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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.