We report the case of a 71-year-old man with diagnosis of aortic valve stenosis for ten years, who came to hospital because of breathlessness during the previous two months and recent low intestinal hemorrhage. On admission, laboratory tests and upper gastrointestinal endoscopy and colonoscopy revealed anemia and bleeding cecal angiodysplasia. The echocardiography study showed a severe aortic stenosis. Classical Heyde syndrome is described as the association of aortic stenosis, bleeding gastrointestinal angiodysplasia and secondary anemia. The antecedent of mediastinal radiotherapy for treatment of Hodgkin´s disease during his youth, and eventual late cardiac adverse effects that may include aortic or mitral valve disturbances are highlighted. Electrocoagulation with argonium was performed on the sites of active bleeding during the colonoscopy. In sequence, surgical replacement by bioprothesis was done on the aortic valve. The patient remains asymptomatic, under long-term outpatient surveillance, with normal control evaluations. The aim of this case study is to emphasize difficulties related to diagnosis, and to highlight the role of endoscopy and imaging studies to confirm a hypothesis of this underestimated condition.

Se presenta el caso de un varón de 71 años con estenosis aórtica diagnosticada diez años antes, que acude al hospital por disnea durante dos meses y reciente hemorragia digestiva baja. La analítica y la endoscopia oral y colonoscopia realizadas en el momento de la admisión revelaron anemia y angiodisplasia cecal con sangrado activo. El ecocardiograma mostró estenosis aórtica severa. El síndrome de Heyde clásico está descrito como asociación entre estenosis aórtica y sangrado por angiodisplasia gastrointestinal, con anemia secundaria. Se destaca el antecedente de radioterapia mediastinal para tratamiento de enfermedad de Hodgkin durante su juventud, y eventuales efectos adversos tardíos que pueden incluir trastornos de las válvulas aórtica y mitral. Durante la colonoscopia se realizó la electrocoagulación con argón del punto de sangrado activo. Posteriormente se realizó cirugía de sustitución valvular aórtica utilizando una bioprótesis. El paciente permanece asintomático, realizando un seguimiento ambulatorio a largo plazo, y con exámenes de control normales. El objetivo de este estudio es enfatizar las dificultades relacionadas al diagnóstico, y resaltar el papel de los estudios endoscópicos y de imágenes para confirmar una hipótesis de esta entidad subestimada.

Gastric lipoma is considered a rare condition that may constitute a challenging diagnosis. A 51-year-old woman presented dysphagia and abdominal pain, and an upper digestive endoscopic study disclosed a gastric tumor located in the submucosa of the pyloric antrum. Conclusive diagnosis was established after repeated endoscopic biopsies, and the patient was subjected to an atypical gastrectomy, which evolved into a pyloric stenosis. This complication was appropriately corrected and the patient remains symptomless, under outpatient surveillance.

Lipoma gástrico es un hallazgo muy raro que suele constituir un desafío diagnóstico. Una mujer con 51 años presentó disfagia y dolor abdominal; en una endoscopia digestiva superior se encontró un tumor gástrico submucoso localizado en el antro pilórico. Se hicieron biopsias endoscópicas para establecer el diagnóstico. Esta paciente se sometió a una gastrectomía atípica, que ocasionó estenosis del píloro. Esta complicación fue adecuadamente tratada, y la paciente se mantiene sin síntomas con control ambulatorio.

We report the case of a man with a diagnosis of invasive gastric adenocarcinoma associated with scattered osteoblastic metastases. This 65-year-old patient was admitted with nausea, vomiting and abdominal pain, in addition to loss of weight (13 Kg in 3 months). Upper digestive endoscopy revealed extensive infiltrating changes in the body of the stomach, and histopathologic data confirmed the diagnosis of a Borrmann IV gastric adenocarcinoma. Complementary exams were indicative of a gastric cancer with bone metastases, characterized by disseminated osteoblastic images of the scintigraphy of the skeleton. Palliative chemotherapy was the treatment of first choice. High serum levels of CA 19-9, CEA and alkaline phosphatase can constitute useful indicative tools of this challenging condition. Images from a scintigraphy study of the skeleton can characterize the type and extension of bone metastases. The aim of this case study is to report a case of a very uncommon condition, considering that disseminated osteoblastic metastases rarely develop in this kind of tumor.

