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One-third of cancer pain patients do not experience adequate pain relief using analgesic ladder by the World Health Organization. Interventional procedures, such as epidural morphine, have been considered. This study aimed to review the literature comparing the effects of epidural administration of morphine with the oral route. This systematic review included randomized controlled trials (RCTs) conducted with patients with gastrointestinal neoplasm. A search was conducted on PubMed, EMBASE, Web of Science, Scopus, Cochrane Library, and CINAHL databases to identify studies published up to May 2023. The retrieved study was evaluated using the Risk of Bias 2 (RoB 2) tool and qualitatively synthesized. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach (Prospero: CRD42021264728). Only one RCT, a crossover trial, was included in this systematic review. The study was conducted with ten participants (one withdrawal) and reported a statistically significant difference between both subcutaneous and epidural morphine solutions and oral morphine. The adverse events were not described. The included study presents some concerns of bias and low certainty of evidence on the effectiveness and security of epidural morphine administration. The available literature does not suffice to elucidate whether morphine administration via the epidural route is more effective than other routes. Further RCTs are necessary to improve the level of evidence on the effectiveness and risk-benefit of epidural morphine in the management of cancer pain in gastrointestinal neoplasm patients.

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Appendicular neoplasms are rare tumors, with an incidence of less than 0.05% among all gastrointestinal tumors. This work presents the case of a 52-year-old patient who manifested colicky pain in the right iliac fossa. Laboratory test results with bandemia and hyperbilirubinemia. Abdominal tomography with an acute appendicular inflammatory process, for which the patient was admitted for surgery. A dependent tumor of the cecum and appendicular region is observed, which compromises the ileocecal valve. The histopathological diagnosis was "low-grade appendiceal mucinous neoplasm." Appendiceal tumors are often incidental findings due to their low frequency; however, their possibility should not be dismissed.

Las neoplasias apendiculares son tumores raros, con una incidencia menor al 0.05% de todos los tumores gastrointestinales. Presentamos el caso de paciente de 52 años, quien acude por dolor cólico en fosa iliaca derecha. Estudios de laboratorio con bandemia e hiperbilirrubinemia. Tomografía abdominal con proceso inflamatorio apendicular agudo por lo que se ingresa a cirugía. Se observa tumoración dependiente de ciego y región apendicular que compromete válvula ileocecal. El diagnóstico histopatológico fue "neoplasia mucinosa apendicular de bajo grado. Los tumores de apéndice son a menudo hallazgos incidentales por su baja frecuencia, sin embargo, su posibilidad no debe descartarse.

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Los tumores del estroma gastrointestinal (TEGI) son las neoplasias mesenquimales más frecuentes del tracto digestivo con una frecuencia de 0,1 a 3 % de todas las neoplasias gastrointestinales. Son derivadas de las células intersticiales de Cajal, localizadas a lo largo del plexo mioentérico de la pared intestinal. Comprenden leiomisarcomas, leiomioblastomas, leimiomas, schwannomas. Están formadas por células fusiformes, en la mayoría, epitelioides o ambas. Se localizan predominantemente en estómago e intestino delgado. Inmunohistoquimicamente se detecta expresión de receptores KIT (antígeno CD117) que puede ser focal, variable o difusa. Involucran tumores benignos pero con potencial malignidad hasta sarcomas metastizantes. Su pronóstico se basa el tamaño y porcentaje de mitosis. La sintomatología depende del lugar de origen, en este caso como masa palpable abdominal y obstrucción intestinal. El tratamiento es la resección completa con márgenes limpios. En caso de metástasis preoperatoria, esta no cambia la conducta quirúrgica, debido a la posibilidad de obstrucción y sangrado. El Imatinib a dosis de 400 mg controla el crecimiento eventual de enfermedad residual. Se presenta el caso clínico de paciente con masa abdominal y cuadro de obstrucción intestinal que evoluciona a la perforación de un TEGI localizado en yeyuno proximal con cuadro peritoneal y absceso subfrenico. Se procede a resección intestinal con yeyuno yeyuno anastomosis resección completa. La histopatología reporta Tumor estronal gastrointestinal y la inmunohistoquimica Neoplasia Fusocelular. CONCLUSION: Los TEGI son de origen mesenquimal, comprenden espectro grande de tumores desde benignos, hasta carcomas altamente malignos. Los factores pronósticos se asocian al tamaño e índice mitótico del tumor. La inmunohistoquimica reporta su expresión para CD117. La resección quirúrgica completa es el pilar de tratamiento y en casos de resección incompleta o irresecabilidad puede usarse imatinib.

