Digestive and Liver Disease

Editorial Board

2012-03-01

Intraductal papillary mucinous neoplasms of the biliary and pancreatic ducts—A shape shifting outlook into an increasingly recognized disease

Stefano Crippa, Massimo Falconi — 2012-01-20

Shape shifting, transformations and metamorphoses are common and fascinating themes in mythology, literature and folklore of different times. Among numerous examples of shape shifting, as physicians it is apt to mention The Strange Case of Dr. Jekyll and Mr. Hyde, by Robert Louis Stevenson, where the good Dr. Jekyll metamorphoses into the evil Mr. Hyde. Dr. Jekyll and Mr. Hyde: same character, two bodies with different morphology and with different biological behaviours.

Diet and risk of inflammatory bowel disease

Vibeke Andersen, Anja Olsen, Franck Carbonnel, Anne Tjønneland, Ulla Vogel — 2011-11-04

Abstract: Background: A better understanding of the environmental factors leading to inflammatory bowel disease should help to prevent occurrence of the disease and its relapses.Aim: To review current knowledge on dietary risk factors for inflammatory bowel disease.Methods: The PubMed, Medline and Cochrane Library were searched for studies on diet and risk of inflammatory bowel disease.Results: Established non-diet risk factors include family predisposition, smoking, appendectomy, and antibiotics. Retrospective case–control studies are encumbered with methodological problems. Prospective studies on European cohorts, mainly including middle-aged adults, suggest that a diet high in protein from meat and fish is associated with a higher risk of inflammatory bowel disease. Intake of the n-6 polyunsaturated fatty acid linoleic acid may confer risk of ulcerative colitis, whereas n-3 polyunsaturated fatty acids may be protective. No effect was found of intake of dietary fibres, sugar, macronutrients, total energy, vitamin C, D, E, Carotene, or Retinol (vitamin A) on risk of ulcerative colitis. No prospective data was found on risk related to intake of fruits, vegetables or food microparticles (titanium dioxide and aluminium silicate).Conclusions: A diet high in protein, particular animal protein, may be associated with increased risk of inflammatory bowel disease and relapses. N-6 polyunsaturated fatty acids may predispose to ulcerative colitis whilst n-3 polyunsaturated fatty acid may protect. These results should be confirmed in other countries and in younger subjects before dietary counselling is recommended in high risk subjects.

MicroRNA and colorectal cancer

Hélène Corté, Gilles Manceau, Hélène Blons, Pierre Laurent-Puig — 2011-11-21

Abstract: Colorectal cancer is still the third most common cancer in the world. Its carcinogenesis has been extensively studied at a molecular point of view, and has recently entered the era of microRNAs, a class small non-coding RNAs that post-transcriptionally regulate gene expression and control various cellular mechanisms. Because they control biological processes that are implicated in carcinogenesis (as developmental transitions, organ morphology, apoptosis and cell proliferation), microRNAs have been linked to cancer development, and these molecules have been recently studied as new potential biomarkers to better characterise tumour prognosis and to predict response to the different active chemotherapy.This review summarizes the potential roles of microRNAs as potential biomarkers for colorectal cancer diagnosis, prognosis and drug-response prediction.Through the literature there is evidence that some microRNA could be used as biomarkers in colorectal cancer; however, there are some discrepancies amongst the different studies. These differences could partially due to heterogeneity between the different series associated with tumour stage, tumour location, genetic background of the tumours and technical issues. More progress is needed before microRNAs can be used in clinical practice. Accumulation of further data will allow to determine the most relevant microRNAs as biomarkers and also to better understand their role in colorectal carcinogenesis.

Association of SLCO1B1*1b with peptic ulcer amongst Japanese patients taking low-dose aspirin

2011-11-16

Abstract: Background: In the recent case–control study, we showed an inverse association between peptic ulcer and angiotensin type 1 receptor (AT1R) blockers (ARBs) or HMG-Co A reductase inhibitors (statins). The aim was to evaluate whether the genotypes of uptake and efflux transporters of ARBs and statins relate to the presence of peptic ulcer and/or ulcer bleeding associated with aspirin use.Methods: Patients taking 100mg of enteric-coated aspirin for cardiovascular diseases who also participated in endoscopic surveillance were studied. SLCO1B, ABCC2, ABCG2, and MDR1 genotypes were determined by PCR or PCR-RFLP.Results: 492 patients enrolled including 78 with peptic ulcer. The frequencies of the SLCO1B1 521TT genotype were significantly higher in the ulcer group (p=0.006) compared to the controls. After adjustment for significant factors, the SLCO1B1 *1b haplotype was significantly associated with peptic ulcer (OR, 3.64; 95% CI, 1.81–7.29).Conclusions: SLCO1B1*1b haplotype may identify patients at increased risk for aspirin-induced peptic ulcer.

