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Background Multidrug-resistant organisms (MDROs) are a reality that can alter the paradigm of treatment and prevention of infection in patients with liver cirrhosis (LC). Objective Identify risk factors for the occurrence of MDROs in patients with LC. Patients and methods Prospective study from October 2017 to March 2018 in consecutively hospitalized patients with decompensated LC with infection. Blood, urine and ascitic fluid cultures were analyzed. A p-value ≤0.05 was considered statistically significant. Results MDROs isolated in 18 of 52 episodes of infection. MDROs were associated with the use of proton pump inhibitors (PPIs) (p = 0.0312), antibiotic therapy in the last 90 days (p = 0.0033) and discharge within preceding 30 days or current hospitalization above 48 h (p = 0.0082). There was higher 90-day mortality in patients with MDROs infection (71.4% versus 35.7%, p = 0.0316). Conclusion MDROs infections were prevalent in this cohort and associated with 90-day mortality. Use of PPIs and antibiotics increased the risk of MDROs infections, suggesting that its prescription should be restricted to formal indication. Hospitalization was associated with the onset of MDROs, so LC patients should stay at the hospital the least possible. It is relevant to investigate other factors predisposing to the emergence of these microorganisms, in order to prevent it.

Aims We evaluated the initial impact of COVID-19 outbreak on endoscopic procedures from a Gastroenterology departmentin a Portuguese hospital. Methods All esophagogastroduodenoscopies (EGD), colonoscopies, endoscopic retrograde cholangio-pancreatographies(ERCP) and endoscopic ultrasounds (EUS) performed between April and June 2020 were compared with all theseprocedures performed between April and June 2019. In EGD and colonoscopies, whether they were elective or urgent wasregistered. The reasons of procedures leading to new cancer diagnosis and the presence of advanced polyps incolonoscopies were recorded. Results Between April and June 2020, 513 EGD and colonoscopies were performed, 42 % of those performed during thesame trimester in 2019. Although this difference occurred mainly due to a reduction to 34.5 % in the number of electiveprocedures, urgent EGD and colonoscopies were also reduced to 73.2 %. The detection rate of advanced adenomas wassimilar in 2019 and 2020 (16.8 % in 2019 and 17.8 % in 2020), meaning that only one third were detected in 2020. In2020, 87.2 % of ERCP and 46.3 % of EUS from 2019 were done. 4 EGD in COVID-19 positive patients were performed inthis trimester. In 2020, only 46 % of new cancer diagnosis were made, when compared to the same period of 2019. This reduction wassignificant in colorectal and esophageal cancers, but not in gastric cancer. The proportions of new oncological diagnosisduring urgent procedures in 2019 and 2020 were 20.5 % and 38.9 % respectively. Conclusions Although repercussions from this pandemic on digestive Oncology are already evident, its real impact is farfrom being known. The delay of colorectal cancer diagnosis, the second most common cause of cancer death in Europe, willlead to a significant increase in overall morbimortality. National and international programs to recover this fall in endoscopicprocedures will be of the most importance to reduce this outcome of COVID-19.

Dear Editor, It was with great interest that we read the article of Luis Alcala-Gonzales et al (1). This work reinforces the scientific evidence regarding safety and effectiveness of self-expandable metal stent placement for the palliation of malignant gastric outlet obstruction (GOO). Our special interest about this topic makes us want to share the experience of our center and to strengthen some of the key points. Between January 2012 and December 2019, we placed 43 stents in patients with GOO. Interestingly, in contrast to the literature and this recently published paper, we had predominance of gastric stenosing neoplasms in relation to pancreatic neoplasms (60.4% vs 25.6%) (2), still achieving a technical (100%) and clinical (95.3%) success. The stent allows rapid clinical improvement, with shorter hospitalization compared to gastrojejunostomy, two important factors in the field of palliation. However, as we have also noted, there is a non-negligible need of reintervention (25.6% of our patients needed a second stent), either due to tumor growth, food impaction or stent migration. This fact becomes an important limitation in patients with reasonable performance status and expected survival, in which gastrojejunostomy should be considered primarily, with the use of gastroduodenal stents being more suited to individuals with shorter life expectancy (2,3). Thirty-day mortality of 46.5% and mean post-procedure survival of 81 ± 13 days are expected results for a technique with palliative purpose in a terminally ill patient. Thus, we consider that gastroduodenal stents constitute an effective and safe alternative to surgery, which is usually associated with greater morbility.

