Benign blockage: gastric outlet obstruction due to a prolapsing gastric pedunculated polyp. Case report and literature review

NO ABSTRACT AVAILABLEAn 89-year-old woman was admitted to the emergency department at “Ospedale Civile Umberto I” in Lugo (Ravenna) for 1 month of vomiting, mild epigastric pain, and postprandial diarrhea without fever. Main comorbidities included chronic atrial fbrillation treated with a direct-acting oral anticoagulant, previous MI, hypertension, diabetes, and hypercholesterolemia, though despite her age the patient was autonomous in her daily activities. On admission, laboratory tests included normal WBC count, Hgb, and CRP. Abdominal X-ray demonstrated a stomach flled by ingested food (Fig. 1a) and difuse air–fuid levels accompanied by abdominal distension (Fig. 1b). A surgical consultation was requested; a CT scan was performed confrming gastric distension by ingested food (Fig. 2). Since gastric outlet obstruction was suspected, the patient was hospitalized in a medical unit, treated with NPO and IV fuids. After 2 weeks, a second surgical consultation was requested due to the recurrence of clinical symptoms with unchanged laboratory tests. An upper GI series reported normal gastric and duodenal transit (Fig. 3) while colonoscopy was negative. The patient underwent EGD that showed a 4-cm pedunculated polyp situated in the gastric antrum; the polyp prolapsed into the duodenal bulb creating a “ball valve”-type intermittent obstruction. Biopsy was consistent with a hyperplastic polyp which was endoscopically resected (Fig. 4a–c). The fnal histological report confrmed a benign lesion; the patient was discharged from the hospital without any further invasive treatment in good general condition

Recuperação e proteção de nascentes em propriedades rurais de Machadinho, RS.

bitstream/item/106898/1/RecuperacaoProtecao0001.pd

Cambona 4: desenvolvimento de uma progênie biclonal de erva-mate em Machadinho, RS.

bitstream/item/46075/1/Doc224.pd

Intensive care of the cancer patient: recent achievements and remaining challenges

A few decades have passed since intensive care unit (ICU) beds have been available for critically ill patients with cancer. Although the initial reports showed dismal prognosis, recent data suggest that an increased number of patients with solid and hematological malignancies benefit from intensive care support, with dramatically decreased mortality rates. Advances in the management of the underlying malignancies and support of organ dysfunctions have led to survival gains in patients with life-threatening complications from the malignancy itself, as well as infectious and toxic adverse effects related to the oncological treatments. In this review, we will appraise the prognostic factors and discuss the overall perspective related to the management of critically ill patients with cancer. The prognostic significance of certain factors has changed over time. For example, neutropenia or autologous bone marrow transplantation (BMT) have less adverse prognostic implications than two decades ago. Similarly, because hematologists and oncologists select patients for ICU admission based on the characteristics of the malignancy, the underlying malignancy rarely influences short-term survival after ICU admission. Since the recent data do not clearly support the benefit of ICU support to unselected critically ill allogeneic BMT recipients, more outcome research is needed in this subgroup. Because of the overall increased survival that has been reported in critically ill patients with cancer, we outline an easy-to-use and evidence-based ICU admission triage criteria that may help avoid depriving life support to patients with cancer who can benefit. Lastly, we propose a research agenda to address unanswered questions

A Controversy That Has Been Tough to Swallow: Is the Treatment of Achalasia Now Digested?

Esophageal achalasia is a rare neurodegenerative disease of the esophagus and the lower esophageal sphincter that presents within a spectrum of disease severity related to progressive pathological changes, most commonly resulting in dysphagia. The pathophysiology of achalasia is still incompletely understood, but recent evidence suggests that degeneration of the postganglionic inhibitory nerves of the myenteric plexus could be due to an infectious or autoimmune mechanism, and nitric oxide is the neurotransmitter affected. Current treatment of achalasia is directed at palliation of symptoms. Therapies include pharmacological therapy, endoscopic injection of botulinum toxin, endoscopic dilation, and surgery. Until the late 1980s, endoscopic dilation was the first line of therapy. The advent of safe and effective minimally invasive surgical techniques in the early 1990s paved the way for the introduction of laparoscopic myotomy. This review will discuss the most up-to-date information regarding the pathophysiology, diagnosis, and treatment of achalasia, including a historical perspective. The laparoscopic Heller myotomy with partial fundoplication performed at an experienced center is currently the first line of therapy because it offers a low complication rate, the most durable symptom relief, and the lowest incidence of postoperative gastroesophageal reflux