Long-term outcome of ulcerative colitis in patients who achieve clinical remission with a first course of corticosteroids

2011-11-14

Abstract: Background: Although the early outcomes of ulcerative colitis after a first course of corticosteroids are well known, data on long-term disease evolution in patients responding to a first corticosteroid course are scarce.Aims: To evaluate the long-term clinical evolution in ulcerative colitis patients responding to a first course of corticosteroids and to identify those factors associated with a poorer outcome.Methods: Retrospective review of 114 patients diagnosed with ulcerative colitis who responded to the first corticosteroid course, and did not start thereafter maintenance therapy with thiopurines were included.Results: Corticosteroids were prescribed because of a moderate (78%) or a severe flare (22%). All but two patients followed maintenance treatment with mesalazine after corticosteroid discontinuation. After a median follow-up of 83 months (7–156), 72% of patients suffered new relapses leading to corticosteroid reintroduction in 65% of patients. The earlier corticosteroids were introduced in the course of ulcerative colitis, the higher the risk of relapse and corticosteroid reintroduction. Thiopurines were started in 51%, and infliximab in 19%. Eleven percent of patients underwent colectomy. No predictors of thiopurine use or colectomy were found.Conclusions: Half of the ulcerative colitis patients responding to a first course of corticosteroids will require immunosuppressors mainly because of steroid-dependence.

Natural history of functional gastrointestinal disorders: Comparison of two longitudinal population-based studies

2011-12-02

Abstract: Background: Functional gastrointestinal disorders are common but information on their natural history is limited.Aims: To document the natural history of functional gastrointestinal disorders in a population based study and to compare with the Olmsted County study.Method: A questionnaire was mailed to the same age- and gender-stratified random sample of the Icelandic population aged 18–75 in 1996 and 2006. Results were compared to the Olmsted County study.Results: Prevalence of functional gastrointestinal disorder symptoms was stable between these periods in time: 16.9% and 17.2% for irritable bowel syndrome, and 4.8% and 6.1% for functional dyspepsia. Onset of each disorder was more often higher in the Olmsted County study than in Iceland. Disappearance rates were similar for both studies. Transition probabilities varied across the different subgroups and were different between studies. The same proportion had the same symptoms in the initial and final studies. More subjects had no symptoms in Iceland (52% vs. 40%) and different symptoms at follow up (38% vs. 23%).Conclusion: Prevalence of functional gastrointestinal disorder symptoms was stable over time but the turnover in symptoms was high. A higher number of subjects had no symptoms in Iceland than in Olmsted County and there was a greater variation in subjects having different symptoms at follow up.

Can clinical features stratify use of endoscopy for dyspeptic patients with high background prevalence of upper gastrointestinal cancer?

2011-11-24

Abstract: Background: Whether clinical features can stratify priority of endoscopy remains controversial for dyspeptic patients with high background prevalence of upper gastrointestinal cancer.Aim: To examine the predictive performance of clinical features for cancerous lesions in dyspeptic patients in Taiwan.Methods: Between April 2008 and July 2009, 2530 consecutive dyspeptic outpatients underwent prospective evaluation with standardized questionnaire and then upper gastrointestinal endoscopy. Performance of using age thresholds and alarm symptoms to predict malignancy was determined. Independent risk factors associated with malignancy and those with negative endoscopic findings were identified.Results: Malignant lesions were found in 31 patients (1.2%) and were independently associated with age, male gender, gastrointestinal bleeding, weight loss, and alcohol consumption. Any symptom of weight loss, bleeding and dysphagia, or simply age >45 years predicted 97% of cancer cases, with the sensitivity, specificity, positive and negative predictive values being 96.8%, 29.3%, 1.7%, and 99.9%, respectively. This strategy achieved a low negative likelihood ratio (0.11) and a high diagnostic odds ratio (12.45). Negative endoscopic finding (n=1377, 54.4%) was independently associated with younger age, female gender, no use of non-steroidal anti-inflammatory drug, and no tobacco or alcohol consumption.Conclusions: Absence of weight loss, dysphagia, and gastrointestinal bleeding predicts low likelihood of malignancy in dyspeptic Taiwanese patients aged <45 years.