Von Willebrand disease (vWD) is the most prevalent hereditary bleeding disorder, affecting 0.6-1.3% of the population. While gastrointestinal bleeding from angiodysplasia is a well-known complication of vWD, the same is not true for Dieulafoy’s lesions (DLs). We report the case of a 21-year-old black male with type 1 vWD and 2 previous hospital admissions for severe anemia with no visible blood loss. In both episodes, DLs were identified and treated endoscopically, one in the stomach and another in the duodenum. The patient presented to the emergency department in September 2016 with dizziness, fatigue, and again no visible blood loss. He was hemodynamically stable, and laboratory workup showed a hemoglobin level of 3.4 g/dL. After transfusion of packed red blood cells, intravenous iron, and von Willebrand factor/factor VIII concentrate infusions, the patient underwent upper endoscopy and colonoscopy, which were normal. Small-bowel capsule endoscopy showed dark blood and a fresh clot in the proximal jejunum. At this site, push enteroscopy identified a pulsatile vessel with an overlying minimal mucosal defect, consistent with a DL, type 2b of the Yano-Yamamoto classification, which was successfully treated with adrenaline and 2 hemoclips. The patient remains stable after 18 months of follow-up, with a hemoglobin level of 13.2 g/dL. This is a case of recurrent severe occult gastrointestinal bleeding from multiple DL in a young patient with vWD who is otherwise healthy. Three other cases of DL bleeding in the setting of vWD have been reported in the literature, suggesting a possible association between these 2 entities. A doença de von Willebrand é a perturbação hemorrágica hereditária mais frequente, afetando 0.6 a 1.3% da população. A hemorragia por angiectasias do tubo digestivo é uma complicação bem estabelecida desta doença. Contudo, o mesmo não é verdade para as lesões de Dieulafoy. Apresentamos o caso de um doente de 21 anos, melanodérmico, com doença de von Willebrand tipo 1 e dois internamentos prévios por anemia grave sem perdas hemáticas visíveis. Em ambos os episódios foram identificadas lesões de Dieulafoy que foram tratadas endoscopicamente, uma das quais no estômago e outra no duodeno. O doente foi admitido no serviço de urgência em Setembro de 2016 por quadro de tonturas e cansaço, novamente sem perdas visíveis. Apresentava-se hemodinamicamente estável e a avaliação laboratorial mostrou hemoglobina de 3.4 g/dL. Após transfusão de concentrados eritrocitários, terapêutica com ferro endovenoso e concentrados de fator de von Willebrand/fator VIII, foram realizadas endoscopia digestiva alta e colonoscopia, sem alterações. A enteroscopia por cápsula detetou a presença de sangue digerido e um coágulo fresco no jejuno proximal. A enteroscopia de pulsão identificou nessa topografia uma solução de continuidade da mucosa milimétrica sobre lesão vascular pulsátil procidente, compatível com lesão de Dieulafoy tipo 2b da Classificação de Yano-Yamamoto, que foi tratada eficazmente com adrenalina e dois hemoclips. Após 18 meses, o doente mantém-se clinicamente estável e com Hb 13.2 g/dL. Este é um caso particular de hemorragia gastrointestinal oculta recorrente por múltiplas lesões de Dieulafoy num jovem com doença de von Willebrand, sem outras patologias. Há três casos semelhantes descritos na literatura, sugerindo uma possível associação entre estas duas entidades.