Gastrointestinal stromal tumors (GIST) are the most frequent mesenchymal neoplasms of the digestive tract with a frequency of 0.1 to 3% of all gastrointestinal neoplasms. They are derived from the interstitial cells of Cajal, located along the myoenteric plexus of the intestinal wall. They include leiomysarcomas, leiomioblastomas, leimiomas, schwannomas. They are made up of spindle cells, in the majority, epithelioids or both. They are located predominantly in the stomach and small intestine. Immunohistochemically, KIT receptor expression (CD117 antigen) is detected, and they can be focal, variable or diffuse. They involve benign but potentially malignancy tumors up to metastatic sarcomas. Their prognosis is based on the size and percentage of mitosis. The symptoms depend on the place of its origin. Treatment is complete resection with clean margins. In the case of preoperative metastases, this does not change the surgical approach, due to the possibility of obstruction and bleeding. Imatinib at a dose of 400 mg controls the eventual growth of residual disease. We present the clinical case of a patient with an abdominal mass and a small bowel obstruction that progresses to perforation of a GIST located in the proximal jejunum with a peritonitis and subphrenic abscess. Intestinal resection is performed with jejunum jejunoanastomosis and complete resection. Histopathology reports gastrointestinal stromal tumor and immunohistochemistry, Fusocellular neoplasia. Conclusion: GIST are of mesenchymal origin, they include a wide spectrum of tumors from benign to highly malignant sarcomas. Prognostic factors are associated with tumor size and mitotic index. Immunohistochemistry reports its expression for CD117. Complete surgical resection is the mainstay of treatment and in cases of incomplete resection or unresectability imatinib can be used.

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Subepithelial lesions (SELs) in the upper gastrointestinal (GI) tract are relatively frequent findings in patients undergoing an upper GI endoscopy. These tumors, which are located below the epithelium and out of reach of conventional biopsy forceps, may pose a diagnostic challenge for the gastroenterologist, especially when SELs are indeterminate after endoscopy and endoscopic ultrasound (EUS). The decision to proceed with further investigation should take into consideration the size, location in the GI tract, and EUS features of SELs. Gastrointestinal stromal tumor (GIST) is an example of an SEL that has a well-recognized malignant potential. Unfortunately, EUS is not able to absolutely differentiate GISTs from other benign hypoechoic lesions from the fourth layer, such as leiomyomas. Therefore, EUS-guided fine needle aspiration (EUS-FNA) is an important tool for correct diagnosis of SELs. However, small lesions (size < 2 cm) have a poor diagnostic yield with EUS-FNA. Moreover, studies with EUS-core biopsy needles did not report higher rates of histologic and diagnostic yields when compared with EUS-FNA. The limited diagnostic yield of EUS-FNA and EUS-core biopsies of SELs has led to the development of more invasive endoscopic techniques for tissue acquisition. There are initial studies showing good results for tissue biopsy or resection of SELs with endoscopic submucosal dissection, suck-ligate-unroof-biopsy, and submucosal tunneling endoscopic resection.

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Propósito: el signo de Leser-Trélat conjuga la presencia simultánea de queratosis seborreica eruptiva con una neoplasia maligna, pero existen publicaciones de pacientes con queratosis con o sin la neoplasia. Se buscó establecer si hay evidencia sobre esta asociación para considerar la potencialidad de la aparición de tales lesiones dermatológicas como un hallazgo precoz de neoplasias malignas. Fuente de datos: revisión sistemática de la literatura ubicada en Medline, Cochrane, Lilacs, Scholar Gloogle e Imbiomed. Selección de estudios: se evaluaron todos los artículos afines a queratosis seborreica eruptiva y cáncer, sin límite en edad, sexo, tipo de artículo o idioma. Extracción de datos: se leyeron de 668 resúmenes y se revisaron 120 artículos completos, 66 utilizados en este informe. Resultados: la evidencia que apoya la asociación entre queratosis seborreica súbita y cáncer es pobre: sólo existen cuatro estudios de casos y controles cuyos resultados no apoyan esta asociación. Conclusiones: la gran mayoría de las publicaciones son producto del hallazgo al azar de las dos entidades y no producto de la búsqueda sistemática de una de ellas cuando aparece la otra, lo que refleja una especie de sesgo de selección a la hora de publicar dichos casos.

Purpose: the sign of Leser-Trélat conjugates the simultaneous presence of eruptive seborrheic keratoses with a malignancy, but there are reports of patients with keratosis with or without neoplasia. The establishment of whether there is evidence for this association to consider the potential for the occurrence of such skin lesions as an early finding of malignant neoplasms was sought. Data Sources: a systematic review of the literature located on Medline, Cochrane, Lilacs, Schoolar Google and Imbiomed. Study Selection: all articles related to eruptive seborrheic keratosis and cancer, with no limit on age, sex, type of article or language were evaluated. Data Extraction: 668 abstracts were read and 120 full articles were reviewed, 66 used in this report. Results: the evidence supporting the association between sudden seborrheic keratosis and cancer is poor: there are only four case-control studies whose results do not support this association. Conclusions: the vast majority of publications are the product of chance finding of the two entities and not the result of a systematic search of one of them when the other appears, reflecting a kind of selection bias in publishing such cases.

