[Adaptation and Validation for European Portuguese of the Auditory Performance Categories-II and Infant-Toddler Meaningful Auditory Integration Scale for Children with Cochlear Implant]

INTRODUCTION

The Categories of Auditory Performance II (CAP-II) scale and the Infant-Toddler Meaningful Audit Integration Scale (IT-MAIS) are simple and quick questionnaires that allow assessment of the auditory performance of children with cochlear implant (CI). The aim of this study was to translate, adapt and validate the European Portuguese version of the CAP-II and IT-MAIS scales.

METHODS

A total of 85 participants completed the European Portuguese version of the CAP-II and IT-MAIS questionnaires, of which 45 were parents of children with pediatric cochlear implants (9.84 ± 4.22 years) and another 40 were parents of children with normal hearing (8.35 ± 3.56 years). Inter-rater reproducibility, test-retest reproducibility, comparison of study group versus control group results, internal consistency and correlation of the new scales were evaluated.

RESULTS

The CAP-II and IT-MAIS scales showed high reliability and reproducibility, respectively, with an intraclass correlation coefficient (ICC) of 0.979 (p < 0.001) and a Spearman's correlation of 0.924 for the CAP-II scale, and an ICC of 0.932 (p < 0.001) and Spearman's correlation coefficient of 0.732 for the IT-MAIS scale. The IT-MAIS and CAP-II versions showed strong internal consistency (Cronbach's α coefficient value of 0.887 for the CAP-II scale and Spearman's positive correlation of 0.677 for the IT-MAIS scale, respectively) and allowed for the differentiation between children with normal hearing and post-implantation children (p = 0.001 and p < 0.001 respectively for each of the scales). There was no association between parental education and the results on the scales (p > 0.05).

CONCLUSION

The findings demonstrated that the European Portuguese version of these scales is a valid and reliable tool for assessing auditory performance in European Portuguese-speaking children with hearing loss.

Prolonged Fasting Induces Histological and Ultrastructural Changes in the Intestinal Mucosa That May Reduce Absorption and Revert after Enteral Refeeding

Background: Malnutrition is usual in patients referred for endoscopic gastrostomy (PEG). Refeeding syndrome is rarely observed in PEG-fed patients, which could possibly be associated with reduced absorption induced by prolonged starvation. Objective: In patients submitted to PEG after a significant period of fasting, the present study aims to: 1. evaluate the histological/ultrastructural initial changes in the intestinal mucosa, potentially associated with reduced absorption, and 2. assess if these changes could reverse with enteral refeeding. Methods: The present study is an observational, prospective, controlled study. Adult patients with ingestion below 50% of daily needs for at least one month and/or diagnosis of malnutrition were enrolled. Duodenal biopsies were taken at baseline and after 3-6 months of PEG feeding, which then underwent histological/ultrastructural analysis. Random healthy individuals were used as controls. Results: A total of 30 patients (16 men/14 women) aged 67.1 ± 13.5 years were included. Malnutrition was found in 40% of patients. Approximately 14 patients completed follow-up during both periods (46.7%). At baseline: duodenal mucosal atrophy was evident in three patients (10%); the median villi length (MVL) was 0.4 mm (0.25-0.6 mm), with it being shorter than the controls, which was 0.6 mm (0.4-0.7 mm) (p = 0.006); ultrastructural changes included focal shortening, bending, and disruption of enterocyte microvilli, the presence of citoplasmatic autophagic vacuoles, dilation and vesiculation of the smooth endoplasmic reticulum, and the presence of dilated intercellular spaces with basement membrane detachment. After refeeding, most patients displayed normal histology (92.9%) and increase MVL (p < 0.001), ultrastructural changes disappeared, and enterocytes resumed a normal appearance, although retaining scarce, small, dense bodies in apical regions from the evolution of previous autophagy. Conclusions: Prolonged fasting induces histological and ultrastructural changes in the intestinal mucosa that may reflect impaired absorption in the early post-PEG period. These changes were reverted after refeeding with enteral nutrition.

Duodenal angiolipoma: a rare tumor causing recurrent upper gastrointestinal bleeding

Duodenal angiolipoma is a rare adipocytic tumor, with non-specific symptoms precluding an early diagnosis. We present a case of a 67-year-old female admitted due to upper gastrointestinal bleeding. The upper endoscopy and endoscopic ultrasound evaluation showed a subepithelial lesion in the third portion of the duodenum. Endoscopic excision was performed using a standard polypectomy technique after endoloop placement. Histopathology was compatible with duodenal angiolipoma. The authors highlight duodenal angiolipoma as a rare adipocytic tumor potentially causing gastrointestinal bleeding, which can be safely treated with endoscopic excision.