Presentamos un caso de adenocarcinoma gástrico infiltrante asociado con metástasis osteoblásticas diseminadas. Un paciente de 65 años ingresó con náuseas, vómitos y dolor abdominal asociados con pérdida de peso (13 Kg en 3 meses). La endoscopia digestiva objetivó extensas alteraciones infiltrativas del cuerpo gástrico y los datos histopatológicos confirmaron el diagnóstico de adenocarcinoma gástrico Borrmann IV. Exámenes complementarios fueran indicativos de cáncer gástrico con metástasis óseas, caracterizadas por imágenes osteoblásticas diseminadas de la cintilografía del esqueleto. Se le administró quimioterapia paliativa como primera opción. Se elevó CA 19-9, CEA y apareció fosfatasis alcalina en el suero un indicador útil del diagnóstico. La extensión y el tipo de metástasis óseas pueden ser imágenes de cintilografías del esqueleto. Este caso tiene como objetivo describir la presencia de metástasis osteoblásticas diseminadas que raramente son producidas por este tipo de tumor.

Corticosteroid-induced lipomatosis is not a rare condition, but lipoma in the central veins has scarcely been described. According to the databases consulted, this is the first report of a lipoma within the central veins coexistent with long-term use of corticosteroid. It involved a 47-year-old male under treatment for pulmonary sarcoidosis with prednisone. Computerized tomography of the thorax was performed and incidentally the images showed a mass within the central veins with the characteristics of lipoma. He was asymptomatic and refused surgical procedures. The intraluminal lipoma originated in the right brachiocephalic and subclavian veins. Control tomography showed a slow development of this lipoma, without obstructive effects or malignant features. Oral prednisone was changed for methotrexate. The patient is asymptomatic and under longstanding out-patient surveillance. Corticosteroid treatments for sarcoidosis can play a role in the development of intravascular lipoma, but this association is not well defined. Case reports could contribute to clarifying whether this relationship is causal or merely casual.

La lipomatosis inducida por glucocorticoides no es una entidad rara, pero hay pocos casos descritos de lipoma en las venas centrales. Según la bibliografía, éste es el primer trabajo de un paciente con un lipoma en las venas centrales coexistente con el uso de glucocorticoide a largo plazo. Se trata de un hombre de 47 años, en tratamiento de sarcoidosis pulmonar con prednisona. Se realizó tomografía computarizada de tórax e incidentalmente, las imágenes mostraron una masa en las venas centrales, con características de lipoma. El paciente estaba asintomático y se negó a la realización del procedimiento quirúrgico. Este lipoma intraluminal se originó en la vena braquiocefálica y subclavia derecha. El estudio tomográfico demostró un desarrollo lento del lipoma, sin efectos obstructivos ni características malignas. La prednisona oral se cambió por metotrexate. El paciente permanece asintomático, realizando un seguimiento ambulatorio. Los tratamientos con glucocorticoides para sarcoidosis pueden desempeñar un papel importante en el desarrollo de lipomas intravasculares, pero esta asociación no está bien definida. Se desconoce si la relación de esta asociación es causal o meramente casual.

We report the case of a 95-year-old woman who had acute esophageal lesions while being treated with oral ciprofloxacin for an acute cystitis. On day 2 of treatment, she reported retroesternal pain with a globus sensation, and presented hematemesis and melena. There was no history of gastric or esophageal disturbances. An upper digestive endoscopy showed bleeding lesions on the middle third of the esophagus. Ciprofloxacin was discontinued and a proton pump inhibitor was administered. One week later, the endoscopic aspect of the esophagus was normal. Only two cases of ciprofloxacin-induced esophageal lesions have been reported previously. A short review of this kind of esophageal injuries is presented, focusing on the main risk factors and preventive measures.