Submitted by arminda sustelo (arminda.sustelo@hff.min-saude.pt) on 2018-11-21T16:48:32Z No. of bitstreams: 1 J Gastrointestin Liver Dis. 2018.pdf: 168396 bytes, checksum: e1509c4eec9ae0d5dcf78840bd7728a6 (MD5) Made available in DSpace on 2018-11-21T16:48:32Z (GMT). No. of bitstreams: 1 J Gastrointestin Liver Dis. 2018.pdf: 168396 bytes, checksum: e1509c4eec9ae0d5dcf78840bd7728a6 (MD5) Previous issue date: 2018 info:eu-repo/semantics/publishedVersion

Submitted by arminda sustelo (arminda.sustelo@hff.min-saude.pt) on 2019-01-29T16:49:12Z No. of bitstreams: 1 Intern Emerg Med. 2018.pdf: 812672 bytes, checksum: 5f4ec3b9c26b1f3f06539c55ca33f888 (MD5) Made available in DSpace on 2019-01-29T16:49:12Z (GMT). No. of bitstreams: 1 Intern Emerg Med. 2018.pdf: 812672 bytes, checksum: 5f4ec3b9c26b1f3f06539c55ca33f888 (MD5) Previous issue date: 2018 info:eu-repo/semantics/publishedVersion

The low-phospholipid-associated cholelithiasis (LPAC) syndrome is a form of symptomatic cholelithiasis occurring in young adults, characterized by recurrence of symptoms after cholecystectomy and presence of hepatolithiasis. The case refers to a healthy 39-year-old Caucasian male who presented with abdominal pain and jaundice. His blood tests showed conjugated hyperbilirubinemia and elevated liver enzymes (total bilirubin 6.65 mg/dL, γ-glutamyltransferase 699 IU/L) and abdominal computed tomography revealed dilation of common bile duct and left intrahepatic ducts. Magnetic resonance cholangiopancreatography identified choledocholithiasis, retrieved by endoscopic retrograde cholangiopancreatography, after which there was a worsening of jaundice (total bilirubin 23 mg/dL), which persisted for several weeks, possibly due to ciprofloxacin toxicity. After an extensive workup including liver biopsy, the identification of two foci of hepatolithiasis on reevaluation abdominal ultrasound raised the hypothesis of LPAC syndrome and the patient was started on ursodeoxycholic acid, with remarkable improvement. Genetic testing identified the mutation c.1954A>G (p.Arg652Gly) in ABCB4 gene (homozygous) and c.1331T>C (p.Val444Ala) in ABCB11 gene (heterozygous). In conclusion, we describe the unique case of an adult male with choledocholithiasis, hepatolithiasis, and persistent conjugated hyperbilirubinemia after retrieval of stones, fulfilling the criteria for LPAC syndrome and with possible superimposed drug-induced liver injury, in whom ABCB4 and ABCB11 mutations were found, both of which had not been previously described in association with LPAC. A síndrome low-phospholipid-associated cholelithiasis (LPAC) é uma forma de coledocolitíase sintomática que ocorre em adultos jovens e que se caracteriza pela recorrência de sintomas após a colecistectomia e pela presença de hepatolitíase. O caso refere-se a um homem caucasiano de 39 anos, saudável, que se apresentou com um quadro de dor abdominal e icterícia. A avaliação laboratorial mostrou hiperbilirrubinémia conjugada e um padrão citocolestático (bilirrubina total 6,65 mg/dL; GGT 699 UI/L) e a tomografia computorizada abdominal revelou dilatação da via biliar principal e vias biliares intra-hepáticas à esquerda. A colangiopancreatografia por ressonância magnética identificou coledocolitíase, extraída por colangiopancreatografia retrógrada endoscópica, tendo-se verificado posterior agravamento da icterícia (bilirrubina total 23 mg/dL) que persistiu por várias semanas, possivelmente por hepatotoxicidade associada à toma de ciprofloxacina. Após uma extensa investigação, incluindo a realização de biópsia hepática, foram identificados dois focos de hepatolitíase em ecografia abdominal de reavaliação, pelo que se colocou a hipótese de LPAC e o doente iniciou terapêutica com ácido ursodesoxicólico, com excelente resposta. O estudo genético identificou a mutação c.1954A>G (p.Arg652Gli) no gene ABCB4 em homozigotia e a mutação c.1331T>C (p.Val444Ala) no gene ABCB11 em heterozigotia. Em suma, descrevemos o caso único de um homem com coledocolitíase, hepatolitíase e hiperbilirribinémia conjugada persistente mesmo após extracção de cálculos, cumprindo critérios de LPAC e possivelmente com sobreposição de lesão hepática induzida por fármacos, tendo-se documentado mutações nos genes ABCB4 e ABCB11, cuja associação com LPAC não havia sido previamente descrita.