Metastatic melanoma: an uncommon cause of upper gastrointestinal bleeding

Melanoma gastrointestinal metastases are rare and represent a late stage of malignant disease with the jejunum and ileum being the most common locations followed by stomach, colon and duodenum. We present a case of a patient with past history of cutaneous melanoma treated twelve years before, in remission. The patient developed upper gastrointestinal bleeding due to metastatic melanoma in the duodenum.

Niti-S Esophageal Mega-Stent: An Emerging Endoscopic Tool with Different Applications in the Management of Surgical Anastomotic Leaks

Introduction

Anastomotic leak (AL) is a dangerous complication in the early postoperative period after total gastrectomy or esophagectomy being associated with high mortality. Self-expandable metal stents (SEMS) play a significant role in AL management. Only one case report described the use of Mega-Stent in AL setting. The authors report a two-case series with different applications of a Niti-S esophageal Mega-Stent in AL management.

Case Report

Case 1 is a 67-year-old male who underwent an esophagectomy due to a squamous cell carcinoma of the distal esophagus. The early postoperative period was complicated with AL and gastropleural fistula. Initially, an OTSC was deployed in the dehiscence but failed to resolve AL. The esophageal Mega-Stent was further placed in-between the esophagus and the bulbus. Post-stenting contrast studies confirmed no further AL.Case 2 is an 86-year-old woman who underwent total gastrectomy with roux-en-y esophagojejunostomy due to a gastric adenocarcinoma, complicated with AL. A partially covered metal stent (PCMS) was placed to cover the anastomosis. Computed tomography confirmed leakage persistence and a second PCMS was deployed, resolving the AL. Several weeks later, both PCMSs presented ingrowth from granulation tissue. An esophageal Mega-Stent was placed (stent-in-stent technique) and 2 weeks later, all stents were removed, with no AL recurrence.

Discussion/Conclusion

SEMS placement for AL is a safe, well-established therapeutic technique. Limitations include stent migration and incomplete cover of large AL. Mega-Stent can be an emerging tool for endoscopic AL management.

EUS-guided hepaticogastrostomy in multimetastatic liver disease - an effective approach for biliary drainage that may complement ERCP

A 36-year-old male was diagnosed with a metastasized colon adenocarcinoma causing obstructive jaundice. Magnetic resonance cholangiography showed a dominant lesion causing hilar stenosis. The patient was submitted to endoscopic retrograde cholangiopancreatography (ERCP), nevertheless it was just possible to place a single uncovered self-expandable metallic stent (SEMS) in the right lobe. Although cholestasis significantly improved, safe levels for oncologic therapy were not reached. EUS-guided hepaticogastrostomy was proposed to complement ERCP biliary drainage. Using a forward-viewing echoendoscope and a transgastric approach, EUS-guided puncture of a dilated left intrahepatic duct at segment III was accomplished with a 19G needle (EchoTip ProCore®) that allowed passage of a 0.035 guidewire. A 6F cystotome and biliary dilators (5Fr+8.5Fr) were used for needle tract dilation. A partially-covered SEMS (GIOBOR™ 8x100mm) could be deployed under endoscopic and fluoroscopic control, being placed 3cm inside the gastric lumen. No associated complications were observed after the procedure.

[Translation, Cultural Adaptation and Contributions to the Validation of the Nijmegen Cochlear Implant Questionnaire (NCIQ) for European Portuguese]

INTRODUCTION

The Nijmegen Cochlear Implant Questionnaire (NCIQ) scale uses a simple and easily administered questionnaire to evaluate the adaptation of individuals to their cochlear implants. The aim of this study was to validate the NCIQ for European Portuguese, through its translation and cultural adaptation. It also presents the evaluation of reproducibility and the description of the results of this questionnaire in patients using IC.

MATERIAL AND METHODS

Fifty postlingually deaf adult multichannel cochlear implant users (uni- or bilateral) participated in the study. Participants used the cochlear implant for at least 12 months and were patients of the Department of Otolaryngology at the Egas Moniz Hospital in Lisbon. Permission, as well the guidelines for translation, were obtained from the authors of the scale. Translation and cultural adaptation were carried out, in addition to the evaluation of reproducibility and internal consistency.

RESULTS

The participants were 44.0% male and 56.0% female, aged between 20 and 79 years (55.50 ± 15.69). The results of the study showed an overall level of satisfaction of 65.07 among cochlear implants users. The level of satisfaction of the subdomains was 64.40 in basic sound perception, 71.35 in advanced sound perception, 57.91 in speech production, 59.05 in self-esteem, 69.75 in activity and 68.50 in social functioning. Internal consistency (Cronbach α score = 0.96) and test-retest reliability coefficients proved to be strong. Furthermore, the questionnaire's overall and subdomains average scores did not differ significantly from the results obtained with the original scale.