Presentamos el caso de una mujer de 95 años con lesiones agudas del esófago que tomaba ciprofloxacino por cistitis aguda. La paciente refería dolor y sensación de cuerpo estraño retroesternal asociados con hematemesis y melena, después del segundo día de tratamiento. No había antecedentes personales de trastornos gástricos o esofágicos. La endoscopia digestiva objetivó lesiones sangrantes en el tercio medio del esófago. El uso de ciprofloxacino fue suspendido y se utilizó un inhibidor de la bomba de protones. Una semana más tarde, el aspecto endoscópico del esófago fue considerado normal. Dos únicos casos de lesiones esofágicas inducidas por ciprofloxacino han sido previamente publicados. Se presenta una revisión breve acerca de este tipo de lesiones del esófago, con énfasis a los principales factores de riesgo y medidas de prevención.

Foi realizado um ensaio utilizando 36 suínos machos castrados, com peso inicial de 83,7±5,1kg, para avaliar o efeito da inclusão de polpa cítrica, 0, 10, 20 e 30%, em um programa de restrição alimentar qualitativa para suínos abatidos aos 130kg de peso, sobre o peso dos órgãos do sistema digestório e sobre características da carcaça e da qualidade da carne. A inclusão de polpa cítrica proporcionou aumento linear (P<0,05) nos pesos do estômago, cólon e fígado, e efeito quadrático (P<0,05) no peso do ceco. Foi observada redução linear (P<0,05) no peso, no rendimento da carcaça e no peso do pernil, porém não houve efeito (P>0,05) sobre o rendimento do pernil. Maior inclusão de polpa cítrica não foi suficiente para reduzir a espessura do toucinho e aumentar a quantidade de carne magra na carcaça, mostrando que a restrição alimentar qualitativa não foi eficiente. Foi observado aumento linear (P<0,05) do pH da carcaça resfriada e linear negativo (P<0,05) sobre as variáveis indicativas de cor da carne em função da inclusão da polpa cítrica nas dietas. A adição de polpa cítrica em programas de restrição alimentar qualitativa não foi eficiente. Por não promover nenhum efeito deletério sobre as características da carne, a polpa cítrica pode ser utilizada como ingrediente alternativo para suínos em terminação.

An assay with 36 swine initially weighting 83.7±5.1kg body weight (BW) was carried out to evaluate the effects of the use of different dietary citrus pulp levels, 0, 10%, 20%, and 30%, upon digestive organs weights, carcass characteristics, and meat quality of animals subjected to qualitative feed restriction program, and slaughtered at 130kg BW. Linear response (P<0.05) on the weight of stomach, colon, and liver were observed. Negative linear responses (P<0.05) on final BW and carcass yield relative to citrus pulp addition to the diet were observed. Although a negative linear effect (P<0.05) of increasing dietary levels of citrus pulp had been observed on ham weight, yield of this by product was not affected (P>0.05). Higher levels of citrus pulp neither decreased backfat thickness nor increased amount of lean meat, indicative that qualitative feed restriction was not efficient. Positive linear effect (P<0.05) on pH measured 24 hours after slaughter and negative linear effect (P<0.05) on color characteristics as function of citrus pulp dietary levels were verified. Citrus pulp addition in qualitative feed restriction program may not be effective. As no deleterious effects upon meat qualities were observed, citrus pulp can be used as an alternative feedstuff for finishing swine.

Hepatic artery aneurysms are scarcely reported, mainly because of non-specific symptoms. More often, they are incidental findings during imaging studies to investigate other acute or chronic abdominal conditions. These aneurysms are usually detected in the sixth decade of life, predominantly among males. We report the case of a 69 year-old female with an unsuspected huge hepatic artery aneurysm associated with ischemic hepatitis. Suspicion of aneurysm arose during imaging studies to clarify the origin of jaundice and abdominal pain. After establishment of the diagnosis, but before open surgery, there was a spontaneous rupture of the aneurysm, which caused hemoperitoneum and death. The necropsy study confirmed ischemic hepatitis. Hepatic artery aneurysms are second among the visceral aneurysms, and may cause abdominal pain, jaundice, and hemorrhagic events. One should suspect abdominal aneurysms in elderly patients with unclear abdominal pain, and this hypothesis should be ruled out by imaging studies.