Introduction: Walled-off necrosis (WON) is a potentially lethal late complication of acute pancreatitis (AP) and occurs in less than 10% of AP cases. It can be located in or outside the pancreas. When infected, the mortality rate increases and can reach 100% if the collection is not drained. Its treatment is complex and includes, at the beginning, intravenous antibiotics, which permit sepsis control and a delay in the therapeutic intervention, like drainage. Nowadays, a minimally invasive approach is advised. Dependin on the location of the collection, computed tomography (CT)-guided drainage or endoscopic necrosectomy are the primary options, then complemented by surgical necrosectomy if needed. Infected WON of the abdominal wall has been rarely described in the literature and there is no report of any infection with Citrobacter freundii. Case: We present the case of a 61-year-old man with necrotizing AP complicated by WON of the left abdominal wall, infected with Citrobacter freundii that was successfully treated with CT-guided percutaneous drainage and intravenous antibiotics. Conclusion: Infected WON accounts for considerable mortality and its location in the abdominal wall is rare; it can be treated with antibiotics and CT-guided drainage with no need for further intervention. Introdução: A necrose pancreática coletada (NPC) é uma complicação potencialmente fatal da pancreatite aguda (PA) e ocorre em menos de 10% dos casos. Pode estar localizada dentro ou fora do pâncreas. Quando infetada, a mortalidade aumenta, podendo atingir os 100% se a coleção não for drenada. O seu tratamento é complexo e inclui, de início, antibioterapia intravenosa que permite o controlo da sepsis e um atraso na terapêutica de intervenção, como a drenagem. Atualmente é aconselhada uma abordagem minimamente invasiva. Dependendo da localização da coleção, a drenagem guiada por tomografia computorizada (TC) ou a necrosectomia endoscópica são as opções de primeira linha, posteriormente complementadas por necrosectomia cirúrgica, caso seja necessário. A NPC infetada na parede abdominal foi raramente descrita na literatura e não existe até ao momento nenhum caso de uma NPC infetada por Citrobacter freundii. Caso: Apresentamos o caso de um doente do sexo masculino de 61 anos com uma PA necrotizante complicada por NPC da parede abdominal esquerda, infetada por Citrobacter freundii, que foi tratada com sucesso através de drenagem percutânea guiada por TC e antibioterapia intravenosa. Conclusão: A NPC infetada condiciona mortalidade considerável e a sua localização na parede abdominal é rara; pode ser tratada através de antibioterapia e drenagem percutânea guiada por TC, sem necessidade de intervenção posterior.