CONCLUSION

This adaptation of the NCIQ questionnaire for European Portuguese should be considered a good tool to evaluate the level of satisfaction of cochlear implant users and, so far, it is the only scale in this field validated for application in the Portuguese population.

Long-Term Intestinal Failure and Home Parenteral Support: A Single Center Experience

<b><i>Introduction:</i></b> Home parenteral nutrition (HPN) and/or home parenteral hydration (HPH) are the gold-standard treatment for patients with long-term intestinal failure (IF). The authors aimed to assess the impact of HPN/HPH on nutritional status and survival of long-term IF patients, as well as HPN/HPH-related complications. <b><i>Methods:</i></b> This was a retrospective study including IF patients under HPN/HPH followed in a single large tertiary Portuguese hospital. The data collected included demographics, underlying conditions, anatomical characteristics, type and duration of parenteral support, IF functional, pathophysiological, and clinical classifications, body mass index (BMI) at the beginning and end of follow-up, complications/hospitalizations, current patient status (deceased, alive with HPN/HPH, and alive without HPN/HPH), and cause of death. Survival after HPN/HPH beginning, until death or August 2021, was recorded in months. <b><i>Results:</i></b> Overall 13 patients were included (53.9% female, mean age 63.46 years), and 84.6% of patients presented type III IF and 15.4% type II. Short bowel syndrome caused 76.9% of IF. Nine patients received HPN and 4 HPH. Eight patients (61.5%) were underweight at the beginning of HPN/HPH. At the end of follow-up, 4 patients were alive without HPN/HPH, 4 maintained HPN/HPH, and 5 died. All patients improved their BMI (mean initial BMI 18.9 vs. 23.5 at the end, <i>p</i> &#x3c; 0.001). Eight patients (61.5%) were hospitalized due to catheter-related complications, mainly infectious (mean hospitalization episodes 2.25, mean hospital stay of 24.5 days). No deaths were related to HPN/HPH. <b><i>Conclusion:</i></b> HPN/HPH significantly improved IF patients’ BMI. HPN/HPH-related hospitalizations were common, however causing no deaths, reinforcing that HPN/HPH is an adequate and safe therapy for long-term IF patients.

NOBLADS-External Validation of a Risk Scoring System for Severe Acute Lower Gastrointestinal Bleeding

BACKGROUND

Acute lower gastrointestinal bleeding is a common cause of hospital admission. NOBLADS is a lower gastrointestinal bleeding clinical risk score.

OBJECTIVE

This study aimed to externally validate NOBLADS in predicting severe acute lower gastrointestinal bleeding and clinical outcome.

DESIGN

Observational retrospective study.

SETTING

This study was performed in a single large tertiary hospital.

PATIENTS

Patients who were admitted with acute lower gastrointestinal bleeding during a 15-month period and underwent endoscopic evaluation were included. Patients with chronic lower gastrointestinal bleeding or acute lower gastrointestinal bleeding who were admitted for other conditions were excluded.

MAIN OUTCOME MEASURES

Primary outcome was acute severe lower gastrointestinal bleeding (classified as severe if requires transfusion of >2 units of packed red blood cells and/or produces a >20% hematocrit fall). Secondary outcomes: red blood cells requirement, therapeutic intervention and hospital stay duration. NOBLADS score was applied to all patients. Its accuracy to predict acute severe bleeding and secondary outcomes were studied using receiver operating characteristic analysis.

RESULTS

A total of 173 patients (50.3% males, age 69 ± 17 years) were included. The most common lower gastrointestinal bleeding etiologies were diverticular bleeding (18.5%) and ischemic colitis (15.6%). Fifty patients (28.9%) presented criteria for severe bleeding and 33 patients required instrumental intervention: endoscopic (n = 28), surgical (n = 4), and radiologic (n = 1) therapy. NOBLADS score was significantly different according with acute lower gastrointestinal bleeding causes (p < 0.001) and accurately predicted severe bleeding (area under the receiver operating characteristic curve 0.923 ± 0.018 (p < 0.001)). NOBLADS ≥2 detected acute severe lower gastrointestinal bleeding with 100% sensitivity/62.4% specificity, identifying the need for higher red blood cells requirement (3.6 vs 0.08, p < 0.001), therapeutic intervention (38% vs 13%, p < 0.001), and longer hospital stay (12.8 vs 3 days, p < 0.001).

LIMITATIONS

Unicenter retrospective study; number of unprepared sigmoidoscopies/left side colonoscopies; comparison between NOBLADS and other scoring systems was not performed.

CONCLUSION

NOBLADS is a practical, highly accurate tool and predicts the need of in-hospital management, early colonoscopy, red blood cells transfusion, and longer hospital stay in patients admitted with acute lower gastrointestinal bleeding. See Video Abstract at http://links.lww.com/DCR/B748.NOBLADS: VALIDACIÓN EXTERNA DE UN SISTEMA DE PUNTUACIÓN DE RIESGO PARA HEMORRAGIA DIGESTIVA BAJA AGUDA GRAVE.

