Volume 84 - 2021 - Fasc.3 - Clinical images
Minimally invasive treatment of a bulging appendiceal orifice
A 60-year-old fecal occult blood test-positive patient
was referred to our center to undergo colonoscopy. Two
diminutive sessile polyps were detected, macroscopically
compatible with sessile serrated lesions (SSL),
which were resected using cold-snare polypectomy.
Furthermore, a bulging appendiceal orifice was identified
with mucoid appearance (Figure 1, left). Biopsies were
taken and abdominal computed tomography (CT) was
performed (Figure 1, right).
What is the diagnosis and which treatment would you
consider?
Giant duodenal polyp
A 52 year-old man was referred with a history of
anemia and fatigue. There was no melena and he was not
taking any medication
Blood analysis revealed microcytic anemia, with
a hemoglobin of 9,7 g/dl (NR 13-18 ), MCV of 65,8 fl
(NR 80-100) and serum ferritine was below 5 ng/ml
(NR 30-400) with normal coagulation.There was no
inflammation, no renal insufficiency and liver function
tests were normal. Vitamine B12 and folic acid were
normal.
He underwent endoscopic work-up. Colonoscopy
was normal. Gastroscopy revealed a large pedunculated
polyp (5x2 cm) localized in the duodenal bulb and it was
eroded on the top (Figure 1A and B). Multiple biopsies
were taken showing no abnomarlity. There was no
Helicobacter pylori nor metaplasia.
A rare complication of acute severe ulcerative colitis
A 21-year-old female with ulcerative colitis presented
with abdominal pain and bloody diarrhea. Laboratory
studies revealed markedly elevated C-reactive protein
and thrombocytosis. Flexible sigmoidoscopy revealed
severe endoscopic activity with ulceration and spontaneous
bleeding along rectum and sigmoid colon.
Ulcerative colitis had been diagnosed 3 years before,
presenting as severe and extensive disease (pancolitis).
She had previously failed therapy with infliximab and
vedolizumab and had recently started induction therapy
with golimumab.
She responded well to intravenous corticosteroids
but, when switched to oral corticosteroids, there was
symptomatic recurrence. Intravenous corticosteroids
were re-started and she was evaluated for surgery.
At this time, she developed new-onset tachycardia.
Electrocardiogram revealed sinus tachycardia with heart
rate of approximately 120 bpm. Because tachycardia
could result from worsening colitis with potential serious
complications, abdominal computerized tomography
scan was performed and demonstrated mild lumen
dilation and wall thickening consistent with acute colitis
without evidence of pneumoperitoneum or toxic megacolon.
Surprisingly, thoracic planes revealed the presence
of free air dissecting mediastinal space (Figure 1). What
is your diagnosis?
A great mimicker of primary biliary cholangitis
A 59 year-old man without past medical history
was referred with biochemical features of cholestasis
(aspartate aminotransferase (AST) 117 U/L, alanine
aminotransferase (ALT) 83 U/L, gamma-glutamyl transferase
(GGT) 1307 U/L, alkaline phosphatase (AP) 1803
U/L, total bilirubin 0,7 mg/dL), a strongly positive antimitochondrial
M2 antibody (AMA-M2) titer (88 U),
weight loss and abdominal pain since several months. He
did not take any medications, nor there was a history of
alcohol abuse or sexual risk behavior. Upon presentation,
clinical examination showed a rather cachectic patient
(body mass index 19 kg/m²), without further abnormalities.
As primary biliary cholangitis (PBC) was
suspected, treatment with ursodeoxycholic acid had
been initiated but did not improve the cholestasis nor the
pain. Additional investigations didn’t reveal any other
irregularities, except for a mildly dilated aortic sinus root
of 42 mm. The histopathological findings of a liver biopsy
are shown below (Figure 1). This showed granulomas
with cholangitis and increased presence of neutrophils,
which raised suspicion for an infectious cause.
