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Volume 76 - 2013 - Fasc.1 - Letters

Inflammatory myofibroblastic tumor of the small bowel

First described in the lung, inflammatory myofibro- blastic tumors (IMT) are pseudosarcomatous lesions that occur in the viscera and soft tissue of children and young adults. Intraabdominal and retroperitoneal locations have been associated with higher degrees of cellular atypia, more aggressive clinical course, higher local recurrence and even distant metastases (1). A 23-year-old woman presented with abdominal pain, fatigue, night sweats and weight loss for six weeks. On physical examination, a large mass was palpable in the lower abdomen. MRI con- firmed the presence of a 7 × 8 × 9 cm solid lesion involv- ing the small bowel (Figs. 1 and 2). A Pfannenstiel lapa- rotomy was performed and a tumor was found arising from the mesenteric border of the terminal ileum. The tumor was completely resected with primary ileo-caecal anastomosis. Histopathology revealed an inflammatory myofibroblastic tumor (IMT) with proliferation of spin- dle-shaped cells in fascicular growth patterns and lym- phocytic inflammatory infiltrate. Immunohistochemistry was highly positive in tumor cells for actin alpha (Figs. 3a and 3b). Postoperative recovery was uncomplicated and the patient left hospital five days after surgery.


Does endoscopic ultrasound-guided fine-needle aspiration of pancreatic cystic lesions provides adequate material for cytology and biochemical analysis ?

Recent data suggest that endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is of limited value in the management of pancreatic cysts (1). In this prospective study endoscopic ultrasound (EUS)-guided FNA was done in 128 patients. Material was sent for cytology from 124/128 patients (96.8%). A classifying diagnosis was obtained in only 44/124 patients (35.4%). Sufficient fluid was available for biochemical analysis in 80/124 cases (64.5%) and analysis succeeded in 70/124 patients (56.4%). Given these results the authors concluded that EUS-FNA has a limited role in the diagnostic approach of pancreatic cysts.


An unusual cause of abdominal pain

A 44-year-old man was referred for acute abdominal pain of the upper left quadrant. His medical history was unremarkable and he was taking no medicine. On exami- nation, the abdomen was soft and tender to palpation at the left costovertebral angle. Cardiac auscultation re- vealed a grade 3/6 pansystolic murmur over the left low- er sternal border. The white-cell count was 12.000 per cubic millimetre, the C-reactive protein was 20 mg/L and the LDH 500 U/L. Liver and pancreatic enzymes were normal. While the patient was in the emergency depart- ment narcotic analgesia was administered intravenously to control pain. Computer tomography of the abdomen showed multiple wedge-shaped areas of hypoenhase- ment in the spleen, consistent with splenic infarcts (Fig. 1).


Pentoxifylline for slow to resolve hepatopulmonary syndrome post liver trans- plantation : Helpful or Unnecessary ?

Hepatopulmonary syndrome (HPS), characterized by hypoxia due to intrapulmonary vasodilation and shunting usually in the setting of cirrhotic portal hypertension, af- fects at least 20% of cirrhotic patients (3). While liver transplantation (LT) is the only effective treatment for HPS, depending on the severity, recipients may experi- ence protracted hypoxia post-LT (1). Hypoxia following LT imposes risks to the recipient such as graft ischemia. Although patients with HPS receive priority for LT, these patients have inferior outcomes, with 1 year recipient survival rates approximating just 70% as compared to 90% in age-matched controls(1,2). Furthermore, pa- tients transplanted with HPS may suffer psychological hardship in the postoperative setting with residual HPS, and there are no reliable means to predict the duration of the resolution after transplant. Nitric oxide and tumor necrosis alpha (TNF-alpha) are potent vasodilators implicated in the pathogenesis of HPS (4,5). The degree of severity of HPS is determined by the recipient's P02 on a room air arterial blood gas ; patients with P02 < 60 mm Hg have severe HPS and the worst surviv- al. Following LT, subjects with advanced HPS may re- quire prolongation of invasive or non-invasive ventila- tion. There is limited data on the epidemiology and natural history of severe HPS post-LT. The mean dura- tion of residual HPS in subjects transplanted with severe HPS that required pre-operative non-invasive ventilation was 40 days in a report of 5 subjects (6).


Pineapple juice ingestion for gastric discomfort in diabetic gastroparesis

Diabetes mellitus with associated gastropathy has also been described as a risk factor for phytobezoar forma- tion (1). The dissolution of phytobezoars with the use of pineapple juice has been reported (2,3). Here we describe a patient with diabetes mellitus type 2 and gastroparesis whose gastric discomfort was relieved by the ingestion of pineapple juice. A 49-year-old man with type 2 diabetes mellitus, abdominal distension and anemia was referred to our clinic for endoscopic evaluation. Two years prior to re- ferral, the patient had begun to use insulin therapy due to his diabetes being poorly controlled. Gastroscopy showed undigested food in the stomach without findings of gas- tric outlet obstruction (Fig. 1). Pineapple juice ingestion was suggested to the patient as a treatment option, and he began drinking 75 ml of Dimes® 100% pineapple juice 3 times a day (after each meal). After 3 days of this treat- ment, repeat gastroscopy revealed an empty stomach (Fig. 2). At this time the patient reported that his gastric discomfort had resolved.


Ventricular tachyarrhythmia after adalimumab therapy in a patient with Crohn's disease

We report a case of a 19-year-old Caucasian male who was admitted to our Department in February 2010 be- cause of the exacerbation of Crohn's Disease (CD) with a presence of an active perianal fistula. He was then qualified for the biological therapy. A routine electro- cardiogram (ECG) performed at that time demonstrated a normal sinus rhythm - 75beats/min. Subsequently, adalimumab was introduced in standard doses.