ANTECEDENTES

La hemorragia digestiva baja aguda es causa común de admisión hospitalaria. NOBLADS es una puntuación de riesgo clínico de hemorragia gastrointestinal baja.

OBJETIVO

Este estudio tuvo como objetivo validar externamente NOBLADS en la predicción de hemorragia digestiva baja aguda grave y sus resultados clínicos.

DISEO

Estudio observacional retrospectivo.

AJUSTE

Realizado en un gran hospital terciario.

PACIENTES

Se incluyeron todas aquellas personas ingresados con hemorragia digestiva baja aguda durante un período de 15 meses y que fueron sometidos a evaluación endoscópica. Se excluyó la hemorragia digestiva baja crónica o la hemorragia digestiva baja aguda en pacientes ingresados por otras afecciones.

PRINCIPALES MEDIDAS DE RESULTADO

El resultado pricipal fue la hemorragia digestiva baja grave aguda (clasificada como grave si requiere >2 transfusiones de glóbulos rojos y / o produce una caída del hematocrit >20%). Las medidas de resultados secundarias fueron: requerimiento de glóbulos rojos, intervención terapéutica y duración de la estancia hospitalaria. Se aplicó la puntuación NOBLADS a todos los pacientes. Se estudió su precisión para predecir la hemorragia aguda grave y los resultados secundarios mediante análisis ROC.

RESULTADOS

Se incluyeron 173 pacientes (50,3% varones, edad 69 ± 17 años). La etiología de hemorragia digestiva baja más frecuentes fueron: la hemorragia de orígen diverticular (18,5%) y la colitis isquémica (15,6%). 50 pacientes (28,9%) presentaron criterios de sangrado severo y 33 pacientes requirieron intervención instrumental: terapia endoscópica (n = 28), quirúrgica (n = 4), radiológica (n = 1). La puntuación NOBLADS fue significativamente diferente según las causas de hemorragia digestiva baja aguda (p <0,001), siendo precisa para predecir hemorragia grave (AUC 0,923 ± 0,018 (p <0,001). NOBLADS ≥2 detectó hemorragia digestiva baja aguda grave con 100% de sensibilidad / 62,4 % de especificidad, identificando la necesidad de mayor requerimiento de glóbulos rojos (3.6 vs 0.08, p <0.001), intervención terapéutica (38% vs 13%, p <0.001) y estadía hospitalaria más prolongada (12.8 vs 3 días, p <0.001).

LIMITACIONES

Estudio retrospectivo Unicentrico; número de sigmoidoscopias / colonoscopias del lado izquierdo no preparadas; no se realizó comparación entre NOBLADS y otros sistemas de puntuación.

CONCLUSIN

NOBLADS es una herramienta práctica y altamente precisa que predice la necesidad de manejo hospitalario, colonoscopia precoz, transfusión de glóbulos rojos y estadía hospitalaria más prolongada en pacientes ingresados con hemorragia digestiva baja aguda. Consulte Video Resumen en http://links.lww.com/DCR/B748. (Traducción-Dr. Xavier Delgadillo).

A Unique Case of Recurrent Upper Gastrointestinal Bleeding Caused by Two Metachronous Dieulafoy's Lesions: The Role of EUS Evaluation

Introduction

Dieulafoy's lesion (DL) is a rare but important cause of acute, severe, life-threatening, and recurrent upper gastrointestinal bleeding (UGIB). It is frequently difficult to diagnose DL with upper GI endoscopy (UGIE), and endoscopic ultrasonography (EUS) may be valuable. There are only 2 reported bleeding cases caused by two synchronous DL but no reported cases of two metachronous DL.

Case Report

A 28-year-old healthy male presented with acute severe UGIB. UGIE was inconclusive. Systematic EUS mapping identified a gastric DL. After several attempts of EUS-guided hemostasis, DL was marked using a through-the-scope clip and the patient underwent successful transcatheter arterial embolization (TAE). Three years later, a new severe UGIB episode was caused by a second gastric DL in a different location, which was identified and marked by EUS and further successfully treated through TAE. The patient maintained follow-up without evidence of further bleeding.

Discussion/Conclusion

The authors report a unique case of severe, recurrent UGIB caused by two metachronous gastric DL lesions. The importance of systematic EUS scanning for diagnosis, treatment, and follow-up of DL is emphasized, as well as the potential influence in the outcome of other techniques like angiographic embolization.

Nutritional Support of Cancer Patients without Oral Feeding: How to Select the Most Effective Technique?

