The liver is usually affected in advanced stages of lymphoproliferative diseases, but primary liver lymphomas (PLLs) are rare. The diagnosis is usually late, especially in patients without identifiable risk factors, with consequent worse prognosis. We report the case of a 59-year-old female with progressive worsening pain in the right hypochondrium and weight loss. She was previously healthy and had a family history of gastrointestinal and gynecologic neoplasms. During the initial investigation, three liver nodules suggestive of liver metastases were found. Nevertheless, no primary neoplasm was identified in a subsequent evaluation with imaging and endoscopic exams. Laboratory exams excluded hepatic infections, metabolic diseases, and acquired immunosuppression. Biopsy of the lesions revealed diffuse large B-cell lymphoma. Lymph node and medullar involvement were excluded, and the diagnosis of PLL was assumed. The patient started chemotherapy with R-CHOP. With this case, we intend to alert for this differential diagnosis of liver nodules, even in the absence of predisposing conditions for lymphoma. We point out the need to define universal diagnosis criteria for this pathology.
INTRODUCTION:
We aim to discuss the utility of self-expandable esophageal metal stent (SEMS) in variceal bleeding in challenging cases.
METHODS:
Case description, discussion on patient management and decision-making process in an uncommon situation, from a multidisciplinary point of view.
RESULTS:
We report a case of a cirrhotic patient with refractory variceal bleeding who underwent a SEMS placement, which remained in situ for 9 months. This decision was based on the initial poor status and short life expectancy, limiting the consideration of other options for lowering portal hypertension, along with an underlying prothrombotic predisposition. However, the patient's general and hepatic improvement and the development of dysphagia led to the SEMS removal, exposing a large esophageal–tracheal fistula.
DISCUSSION:
Early patient evaluation, risks of long-term SEMS, and life expectancy should be taken in consideration before SEMS placement.
Purpose To evaluate the efficacy and safety of ambulatory seton placement followed by superficial fistulotomy as treatment of perianal fistula. Methods Retrospective observational analysis of patients with cryptogenic perianal fistula aged 18-90 years, followed in a central hospital proctology consultation between 2006 and 2017. Data were obtained through clinical record's analysis. Fistula was characterized, using Parks Classification. A probe was passed through the fistula tract, followed by a seton, which remained in situ until superficial fistulotomy was possible. Results Ninety-six patients were included (66.67% males, mean age 56 ± 15 years old). Nineteen patients (19.89%) had previous history of perianal fistula and 14 (14.58%) previous anorectal surgery. Seventy-four patients (78.72%) were submitted to fistulotomy, three (3.19%) had seton fistulotomy and one had no seton progression. Intention-to-treat and perprotocol efficacy analyses were 80.2 and 98.7%, respectively. Among the 74 patients who completed the procedure, type of fistula and time with seton were distributed as followed: 47 (63.51%) intersphincteric fistula (15 ± 31 weeks), 26 (35.14%) transsphincteric fistula (32 ± 47 weeks), one (1.35%) suprasphincteric fistula (11 weeks). Previous fistula was associated with a longer time with seton (P = 0.018). Incontinence was reported in two (2.7%) patients, who had previous perianal fistula or anorectal surgery. Two patients (2.7%) had recurrence after fistulotomy. Conclusion Placement of seton followed by superficial fistulotomy in an ambulatory setting is a safe and effective method for simple low perianal fistula treatment. Incontinence rate may be higher in patients with previous perianal fistula or anorectal surgery.
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