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El síndrome de lisis tumoral (SLT) es una complicación catastrófica del tratamiento de ciertas enfermedades neoplásicas. Si bien es más frecuente en pacientes con neoplasias hematológicas malignas tras el inicio de la quimioterapia, puede presentarse excepcionalmente, tras la necrosis espontánea de algunos tumores, en ausencia de tratamiento citostático. Clínicamente cursa con hiperuricemia, hiperfosfatemia, hipocalcemia, hiperpotasemia y fallo renal agudo. Presentamos el caso de un paciente con enfermedad de Crohn en tratamiento inmunospresor, que desarrolló un síndrome de lisis tumoral espontáneo como debut de un plasmocitoma. Al ingreso, se objetivó un fracaso renal oligoanúrico que, a pesar de tratamiento precoz con hiperhidratación, alcalinización de la orina, urato-oxidasa y hemodiálisis, tuvo un desenlace fatal en 72 horas. Este caso reviste un interés particular por lo excepcional de la naturaleza "espontánea" del síndrome de lisis tumoral en ausencia de quimioterapia, por presentarse con una hiperuricemia extrema, probablemente la más alta de las recogidas en la literatura, y por la controversia actual de la terapia con inmunosupresores y/o biológicos en la enfermedad inflamatoria intestinal y su relación con el desarrollo de determinados tumores.Acute tumour lysis syndrome (TLS) is a catastrophic complication of the treatment of certain neoplastic disorders. It most commonly occurs in association with hematologic malignancies and appears a few hours to a few days after initiation of specific chemotherapy, as the result from the release of intracellular components into the bloodstream due to abrupt malignant cell death. Acute spontaneous TLS is rare, and it has been described in leukemia and lymphoma and in some patients with solid tumors prior to institution of therapy. The syndrome is characterized by hyperuricemia, hyperphosphatemia, hypocalcemia, hyperkalemia, and acute oliguric or anuric renal failure due to uric acid precipitation within the tubules (acute uric acid nephropathy) and to calcium phosphate deposition in the renal parenchyma and vessels. We report a case of acute spontaneous TLS in a patient with Crohn's disease treated with immunosuppressive drugs, who developed a plasmocytoma, in which serum uric acid concentration attained exceptionally high levels (44 mg/dL). The patient underwent acute oliguric renal failure, which required treatment with hyperhydration, urine alkalinization, urate oxidase and hemodialysis, with a fatal evolution. In conclusion, the present case report has several peculiarities: that of being one of the rare examples of spontaneous TLS, that of showing an exceptionally severe hyperuricemia, probably the highest ever reported in the literature, and that of the possible increased risk of tumours in patients with Crohn's disease taking inmunosuppressives and/or TNF antagonists.

Alterations in blood clotting are a frequent complication of serious heatstroke and may result in gastrointestinal bleeding. We report the case of a 26-year-old man who was admitted to our hospital with symptoms of hyperthermia associated with encephalopathy and disseminated intravascular coagulation (DIC) after prolonged exposure to sunlight. He presented hematemesis, after which he was diagnosed with having a bruising of the esophagus that took up the upper and lower thirds, there being no other lesions in the stomach or duodenum. After supportive treatment and following the resolution of the underlying pathology, the endoscopy-revealed injuries healed with a complete normalization of the esophageal mucosa. Esophageal submucosal bruising is an exceptional cause of hematemesis in serious heatstroke not previously described in the literature.Las alteraciones de la coagulación son una complicación frecuente en el golpe de calor grave, y pueden ser causa de hemorragia digestiva. Presentamos el caso de un varón de 26 años que fue admitido en nuestro hospital por un cuadro de hipertermia, asociado con encefalopatía y coagulación intravascular diseminada tras exposición solar prolongada. Presentó hematemesis por la que fue diagnosticado de múltiples hematomas esofágicos que ocupaban los tercios superior e inferior del órgano, en ausencia de otras lesiones en estómago y duodeno. Tras el tratamiento de soporte y la resolución de la patología subyacente, desaparecieron las lesiones endoscópicas, normalizándose la mucosa esofágica.