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Endoscopic treatment of early gastrointestinal neoplasias has become the standard treatment in Japan and other Asia-Pacific countries, while it is still a developing technology in the West. The advent of endoscopic mucosal resection and endoscopic sub-mucosal dissection in the last decade has allowed early treatment of malignancies in a manner that preserves the organ, avoiding major surgery with less morbidity and mortality, and overall survival rates compared to standard surgery. In Japan and other Asia-Pacific countries, submucosal dissection has shifted over endoscopic mucosal resection as the technique of choice in the recent years, because of the possibility of treating deeper and larger lesions, with higher rates of bloc and curative resections, and lower recurrence rates, but with a higher rate of complications and a longer learning curve.

El tratamiento endoscópico de las neoplasias gastrointestinales precoces se ha convertido en el estándar de tratamiento en Japón y otros países del Asia-Pacífico, siendo aún una técnica en desarrollo en occidente. La aparición de la resección endoscópica de la mucosa y la disección endoscópica submucosa en la última década, ha permitido tratar las neoplasias precoces, logrando preservar el órgano, y evitando así una cirugía mayor, con menor morbi-mortalidad y cifras de sobrevida comparables con el tratamiento quirúrgico convencional. En Japón y otros países del Asia-Pacífico, la disección sub-mucosa ha desplazado en los últimos años a la resección endoscópica de la mucosa como técnica de elección, debido a la posibilidad de resecar lesiones más profundas y de mayor tamaño, con mayor tasa de resección en bloque y curativa, y menor recidiva. Sin embargo, con una mayor tasa de complicaciones y una curva de aprendizaje más larga.

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Report of a rare case of an 83-year-old patient with lymphoma of the terminal ileum causing obstructive/perforated acute abdomen synchronous with sigmoid colon adenocarcinoma and review of literature data about small bowel malignancies, particularly lymphomas. It seems to correspond to a rare disease (2% of all bowel cancers), more prevalent in elderly and immunocompromised patients, whose symptoms are vague and early diagnosis is difficult, often making it impossible to establish the correct therapy. (AU)

Relato de caso raro de um paciente de 83 anos, com linfoma de íleo terminal causador de abdome agudo obstrutivo/perfurativo sincrônico à adenocarcinoma de cólon sigmoide e revisão dos dados disponíveis na literatura acerca das neoplasias de intestino delgado, em especial os linfomas. Constata-se que corresponde a uma afecção rara (2% de todas as neoplasias intestinais), mais predominante em pacientes idosos e imunodeprimidos, cuja sintomatologia é vaga e o diagnóstico precoce difícil, fato que impossibilita muitas vezes a instituição da terapêutica correta. (AU)

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The authors report a case of a male patient in his forties with progressive abdominal pain associated with weight loss, dyspnea, and edema of the inferior limbs, culminating in a surgical acute abdomen. A segmental enterectomy containing a lesion of about 10cm in diameter was performed. It was later confirmed, by means of immuno-hystochemistry, as being a Gastrointestinal Stromal Tumor of high biological aggressiveness. Etiology, diagnosis, classification, prognosis and therapeutic with Imatinib Mesylate - STI-571 (Glivec® - Novartis) are hence discussed.

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INTRODUÇÃO: O tumor estromal gastrointestinal (GIST) é neoplasia pouco freqüente, sendo rara a combinação de acometimento duodenal e hemorragia digestiva, por isso apresenta-se este relato. RELATO DO CASO: Homem de 64 anos admitido com quadro de dor abdominal, melena e tumoração palpável em epigástrio e hipocôndrio esquerdo, sendo notado um tumor de paredes espessadas e conteúdo cístico na tomografia computadorizada de abdome, em topografia de cauda pancreática. Encontrado na laparotomia de urgência tumor em quarta porção duodenal com invasão de cólon em ângulo esplênico, sendo realizada ressecção em bloco do duodeno acometido, segmento de cólon transverso e descendente, com boa evolução pós-operatória. Diagnosticado por imunoistoquímica GIST de duodeno com invasão de parede colônica, sendo o tratamento complementado com mesilato de imatinib. CONCLUSÃO: A hemorragia digestiva é uma das possíveis complicações do GIST. Apenas o tratamento cirúrgico precoce é capaz de prevenir as graves complicações do choque hemorrágico.

BACKGROUND: Gastrointestinal stromal tumor (GIST) represents an uncommon form of neoplasm. The combination of duodenal GIST and gastrointestinal bleeding consist of a rare presentation for such tumors. AIM: To report duodenal GIST case complicated by gastrointestinal bleeding. CASE REPORT: A 64-year-old male was admitted presenting abdominal pain, melena and a palpable mass in epigastrium and left upper abdomem regions. CT scan reveled a thick wall tumor containing cystic content in the pancreatic tail topography. At emergency laparotomy, a tumor in the fourth portion of the duodenum presenting colonic invasion in splenic flexure was found. En-bloc resection of the tumor was carried out, included the fourth portion of the duodenum and the transverse and descending colon, without postoperative complications. Immunohistochemical staining of the resected specimen confirmed the diagnosis of duodenal GIST with colon wall invasion. CONCLUSION: Gastrointestinal hemorrhage is one of the possible complications of GIST. Early surgical treatment is the only effective therapeutic option to avoid severe complications of hemorrhagic shock.