A randomized controlled trial evaluating a new 2-L PEG solution plus ascorbic acid vs 4-L PEG for bowel cleansing prior to colonoscopy

2011-11-28

Abstract: Background: Bowel preparation is critical for the efficacy and safety of colonoscopy. Poor patient tolerance to bowel preparation has been associated with the high amount of fluid administered. A 2-L polyethylene glycol (PEG) solution containing ascorbic acid has been recently developed.Aims: To compare the efficacy, safety and acceptability of 2-L PEG+ascorbic acid vs 4-L PEG for colonoscopy.Methods: We designed a single blind randomized non-inferiority study in order to compare the two bowel preparations. A blinded assessment of cleansing was made by the endoscopist according to the Aronchick scale. Acceptability was assessed by questionnaire. Intention-to-treat (ITT) and per-protocol (PP) analysis were reported.Results: Overall, 169 patients (PP: 166) were selected for the 2-L PEG+ascorbic acid and 170 (PP: 166) for the 4-L PEG. When rating global bowel cleansing at ITT, an excellent-good level was reported in 84.6% (PP: 86.2%) of patients who received 2-L PEG+ascorbic acid and 75.3% (PP: 77%) of patients who received 4-L PEG (p=0.04). Acceptability rate favoured 2-L PEG+ascorbic acid vs 4-L PEG (83% vs 76%; p=0.02).Conclusions: 2-L PEG+ascorbic acid, completed with an additional L of clear fluids, provided bowel cleansing which appeared to be more effective and acceptable than 4-L PEG.

Magnetic resonance imaging versus endoscopic ultrasonography for the detection of pancreatic tumours in multiple endocrine neoplasia type 1

2011-11-14

Abstract: Objective: In multiple endocrine neoplasia type 1, the main risk factor for metastases is pancreatic tumour size. We and others recommend limiting surgery to non-functioning pancreatic tumors ≥20mm or growing, based on their size measured with endoscopic ultrasonography. Because endoscopic ultrasonography is invasive, we compared endoscopic ultrasonography (EUS) to non-invasive magnetic resonance imaging (MRI) for the detection of pancreatic tumours ≥10mm in multiple endocrine neoplasia type 1 patients.Methods: A prospective study was performed in nine participating centres; 90 patients with multiple endocrine neoplasia type 1 underwent EUS and MRI with gadolinium infusion. Gastroenterologists and radiologists were blinded to the results, magnetic resonance images were reviewed centrally.Results: EUS detected 86 tumours ≥10mm, and 48 (53.3%) patients had at least one tumour ≥10mm. MRI detected 67 tumours ≥10mm, and 46 (51.1%) patients had at least one tumour ≥10mm. EUS and MRI agreement was moderate for detection of tumours ≥10mm (Kappa coefficient=0.49), and for selection of patients with tumours ≥10mm (Kappa coefficient=0.55). EUS and MRI missed 11/24 and 4/24 lesions ≥20mm, respectively. EUS failed to identify 9/57 (15.7%) patients with pancreatic tumours ≥10mm, and MRI failed to identify 11/57 (19.3%) patients with pancreatic tumours ≥10mm.Conclusions: EUS and MRI are complementary and should be performed at initial evaluation in multiple endocrine neoplasia type 1 patients. Whether follow-up should be based on either technique or both, requires further evaluation.