Objective: cavernous hemangioma of the rectosigmoid colon is a rare disease, with no more than 200 cases reported in the literature. The rectosigmoid is the most common site of this disease in the gastrointestinal tract. Case report: we report the case of a 31-year-old male with recurrent episodes of rectal bleeding, who was finally diagnosed of diffuse cavernous hemangioma of the rectum. The tumor, of 12 x 10 x 9 cm in size, occupied the rectum to the margin of the anal sphincter. A surgical procedure was ruled out because of the inability to carry out a safe anastomosis while preserving anal sphincters. Discussion: rectal hemangiomas are less frequent vascular malformations. The clinical presentation of a cavernous hemangioma of the rectum is usually acute, recurrent or chronic rectal bleeding. Other symptoms stem from the possible compression or invasion of adjacent structures, such as lumbar or perianal pain, metrorrhage, hematuria, etc. This diagnosis is commonly made in younger patients. Colonoscopy is without doubt the diagnostic technique of choice, and it allows to establish the localization, morphology, and total extension of the lesion; its characteristic image is a red-purplish nodule with great vascular congestion. According to the opinion of most authors, biopsy is not advisable during colonoscopy, since imaging techniques are sufficient for an accurate diagnosis, and the risk of bleeding while manipulating this lesion is not negligible. Computed tomography and particularly magnetic resonance imaging, given their high precision to delimit the lesion and its relations to adjacent structures, are imaging studies that are mandatory before surgical treatment. Other techniques such as selective angiography, barium enema, gastrointestinal transit, and upper-tract endoscopy may be supplementary and help locate more lesions along the gastrointestinal tract. Failure to recognize the exact diagnosis and extent of diffuse cavernous hemangioma may lead to failed surgical treatment and severe complications. Complete surgical excision of the lesion with a sphincter-saving procedure is the primary mode of treatment: conservative proctectomy with coloanal anastomosis.Objetivo: el hemangioma cavernoso rectal constituye una rara patología, de la cual no se han descrito más de 200 casos en la literatura. El recto y colon sigmoide son la localización más frecuente de esta enfermedad en el tracto gastrointestinal. Caso clínico: a continuación presentamos el caso de un varón de 31 años de edad con episodios recurrentes de sangrado digestivo en forma de rectorragias, el cual finalmente fue dignosticado de hemangioma cavernoso difuso rectal. El tumor, de 12 x 10 x 9 cm de tamaño, ocupaba el recto y se extendía hasta el margen del esfínter anal. El tratamiento quirúrgico fue rechazado ante la imposibilidad de llevar a cabo una resección y una anastomosis segura preservando los esfínteres anales. Discusión: los hemangiomas rectales son malformaciones vasculares infrecuentes que se manifiestan en forma de sangrado rectal agudo, crónico o recurrente como primera sintomatología. Otros síntomas vienen derivados de la compresión de estructuras adyacentes como dolor lumbar o perianal, metrorragias, hematuria, etc. El diagnóstico se realiza casi siempre en adultos jóvenes. La colonoscopia es sin duda la prueba diagnóstica de elección, mostrando la extensión, morfología, características del tumor y la típica imagen es la de una formación nodular, rojo-violácea, con gran congestión vascular. De acuerdo con la opinión de la mayoría de los autores, la toma de biopsias durante la endoscopia no está indicada, dado que las técnicas de imagen son suficientes para el diagnóstico y que el riesgo de sangrado durante la manipulación del tumor no es en absoluto despreciable. La TAC y especiamente la RMN permiten definir mejor la lesión y su relación con estructuras adyacentes, siendo primordiales de cara a un tratamiento quirúrgico. El estudio baritado, la arteriografía selectiva mesentérica o la gastroscopia pueden complementar y descartar además patología similar en otras localizaciones del tracto gastrointestinal. El diagnóstico erróneo de hemangioma cavernoso rectal o de su extensión completa puede derivar en un fallo en el tratamiento quirúrgico y graves complicaciones. La completa resección del tumor preservando los esfínteres anales constituye la técnica quirúrgica de elección: proctectomía conservadora con anastomosis coloanal.

Introduction: controversial data have been reported on the potential association between celiac disease (CeD) and inflammatory bowel disease (IBD)., Objective: to study the prevalence of CeD in patients newly diagnosed cases with IBD., Methods: an observational, retrospective study was performed in patients with newly diagnosed IBD who were screened for CeD by anti-tissue transglutaminase antibodies (anti-tTG) measurements and an endoscopic duodenal biopsy. No patients had received corticosteroids, immunosuppressants or biologic drugs within the three months prior to gastroscopy. In the presence of Marsh 1, other causes were ruled out. CeD was diagnosed in patients positive for anti-tTG, compatible duodenal biopsy findings and a good response to a gluten-free diet., Results: a total of 163 patients were screened for CeD. Of these, six (3.7%) were positive for anti-tTG and four were diagnosed with CeD (three had ulcerative colitis, one had Crohn's disease). All patients with both CeD and IBD had normal IgA levels, positive anti-tTG and CeD genetic markers., Conclusions: the prevalence of CeD in our patients with IBD was higher than that reported in the literature for other series of patients with IBD. A combination of anti-tTG testing and CeD genetics may screen patients for CeD in this population of patients with IBD.