Background

Digestive tumours are among the leading causes of morbidity and mortality. Many cancer patients cannot maintain oral feeding and develop malnutrition. The authors aim to: review the endoscopic, radiologic and surgical techniques for nutritional support in cancer patients; address the strategies for nutritional intervention according to the selected technique; and establish a decision-making algorithm to define the best approach in a specific tumour setting.

Summary

This is a narrative non-systematic review based on an electronic search through the medical literature using PubMed and UpToDate. The impossibility of maintaining oral feeding is a major cause of malnutrition in head and neck (H&N) cancer, oesophageal tumours and malignant gastric outlet obstruction. Tube feeding, endoscopic stents and gastrojejunostomy are the three main nutritional options. Nasal tubes are indicated for short-term enteral feeding. Percutaneous endoscopic gastrostomy (PEG) is the gold standard when enteral nutrition is expected for more than 3-4 weeks, especially in H&N tumour and oesophageal cancer patients undergoing definite chemoradiotherapy. A gastropexy push system may be considered to avoid cancer seeding. Radiologic and surgical gastrostomy are alternatives when an endoscopic approach is not feasible. Postpyloric nutrition is indicated for patients intolerant to gastric feeding and may be achieved through nasoenteric tubes, PEG with jejunal extension, percutaneous endoscopic jejunostomy and surgical jejunostomy. Oesophageal and enteric stents are palliative techniques that allow oral feeding and improve quality of life. Surgical or EUS-guided gastrojejunostomy is recommended when enteric stents fail or prolonged survival is expected. Nutritional intervention is dependent on the technique chosen. Institutional protocols and decision algorithms should be developed on a multidisciplinary basis to optimize nutritional care.

Conclusions

Gastroenterologists play a central role in the nutritional support of cancer patients performing endoscopic techniques that maintain oral or enteral feeding. The selection of the most effective technique must consider the cancer type, the oncologic therapeutic program, nutritional aims and expected patient survival.

Mauriac Syndrome: A Rare Hepatic Glycogenosis in Poorly Controlled Type 1 Diabetes

Background

Hepatic glycogenosis (HG) is a complication of poorly controlled type 1 diabetes mellitus (T1DM), characterized by glycogen accumulation in hepatocytes. Mauriac syndrome (MS) is a glycogenic hepatopathy, initially described in 1930, characterized by growth failure, delayed puberty, cushingoid appearance, hepatomegaly with abnormal liver enzymes, and hypercholesterolemia. HG is a condition with good prognosis and fast resolution after adequate glycemic control (although it has potential for relapse), with no case of evolution to end-stage liver disease described.

Case

We describe a 26-year-old female, with T1DM complicated by severe retinopathy. The patient maintained poor glycemic control since childhood, presenting glycated hemoglobin persistently higher than 10% and recurrent episodes of ketoacidosis. In adolescence, she developed hepatomegaly and fluctuating elevation of aminotransferases and triglycerides. A small, nonrepresentative hepatic biopsy suggested macrovacuolar steatosis and mild fibrosis. After 15 years of diabetes, the patient was referred for gastroenterology clinic due to chronic diarrhea and exuberant hepatomegaly. Laboratory showed persistent elevation of aminotransferases and triglycerides. Bilirubin, iron metabolism, and coagulation were normal; viral serologies and autoimmune study were negative. Upper endoscopy, ileocolonoscopy, and enteroscopy presented no lesions. Abdominal magnetic resonance imaging displayed massive hepatomegaly. Liver biopsy was repeated showing marked nuclear glycogenization, mild steatosis, and no fibrosis; electron microscopy revealed very large deposits of glycogen and pleomorphic mitochondria with an unusually dense matrix, described for the first time in this entity. The diagnosis of MS variant and diarrhea due to autonomic neuropathy were assumed.

Conclusion

Currently, HG is a well-recognized disease that occurs at any age and can be present without the full spectrum of features initially described for MS. In the era of insulin therapy, this entity represents a rare complication, caused by low therapeutic compliance.

ARE CARIOGENIC BACTERIA THE MAJOR RISK FACTOR TO DENTAL CARIES IN PATIENTS WITH ULCERATIVE COLITIS?

BACKGROUND

High prevalence of dental caries in ulcerative colitis (UC) has been attributed to diet and changes in salivary environment.

OBJECTIVE

We aimed to characterize the prevalence of dental caries, salivary flow rates, salivary buffering capacity and cariogenic bacteria counts of Mutans streptococci and Lactobacillus spp and to evaluate their relationship with drug therapy, disease activity and duration.

METHODS

A cross-sectional study was performed with UC patients followed in a tertiary center. Participants were submitted to a questionnaire (including demographic data, oral hygiene, eating habits) and a clinical observation with assessment of plaque index and Decayed, Missing and Filled Teeth index. Unstimulated/stimulated saliva was collected. Medical records, disease activity (Partial Mayo Score) and disease duration were collected. Laboratory data included salivary flow rates, salivary buffering capacity (CRT® buffer) and cariogenic bacteria count (Mutans streptococci and Lactobacillus spp) in saliva using the CRT® bacteria test (results: high or low counts).

