending to the esophagogastric junction and cardia (Figure 1). There wasn’t any active bleeding so the patient didn’t need any intervention. CT scan showed that the haematoma was restricted within submucosa of oesophagus and that there wasn’t any sign of vascular association or active bleeding. Subsequent endoscopic evaluations showed that haematoma improved without any complications. The patient was then followed up as outpatient and at the end of three weeks, endoscopy revealed complete resolution of haematoma with normal esophageal mucosa (Figure 1). [Product Details...]



Acute hepatitis A infection in an adult and isolated thrombocytopenia as extrahepatic manifestation: a case report description


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Usually, hepatitis A virus resolves itself in a few weeks, but uncommon types such as prolonged/biphasic acute and fulminant hepatitis A are also reported (1). In 5-8% of cases, extrahepatic manifestations are reported (2). In particular cutaneous, renal, neurological and haematologic manifestations could be diagnosed (2). In March 2015, a 31-year-old Italian woman was admitted to our Internal Medicine Department because one week before she experienced fever associated to malaise, dyspepsia and jaundice. Her personal history was negative for alcohol, drugs intake or tobacco consumption. Her past medical history was negative. The physical examination was negative for hepatosplenomegaly or purpura. Biochemical investigations revealed cholestasis with high bilirubin levels (11.4 mg/dl), as well as acute hepatitis A (IgM were positive for acute infection) with associated thrombocytopenia (PLT 27x10e9/L), hepatitis B or C virus and Human Immunodeficiency Virus were excluded, the autoimmunity was negative. The abdomen ultrasound scan was normal. [Product Details...]



An unusual cause of dyspepsia due to a retained epicardial pacing wire


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Temporary epicardial pacing wire (TEPW) are frequently inserted in cardiac surgery. Although overall morbidity related to TEPW is low, complications related to the insertion, utilization, retrieval, and migration of these wires have been reported in the literature (1). In this report, we describe a case of gastric migration of a TEPW, which caused dyspeptic symptoms. A 74-year-old man was admitted to our gastroenterology clinic for evaluation of worsening dyspeptic symptoms. Over the previous four months, he had suffered from continuous epigastric burning and pain. The patient had undergone coronary bypass grafting one year prior to the admission. Findings on abdominal examination were non-specific. On upper gastrointestinal endoscopy, a blue wire was identified that had penetrated the distal anterior wall of the gastric corpus (Figure 1). Retrieval of the foreign body was attempted but failed. Thoracic and abdominal computed tomography showed the wire, which originated from the right ventricle, passing through the sternocostal triangle, entering the abdomen, and penetrating the gastric wall (Figure 2). Consultation with cardiovascular surgery confirmed this wire to be a TEPW, which was cut at the surface of the skin after the bypass procedure. Although surgical intervention was planned, the patient did not provide consent for surgery. [Product Details...]



First long-term prospective case series of Percutaneous Endoscopic Gastrostomy with Jejunal Extension for drug administration


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Direct jejunal feeding by Percutaneous Endoscopic Gastrostomy with Jejunal Extension (PEG- J) or direct percutaneous endoscopic jejunostomy (DPEJ) is more indicated than gastric feeding in patients with aspiration of gastric contents, gastroparesis or gastric outlet obstruction. Other indication is administration of drugs that must be directly delivered to duodenum or jejunum to achieve a precise and controlled absorption. In this setting, PEG- J may be preferable to DPEJ, despite the risk of tube dysfunction or dislocation (1, 2). There are large series describing DPEJ outcomes (3), but the long- term outcome of PEG- J is not well reported, particularly regarding drug administration. A retrospective study compared DPEJ with PEG- J for the purpose of nutritional support (4). PEG- J had the advantage of being easier to place and to allow gastric decompression, but it required more endoscopic interventions, due migration of the extension, leakage, occlusion or infection. However, these results may not be reproducible for PEG- J used for other purposes. [Product Details...]



Primary gastric diffuse large B-cell lymphoma presenting as dysphagia


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To the Editor, Dysphagia can be caused by various conditions such as diverticula, motor function abnormality, vascular compression, esophagitis, and neoplasm. Primary gastric diffuse large B-cell lymphoma (DLBCL) rarely initially presents as dysphagia. Most common presentation of DLBCL is abdominal pain, anorexia, and weight loss. Less commonly, ulceration and bleeding may be seen. We present a rare case of patient with DLCBL who presented with Dysphagia. The patient is a 68-year-old male with history of esophageal reflux, and a former smoker presented to clinic with a two-week history of dysphagia to solids. He denied recent weight loss, abdominal pain, melena, or bright red blood per rectum. On physical exam, there was no lymphadenopathy and cardiopulmonary exam was normal. The abdomen was soft, non-tender, and non-distended. Laboratory findings were notable only for mild normocytic anemia with hemoglobin 12.8 g/ dL. Shortly thereafter, the patient underwent EGD for evaluation of dysphagia. EGD was notable for an 8-9 cm sub epithelial lesion with multiple superficial clean based ulcerations extending from the GE junction along the lesser curvature. Multiple deep biopsies were taken. A subsequent CT abdomen/pelvis showed an 11 cm mass along the lesser curvature of the stomach which encased the mesenteric vessels and appeared inseparable from the pancreatic body, gastric wall, and left hepatic lobe. Histopathology was consistent with DLBCL. After consultation with oncology the patient was started on R-CHOP therapy. Patient tolerated initial chemotherapy sessions well, with improvement of his dysphagia and decreased epigastric pain. [Product Details...]



Succesful treatment of chronic hepatitis C virus infection with daclatasvir and asunaprevir in a transfusion dependent thalassaemia patient


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Thalassaemia is one of the most common inherited hemoglobinopathies that is characterized with defective hemoglobin synthesis and ineffective erythropoiesis. Chronic transfusion therapy which increases the risk of hepatitis C virus (HCV) infection is the main treatment for severe forms of disease. Upon routine implementation of HCV screening in blood banks, chronic Hepatitis C incidance in thalassaemia patients has decreased. Nevertheless, HCV prevalence in transfusion dependent thalassemia patients, most of whom have acquired HCV prior to screening, is 23–47%. Cirrhosis occurs in about 10–20% of chronically infected patients. Iron overload associated with chronic transfusion also contributes to the development of cirrhosis in these patients. Therefore successful treatment of hepatitis C in thalassemia patients is imperative. The classical treatment regimen of hepatitis C with peginterferon alfa and ribavirin combination does not have an optimal efficacy and tolerability in the general hepatitis C population. Furthermore ribavirin can induce hemolysis that leads to worsening of the anemia, a need for increased transfusion frequency and iron overload in thalassemia patients (1). However, chronic hepatitis C treatment has improved significantly in recent years due to novel, direct-acting antiviral agents (2,3). In the general hepatitis C population, these agents have shown high efficacy and tolerability, while for hepatitis C patients with thalassaemia, there is only a single case report on direct-acting antivirals, where the sofosbuvirsimeprevir combination was used (4). Herein, we reported a young beta-thalassaemia major patient with chronic hepatitis c infection who was treated with daclatasvir and asunaprevir, another direct-acting antiviral combination, successfully. [Product Details...]


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