Introduction: Infliximab (IFX) therapy intensification in ulcerative colitis (UC) is more common than established in pivotal studies., Objectives: To establish the frequency and form of intensification for UC in clinical practice, as well as predictors, and to compare outcomes between intensified and non-intensified treatment., Methods: A retrospective study of 10 hospitals and 144 patients with response to infliximab (IFX) induction. Predictive variables for intensification were analyzed using a Cox regression analysis. Outcome, loss of response to IFX, and colectomy were compared between intensified and non-intensified therapy., Results: Follow-up time from induction to data collection: 38 months [interquartile range (IQR), 20-62]. Time on IFX therapy: 24 months (IQR, 10-44). In all, 37% of patients required intensification. Interval was shortened for 36 patients, dose was increased for 7, and 10 subjects received both. Concurrent thiopurine immunosuppressants (IMM) and IFX initiation was an independent predictor of intensification [Hazard ratio, 0.034; p, 0.006; CI, 0.003-0.371]. In patients on intensified therapy IFX discontinuation for loss of response (30.4% vs. 10.2%; p, 0.002), steroid reintroduction (35% vs. 18%; p, 0.018), and colectomy (22% vs. 6.4%; p, 0.011) were more common. Of patients on intensification, 17% returned to receiving 5 mg/kg every 8 weeks., Conclusions: Intensification is common and occasionally reversible. IMM initiation at the time of induction with IFX predictsnon-intensification. Intensification, while effective, is associated with poorer outcome.

Acute tumour lysis syndrome (TLS) is a catastrophic complication of the treatment of certain neoplastic disorders. It most commonly occurs in association with hematologic malignancies and appears a few hours to a few days after initiation of specific chemotherapy, as the result from the release of intracellular components into the bloodstream due to abrupt malignant cell death. Acute spontaneous TLS is rare, and it has been described in leukemia and lymphoma and in some patients with solid tumors prior to institution of therapy. The syndrome is characterized by hyperuricemia, hyperphosphatemia, hypocalcemia, hyperkalemia, and acute oliguric or anuric renal failure due to uric acid precipitation within the tubules (acute uric acid nephropathy) and to calcium phosphate deposition in the renal parenchyma and vessels.We report a case of acute spontaneous TLS in a patient with Crohn s disease treated with immunosuppressive drugs, who developed a plasmocytoma, in which serum uric acid concentration attained exceptionally high levels (44 mg/dL). The patient underwent acute oliguric renal failure, which required treatment with hyperhydration, urine alkalinization, urate oxidase and hemodialysis, with a fatal evolution.In conclusion, the present case report has several peculiarities: that of being one of the rare examples of spontaneous TLS, that of showing an exceptionally severe hyperuricemia, probably the highest ever reported in the literature, and that of the possible increased risk of tumours in patients with Crohn s disease taking inmunosuppressives and/or TNF antagonists.

Alterations in blood clotting are a frequent complication of serious heatstroke and may result in gastrointestinal bleeding. We report the case of a 26-year-old man who was admitted to our hospital with symptoms of hyperthermia associated with encephalopathy and disseminated intravascular coagulation (DIC) after prolonged exposure to sunlight. He presented hematemesis, after which he was diagnosed with having a bruising of the esophagus that took up the upper and lower thirds, there being no other lesions in the stomach or duodenum. After supportive treatment and following the resolution of the underlying pathology, the endoscopy-revealed injuries healed with a complete normalization of the esophageal mucosa. Esophageal submucosal bruising is an exceptional cause of hematemesis in serious heatstroke not previously described in the literature.

Objective: cavernous hemangioma of the rectosigmoid colon is a rare disease, with no more than 200 cases reported in the literature. The rectosigmoid is the most common site of this disease in the gastrointestinal tract., Case Report: we report the case of a 31-year-old male with recurrent episodes of rectal bleeding, who was finally diagnosed of diffuse cavernous hemangioma of the rectum. The tumor, of 12 x 10 x 9 cm in size, occupied the rectum to the margin of the anal sphincter. A surgical procedure was ruled out because of the inability to carry out a safe anastomosis while preserving anal sphincters., Discussion: rectal hemangiomas are less frequent vascular malformations. The clinical presentation of a cavernous hemangioma of the rectum is usually acute, recurrent or chronic rectal bleeding. Other symptoms stem from the possible compression or invasion of adjacent structures, such as lumbar or perianal pain, metrorrhage, hematuria, etc. This diagnosis is commonly made in younger patients. Colonoscopy is without doubt the diagnostic technique of choice, and it allows to establish the localization, morphology, and total extension of the lesion; its characteristic image is a red-purplish nodule with great vascular congestion. According to the opinion of most authors, biopsy is not advisable during colonoscopy, since imaging techniques are sufficient for an accurate diagnosis, and the risk of bleeding while manipulating this lesion is not negligible. Computed tomography and particularly magnetic resonance imaging, given their high precision to delimit the lesion and its relations to adjacent structures, are imaging studies that are mandatory before surgical treatment. Other techniques such as selective angiography, barium enema, gastrointestinal transit, and upper-tract endoscopy may be supplementary and help locate more lesions along the gastrointestinal tract. Failure to recognize the exact diagnosis and extent of diffuse cavernous hemangioma may lead to failed surgical treatment and severe complications. Complete surgical excision of the lesion with a sphincter-saving procedure is the primary mode of treatment: conservative proctectomy with coloanal anastomosis.