RESULTS

Thirty UC patients were recruited. Oral hygiene routines were daily teeth brushing once or more (96.7%) and fluoride toothpaste (73.3%). Decayed, Missing and Filled Teeth index (mean 16.17±6.428) was not affected by the frequency of soft drinks, cakes, sweets and sugars between meals (P>0.2). Long-term disease showed a trend towards higher prevalence of caries (P=0.06). Most presented normal salivary flow rates, unstimulated (73.3%) and stimulated (60.0%), and high salivary buffering capacity (66.7%). Any association was found with age, gender, disease activity, disease duration and drug therapy. High Mutans streptococci and low Lactobacillus spp count were observed in 73.3% and 60% of patients, respectively. Patients with active disease (100%) and longer duration (88.9%) displayed higher Mutans streptococci count.

CONCLUSION

The prevalence of dental caries observed in UC patients was significant and did not seem to be influenced by their eating habits. The high prevalence of Mutans streptococci count may be a major risk factor for dental caries and may be looked as part of the UC dysbiosis. Dental care of UC patients should be planned according with this microbiota variation.

Ménétrier's disease : a case of successful treatment using long-acting octreotide

The authors describe a 31 years old male, admitted for hematemesis, epigastric pain and lower limb edema. Laboratorial data showed haemoglobin 18.4g/dl, total proteins 2.8g/dl, albumin 1.6g/dl and hipogammaglobulinaemia. 24h urinary proteins were normal. HIV and CMV serology were negative. Upper GI endoscopy revealed markedly enlarged gastric folds covered by abundant exudative fluid. Endoscopic ultrasound showed ascites, pleural effusion and gastric wall thickening with mucosa expansion and intact submucosa. In gastric biopsies foveolar hyperplastic and regenerative mucosa were observed being suggestive of Ménétrier´s disease. Helicobacter pylori was not detected. Albumin replacement and diuretics corrected anasarca and long-acting octreotide was instituted. Nine months later, the patient was asymptomatic, serum proteins were normal (albumin 4.6g/dl and total proteins 6.5g/dl), signs of endoscopic improvement were observed with marked reduction in gastric folds and mucosal inflammation and no ultrastructural changes were detected in gastric specimens sent for electron microscopy. Ménétrier´s Disease (MD) is a rare form of hypertrophic gastropathy characterized by massive enlargement of gastric folds causing marked protein exudation. The increase in tight junction diameter is the most consistent ultraestrutural change. Octreotide is a somatostatin analogue that acts by modulating TGFαEGFR pathway, which has been associated with the pathogenic mechanisms. As well as other cases reported in literature, this case report highlights the potential of long-acting octreotide for MD treatment avoiding more expensive therapies like cetuximab and gastrectomy.

Long-Term Gastrocolocutaneous Fistula after Endoscopic Gastrostomy: How Concerned Should We Be?

Percutaneous endoscopic gastrostomy (PEG) is a safe technique for long-term enteral feeding. The most common PEG-associated adverse events are minor. Gastrocolocutaneous fistula (GCCF) results from misplacement of the PEG tube through the colon. The importance of this complication is not currently defined, and there is no clearly established therapeutic algorithm. The authors report a series of 3 cases of GCCF diagnosed and treated in a tertiary center.

Case 1

An 88-year-old man underwent PEG due to head and neck cancer. The procedure was uneventful, and the patient remained asymptomatic. After the first PEG tube substitution performed at 6 months, stool drainage through the stoma was observed. Computed tomography (CT) showed a GCCF. After tube removal, the fistula spontaneously closed, and the patient remained under nasogastric feeding until death.

Case 2

A 31-year-old man with hereditary spastic paraplegia was submitted to PEG without early complications. The patient remained asymptomatic, and 7 months later, replacement of the PEG tube was planned. Under endoscopic control, the primary tube was removed, but the balloon replacement tube, introduced through the skin, was not observed in the gastric lumen. CT displayed a GCCF that spontaneously closed after a few days. A combined laparoscopic and endoscopic approach was used to resect the fistula tracts and perform a new gastrostomy.

Case 3

A 45-year-old man with cerebral palsy was referred to PEG. Skin transillumination was only observed transiently, and the abdominal puncture was performed obliquely. The patient remained asymptomatic until the 7th month, when the primary PEG tube replacement was performed. The percutaneously placed substitution tube did not reach the stomach. GCCF was evident on CT. The fistula spontaneously closed, and the patient was referred to elective surgery for laparoscopic gastrostomy. GCCF is an uncommon complication of PEG. Its clinical course seems to be benign with patients remaining asymptomatic under ambulatory enteral feeding for long periods until PEG tube replacement. Spontaneous fistula closure is the rule in this setting. Laparoscopic gastrostomy should be considered when a new PEG is advised and cannot be safely performed due to colon interposition.