Submitted by arminda sustelo (arminda.m.sustelo@hff.min-saude.pt) on 2020-06-22T15:51:18Z No. of bitstreams: 1 Clin Res Hepatol Gastroenterol.pdf: 516436 bytes, checksum: ac1051e7de87ed75dcd05a1c10bc94b4 (MD5) Made available in DSpace on 2020-06-22T15:51:18Z (GMT). No. of bitstreams: 1 Clin Res Hepatol Gastroenterol.pdf: 516436 bytes, checksum: ac1051e7de87ed75dcd05a1c10bc94b4 (MD5) Previous issue date: 2018 info:eu-repo/semantics/publishedVersion

Submitted by arminda sustelo (arminda.sustelo@hff.min-saude.pt) on 2018-10-22T16:39:20Z No. of bitstreams: 1 Turk J Gastroenterol. 2017 Nov.pdf: 72686 bytes, checksum: 72ae414e65f8ddec976e5928c5538e4e (MD5) Made available in DSpace on 2018-10-22T16:39:21Z (GMT). No. of bitstreams: 1 Turk J Gastroenterol. 2017 Nov.pdf: 72686 bytes, checksum: 72ae414e65f8ddec976e5928c5538e4e (MD5) Previous issue date: 2017 info:eu-repo/semantics/publishedVersion

Submitted by arminda sustelo (arminda.sustelo@hff.min-saude.pt) on 2017-03-06T14:58:24Z No. of bitstreams: 1 Rev Esp Enferm Dig. 2017 Feb 23;109.pdf: 690361 bytes, checksum: c939d8524a8b3b1a37cd9ece288ad275 (MD5) Made available in DSpace on 2017-03-06T14:58:24Z (GMT). No. of bitstreams: 1 Rev Esp Enferm Dig. 2017 Feb 23;109.pdf: 690361 bytes, checksum: c939d8524a8b3b1a37cd9ece288ad275 (MD5) Previous issue date: 2017 info:eu-repo/semantics/publishedVersion

Spontaneous bacterial peritonitis (SBP) is a prevalent and high mortality complication of cirrhosis. We aimed to describe these patients' clinical and microbiological characteristics and evaluate their impact on outcomes.This was a retrospective cohort study including 139 consecutive patients with positive culture SBP from three Portuguese centers diagnosed between 2009 and 2014. Multivariate logistic regression was used to study associations with 30-day mortality.The mean age of the patients was 62 years and 81% of patients were men. The mean model for end-stage liver disease score was 19. Hepatic encephalopathy, hepatorenal syndrome, and variceal bleeding developed in 47, 30, and 21% of patients, respectively. Gram-positive bacteria were isolated in the ascitic fluid of 42% of patients. Resistance to quinolones and multiresistance were found in 33 and 17% of patients, respectively. C-reactive protein level (adjusted odds ratio, 1.16 per 1 mg/l increment) and development of hepatorenal syndrome (adjusted odds ratio, 2.86) were associated independently with 30-day mortality (model's area under the curve, 0.78).In this cohort, SBP portended high early mortality. Gram-positive bacteria, bacteria resistant to quinolones, and multiresistant bacteria were identified in considerable proportions of patients. In the setting of the high early mortality and changing microbiological profile, SBP management strategies need to be improved.

Submitted by arminda sustelo (arminda.sustelo@hff.min-saude.pt) on 2019-05-06T15:17:11Z No. of bitstreams: 1 Gastroenterol Hepatol. 2017.pdf: 465861 bytes, checksum: 84b7f72988949ec90c478f3009e87e51 (MD5) Made available in DSpace on 2019-05-06T15:17:12Z (GMT). No. of bitstreams: 1 Gastroenterol Hepatol. 2017.pdf: 465861 bytes, checksum: 84b7f72988949ec90c478f3009e87e51 (MD5) Previous issue date: 2017 info:eu-repo/semantics/publishedVersion