La publicación de trabajos sobre aneurismas en la arteria hepática es escasa, debido a los síntomas no específicos y a que constituyen hallazgos incidentales durante investigación de otras condiciones abdominales agudas o crónicas. Estos aneurismas son más frecuentes en varones y en la sexta década de la vida. Presentamos el caso de una mujer de 69 años de edad que ingresa en el hospital con un aneurisma de arteria hepática no sospechado previamente, asociado con hepatitis isquémica. La sospecha de aneurisma empezó durante estudio de imágenes para aclaramiento del origen de ictericia y dolor abdominal. Después de confirmado el diagnóstico, pero antes de la operación planeada, ocurrió rotura espontánea del aneurisma causando hemoperitoneo y muerte. El estudio de necropsia confirmó hepatitis isquémica. Los aneurismas de la arteria hepática son los segundos entre los aneurismas viscerales y pueden causar dolor abdominal, ictericia y eventos hemorrágicos. Debemos sospechar de aneurisma visceral en ancianos con dolor abdominal no aclarada, posibilidad que debe ser descartada por estudios de imágenes.

Avaliou-se o custo de inclusão da polpa cítrica em programa de restrição alimentar qualitativa, utilizando dados de desempenho de 36 suínos da linhagem Topigs, dos 83,7±5,1kg aos 129,8±1,9kg de peso, alimentados com dietas contendo porcentagens crescentes (0, 10, 20 e 30%) de polpa cítrica. Os animais foram abatidos aos 130kg e dos valores (R$) da carcaça foram descontados o valor de compra dos animais e o custo com alimentação, de acordo com cada tratamento. Não houve efeito (P>0,05) da inclusão da polpa cítrica sobre o custo com ração e receita bruta, porém houve efeito linear negativo (P<0,05) sobre o rendimento líquido parcial com o aumento da participação da polpa cítrica nas dietas. A queda no rendimento líquido parcial foi causada pelo menor peso da carcaça obtida de animais alimentados com porcentagem mais elevada de polpa cítrica. Considerando a evolução dos preços do milho, do farelo de soja e do suíno entre junho de 2005 e maio de 2006, foram determinados 12 diferentes cenários para o rendimento líquido parcial. Em todos esses cenários, foi observada redução linear da receita líquida parcial em função da inclusão da polpa cítrica, mostrando que esse ingrediente não foi eficiente em promover melhora no rendimento (R$) ao produtor.

The cost of inclusion of citrus pulp was evaluated in a qualitative feed restriction program using performance data of 36 pigs of Topigs lineage (from 83.7±5.1kg to 129.8±1.9kg) fed with crescent levels of citrus pulp (0, 10, 20, and 30%). The animals were slaughtered when they reached 130kg. The value paid for animal and its feeding cost were discounted from the carcass value (R$), according to each treatment. No effect (P>0.05) of the inclusion of citrus pulp on ration cost and gross income was observed. A negative linear effect (<0.05) on partial net income with the increasing participation of the citrus pulp in diets was found. The decreasing trend in the partial net income was caused by the reduction on carcass weight of animals fed on crescent levels of citrus pulp. Considering the increase on corn, soybean, and swine prices from June 2005 to May 2006, 12 different sceneries were determined for partial net income analysis. In all situations, linear reductions on partial net income were observed as a function of citrus pulp inclusion, evidencing that the ingredient was not efficient in promoting profits for producers.

É descrita a correlação anatomopatológica de um paciente usuário de drogas injetáveis com talcose sistêmica acometendo pulmões, pleuras, fígado, baço e linfonodos e que desenvolveu hipertensão arterial pulmonar e cor pulmonale. Destaca-se o fato de que apesar do uso crônico de drogas injetáveis e outros comportamentos de alto risco para infecção pelo retrovírus, o paciente era HIV negativo, não apresentava linfocitopenia, nem alterações histopatológicas compatíveis com AIDS à necropsia.

Anatomo-pathological correlation in a case of systemic talc granulomatosis affecting lungs, pleura, liver, spleen and mesenteric lymph nodes resulting in pulmonary arterial hypertension and cor pulmonale is described. The patient, a 26-year-old male HIV-negative intravenous drug addict had no lymphopenia or any histopathologic findings at necroscopy compatible with AIDS, despite of a chronic high-risk behavior favoring this illness.