Mantle cell lymphoma of the cecum

The authors have read with great interest the recently published article "Colon lymphomas: an analysis of our experience over the last 23 years" by Martín Domínguez V et al., a single center retrospective review of 29 patients diagnosed with colon lymphoma. The present report describes a case of mantle cell lymphoma (MCL) of the cecum that aims to improve the knowledge regarding this unusual clinical and endoscopic entity.

Compensatory plasticity in the congenitally deaf for visual tasks is restricted to the horizontal plane

Congenitally deaf individuals, compared to hearing individuals, typically show differential performance (improvements or impairments) on certain nonauditory tasks. Concomitantly, their auditory cortex is recruited to process information from the spared senses. Are these compensatory behavioral strategies equally observable across the sensory fields of each particular unaffected sense (e.g., across the full visual field for vision-related compensatory plasticity)? There are neural data in human and nonhuman mammals that may be suggestive of there being a differential processing advantage for stimuli presented in the horizontal visual plane than in the vertical visual plane. To test for these visual field asymmetries in compensatory behavioral performance, we used a direction of motion discrimination task and found that deaf participants were better at determining the direction of motion of dot patterns presented in the horizontal plane compared to those presented in the vertical plane and in the center-that is, we show that the neuroplasticity-induced bias toward the horizontal plane is also present in the behavioral advantage that deaf individuals present. These data may suggest that the neuroplastically changed auditory cortex of deaf individuals is functionally responsible for the enhanced processing of information from the spared senses. (PsycINFO Database Record

SERUM ELECTROLYTES AND OUTCOME IN PATIENTS UNDERGOING ENDOSCOPIC GASTROSTOMY

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is a gold standard for long term enteral feeding. Neurologic dysphagia and head/neck cancer are the most common indications for PEG as they can lead to protein-energy malnutrition and serum electrolyte abnormalities, with potential negative impact on metabolic balance. Refeeding syndrome may also be related with severe electrolyte changes in PEG-fed patients and contribute to poor prognosis.

OBJECTIVE

This study aims to evaluate the changes in serum concentrations of the main electrolytes and its possible association with the outcome.

METHODS

Retrospective study of patients followed in our Artificial Nutrition Clinic, submitted to PEG from 2010 to 2016, having head/neck cancer or neurologic dysphagia, who died under PEG feeding. Serum electrolytes (sodium, potassium, chlorine, magnesium, calcium and phosphorus) were evaluated immediately before the gastrostomy procedure. Survival after PEG until death was recorded in months.

RESULTS

We evaluated 101 patients, 59 with electrolyte alterations at the moment of the gastrostomy. Sodium was altered in 32 (31.7%), magnesium in 21 (20.8%), chlorine in 21 (20.8%), potassium in 14 (13.8%), calcium in 11 (10.9 %) and phosphorus in 11 (10.9%). The survival of patients with low sodium (<135 mmol/L) was significantly lower when compared to patients with normal/high values, 2.76 months vs 7.80 months, respectively (P=0.007).

CONCLUSION

Changes in serum electrolytes of patients undergoing PEG were very common. More than half showed at least one abnormality, at the time of the procedure. The most frequent was hyponatremia, which was associated with significantly shorter survival, probably reflecting severe systemic metabolic distress.

Nutritional deficiency during colonoscopy preparation: the forgotten iatrogeny

BACKGROUND AND AIMS

bowel preparation for colonoscopy induces a semi-fasting state, with a potential negative impact on fragile patients. The present study aims to quantify nutritional deficiency during colonoscopy preparation.

METHODS

this was an observational and cross-sectional study. A convenience sample was obtained that included adults that underwent colonoscopy after bowel preparation with Klean-Prep® according to the center protocol. Anthropometric evaluation was performed and nutritional deficiency was calculated via the quantification of energy and protein intake during the 48 hours prior to the examination which was compared with the individuals' needs. The association between nutritional deficiency with the quality of bowel preparation, age and status (hospitalized/ambulatory) was evaluated.

RESULTS

the study included 131 patients aged 21-91 years (mean 63.6 ± 13.2 years); 73 cases were male. Malnutrition reached 67.2% using specific anthropometric tools. A median preparation quality of six points was found when the Boston Bowel Preparation Scale was considered. The mean intake 48 hours prior to the procedure was 1,795 kcal and 100 g of protein. A daily energy intake of less than 50% of the individual needs was observed in 88 patients and less than 25% in 29 cases. The mean energy and protein deficiency were 59% (p < 0.01) and 45% (p < 0.01), and there was no correlation with preparation quality (p > 0.05). Nutritional defiency is similar in hospitalized and ambulatory patients (p > 0.05), but higher in older individuals (p = 0.04).