info:eu-repo/semantics/publishedVersion

Background Objectives As all other crystal-related arthropathies, uric gout (UG) is a disease that is relatively disabling in its acute phase. There is a lack of published works on the characterisation and prevalence in the portuguese population. The authors’ have initiated a study on the sociodemographic and clinical characterisation of the patients with UG of their outpatients rheumatology clinic. Methods It is a retrospective study, whose data collection took place between May and October 2000, and was later restarted in December 2000. The sample included all patients which presented a UG diagnosis. A 48 variable questionnaire and the patient’s clinic register were used for the gathering of data. The questionnaire comprised the patient’s identification, professional occupation, clinical profile, changes in the laboratorial and radiological exams, associated diseases, habits, family history. The data analysis was performed using the SPSS 9.0 for Windows software. Results Of an outpatient’s clinic universe of 3000 patients, a total of 39 (1.9%) patients with UG diagnosis was selected. Only 32 of these, were included in the study, representing the sample. It is characterised by an average age of 59.4 and 87.5% males. The average age at which the first UG crisis happens is 45. The average duration of crisis without therapeutics is 13.7 days, and with therapeutic is 5.4 days. The average asymptomatic period is variable, with a minimum of 15 days and a maximum of 100 days. In 51.6% of the patients the first affected joint is the 1st MTP, followed by the instep, knee and ankle. Globally, the most affected joints are, in decreasing order, 1st MTP and foot, knee, ankle, hand and fingers, elbow, wrist and shoulder. About 33% of the sample patients show gouty tophi. The precipitating factors can only be identified by 78% of the patients, and they are, in decreasing order, alcohol + meals, meals, other disease or trauma, alcohol, and cold. The average of the serum uric acid measured at the first appointment is 9.7 mg/dl. The urine uric acid was measured in 50% of the patients, presenting an average value of 670 mg/24 h. The average serum creatinine is 1.7 mg/dl, in which 5 patients had renal impairment. Only 28.1% of the sample was researched for crystals in sinovial fluid, being positive in 11.1% of these. X-rays were performed on 53.1% of the patients, and among these 88.2% present radiological abnormalities. In what concerns associated diseases, 60% were obese, having also been considered the following diseases: diabetes, hypertension and hyperlipidemia. Additionally, 35.5% of the patients have moderate to heavy alcoholic habits, 42.6% have family history of UG. Conclusion The results obtained in this study are in good agreement with the published literature concerning the european and north-american population. The sample considered is small due to the fact that this study was paused, and restarted latter, now tuned into the research of monosodium urate monohydrate crystals to confirm the clinical diagnosis.

Background The real impact of COVID-19 infection on patients with Inflammatory Bowel Disease (IBD) is unknown. It was speculated that this population could be a risk group. The aim of this study is to evaluate the incidence of SARS-CoV2 infection, the impact of initiation/change of IBD therapy and its morbidity and mortality, during the COVID-19 pandemic in Portugal. Methods Prospective cross-sectional study. Patients with IBD followed at a Gastroenterology Department in an area with a high incidence rate of SARS-CoV2 were included, from 01/03/2020 to 31/08/2020. Data was obtained through telephonic appointments, hospital inpatients admissions, Emergency Department Service and Day Hospital episodes. Results 335 patients were included, 194 female, with a mean age of 47.4 years (18–88). 200 had Crohn’s disease (CD), 132 Ulcerative Colitis, 3 unclassified colitis. 320 were on therapy (95.5%): salicylates n=230 (71.9%), systemic corticosteroids n=34 (10.6%) (18 started during the pandemic), thiopurines/methotrexate n=117 (36.6%) (8 started in this period), biological n=148 (46.3%) (14 started in this period). 7 patients (2.2%) triple immunosuppressed. 75 patients had disease in remission, 232 mild/moderate, 28 severe disease (requiring hospitalization). SARS-CoV2 infection was observed in 3 patients (incidence rate: 0.89%), treated as an outpatient basis. 2 male, mean age 58 years, 2 with CD. Comorbidities: 0: n = 1; 2: n = 1; 4: n = 1. 2 patients were on salicylates and one on adalimumab (monotherapy, before the pandemic). There were no deaths. Conclusion All patients started or maintained their IBD therapy according to current international guidelines. A significantly higher incidence of COVID-19 infection than that of the local and Portuguese population in general has not been documented. According to our preliminary results, the population with IBD does not appear to be a risk group for acquiring infection or having a severe course of the disease.