CONCLUSIONS

nutritional deficiency during colonoscopy preparation was significant, more so in older patients, and there was no correlation with the quality of bowel preparation. We conclude that bowel preparation regimens should be reformulated with an improved nutritional intake and the inclusion of nutritional supplements without residues.

168 The Effect of Prematuration Culture Using Epidermal Growth Factor Receptor Kinase Inhibitor on Nuclear Maturation of Bovine Oocytes and Cumulus Cell Gene Expression

Epidermal growth factor receptor (EGFR) activation is an essential step in triggering LH-induced meiotic resumption. Here, we used an EGFR kinase inhibitor (AG1478) to assess the blockage and reversal of meiosis block in bovine oocytes, the competence of such oocytes for the embryonic development, and the gene expression of cumulus cells (CC). Cumulus-oocyte complexes (COC, n = 583) were pre-matured (PM) during 8 h in TCM-199 with 1 μM AG1478 (EGFR-group). Next, COC were washed from meiotic inhibitor and cultured for 22 h in in vitro maturation (IVM) medium (TCM-199 with bicarbonate, 0.5 mg mL−1 FSH, 100 IU mL−1 hCG, and 10% FCS). The control group was only cultured for 22 h in IVM medium. Meiosis progression in oocytes was evaluated after PM (blocked_GV) and after IVM of PM oocytes (blocked_MII) or immediately after follicle aspiration (immature control = control_GV) and IVM (matured control = control_MII); oocytes were classified as immature (germinal vesicle; GV) or mature (metaphase II; MII). Another sample of matured oocytes was fertilized and cultured to the blastocyst stage. Abundance of 81 transcripts was evaluated by qPCR using a microfluidic platform (BioMark HD System™, Fluidigm®, South San Francisco, CA, USA) in CC collected at the same time as oocyte evaluation. Relative mRNA abundance was calculated by ΔCt (target genes were normalized by 2 reference genes: PPIA and RPL15). Data were analysed by ANOVA followed by Tukey’s test (P ≤ 0.05). The GV rates after 8-h PM differed (P ≤ 0.05) between 0-h oocytes (96.4 ± 2.2%) and EGFR- (59.8 ± 2.2%). After 22-h IVM, meiosis block was fully reversed and there was no difference (P ≥ 0.05) in MII rates between treatments (84.8%, averaged). Blastocyst rates (38.2%, averaged) were unaffected by treatment (P ≥ 0.05). Abundance of several transcripts was modulated by PM culture (blocked_GV v. control_GV), including up-regulation of genes that control the expansion of CC/COC competence markers (GREM1 and VCAN), cell proliferation/survival control (IGF1R and EGFR) and maintenance of cellular structural integrity/prediction of embryo quality (KRT8 and GATM), and down-regulation of genes associated with failures in pregnancy establishment/glucose metabolism (AKR1B1), endoplasmic reticulum stress (ATF4), meiotic arrest (ADCY3 and NOS2) and cell survival(HSPA1A). After IVM (blocked_MII v. control_MII), it was found an up-regulation in the relative abundance of PTX3 and PTGS2 (expansion of CC), RGS2 (regulator of G-protein signalling), LUM (embryo quality) and FOXO3 (apoptosis and oxidative stress resistance), whereas relative abundance of PFKP (glucose metabolism) was down-regulated. Our results indicate that blockade of meiosis with the EGFR kinase inhibitor before IVM is reversible and does not affect subsequent embryonic development. The gene expression profile of CC indicates a possible improvement in the quality of COC; however, more studies will be necessary to evaluate whether these improvements will be maintained until the embryonic stage. Financial support provided by FAPESP (#2015/06733-5 and #2012/50533-2) and CNPq (#307416/2015-1).

Adult Celiac Disease: The Importance of Extraintestinal Manifestations

Celiac disease (CD) is a chronic immune-mediated enteropathy driven by gluten and affecting individuals of all ages. The diagnosis of CD in adulthood is emerging and patients often present with nonclassical extraintestinal manifestations. We report the case of a 53-year-old man presenting with neuromuscular symptoms, skin rash, inconspicuous chronic diarrhea, marked weight loss, and biochemical markers of malabsorption. A strong clinical suspicion led to the diagnosis of CD with clinical recovery after the initiation of a gluten-free diet. Clinical presentation with atypical symptoms in adult CD patients is the rule and not the exception. Most of the extraintestinal manifestations depend on background autoimmune phenomena and micronutrient malabsorption. A gluten-free diet re-establishes homeostasis and prevents long-term complications.