Hepatitis B virus and lymphomagenesis: Novel insights into an occult relationship

2011-10-13

Abstract: Background: Increasing evidence shows that Hepatitis B virus infection associates with B-cell but not T-cell malignancies. It remains unclear (a) whether this association is restricted to discrete subtypes of B-cell neoplasms and (b) if occult hepatitis B virus infection can impact on the risk of B-cell malignancy.Methods: We analysed the prevalence of occult hepatitis B virus infection in three age and sex matched groups: patients with multiple myeloma, chronic lymphocytic leukaemia and healthy volunteers (N=80 each group). Hepatitis B virus sequences were detected by PCR in blood mononuclear cells isolated prior to treatment.Results: Fifteen subjects tested positive for occult hepatitis B virus infection and its distribution significantly favoured chronic lymphocytic leukaemia (p<0.02) over the other groups. No difference in age, gender and proportion of anti-HBc seropositivity was noted according to occult hepatitis B virus infection status. Chronic lymphocytic leukaemia had an odds ratio of 4.6 (95% CI 1.5–13.9) for the presence of occult hepatitis B virus infection in comparison to multiple myeloma and controls. Most occult hepatitis B virus infection cases (10/15, 67%) were detected in completely hepatitis B virus seronegative subjects.Conclusions: Our data support a potentially causal relationship for hepatitis B virus in chronic lymphocytic leukaemia but not in multiple myeloma. HBsAg seropositivity alone may bias the study of this association, potentially leading to underestimation. Primary occult hepatitis B virus infection appears the most frequent setting in our patients, extending the clinical relevance of hepatitis B virus vaccination to a preventative measure for B-cell neoplasms.

Effects of pentoxifylline on intestinal bacterial overgrowth, bacterial translocation and spontaneous bacterial peritonitis in cirrhotic rats with ascites

2011-11-28

Abstract: Background: Prophylaxis of spontaneous bacterial peritonitis with norfloxacin has been associated to development of antibiotic resistance. We investigated whether pentoxifylline compared to norfloxacin reduces bacterial translocation and spontaneous bacterial peritonitis in rats with CCl4-induced cirrhosis and ascites.Method: After development of cirrhosis and ascites, animals were randomly allocated to receive pentoxifylline (16mg/kg/d every 8h, oral route, n=13) or placebo (n=12) for 15 days. An additional group of 8 cirrhotic rats was given norfloxacin (5mg/kg/d for 15 days). Six healthy rats served as controls. Cecal flora and the prevalence of bacterial translocation and spontaneous bacterial peritonitis were analysed. Serum and ascitic fluid levels of TNF-alpha and cecal levels of malondialdehyde were also measured.Results: Pentoxifylline in comparison to placebo reduced intestinal bacterial overgrowth (21% vs. 67%, p=0.04), bacterial translocation to cecal lymph nodes (23% vs. 75%, p=0.03) and prevented spontaneous bacterial peritonitis (0% vs. 33%, p=0.04) by Enterobacteriaceae. Norfloxacin administration induced similar results. Pentoxifylline (0.18±0.10nmol/mg), but not norfloxacin (0.25±0.13; p=0.02), significantly reduced cecal mucosal levels of malondialdehyde compared to placebo (0.33±0.16; p=0.03).Conclusion: In cirrhotic rats with ascites: (a) pentoxifylline as well as norfloxacin reduced intestinal bacterial overgrowth and bacterial translocation and prevented spontaneous bacterial peritonitis; (b) pentoxifylline, but not norfloxacin, reduced oxidative stress in cecal mucosal.

Inverse correlation between plasma oxysterol and LDL-cholesterol levels in hepatitis C virus-infected patients

2011-12-12

Abstract: Background: Hepatitis C virus infection is characterised by enhanced oxidative stress, which can be measured quantitatively by plasma oxysterol concentration. These molecules may affect lipid metabolism through the activation of Liver X Receptors. Hepatitis C virus exploits host lipid metabolism to facilitate its replication and diffusion. In our study we aimed to evaluate and highlight the potential pathogenetic role of oxysterols, 7-ketocholesterol and 7-β-hydroxycholesterol, in hepatitis C virus-related lipid dysmetabolism.Methods: The study was performed in 42 patients with chronic hepatitis C (93% genotype 1b) and 38 non-alcoholic fatty liver disease patients. Plasma oxysterols 7-ketocholesterol and 7-β-hydroxycholesterol were determined by isotope dilution gas chromatography/mass spectrometry.Results: Gas chromatography/mass spectrometry revealed higher 7-ketocholesterol (71.2±77.3 vs 30.4±14.5; p<0.005) and 7-β-hydroxycholesterol (23.7±20.6 vs 11.5±4.9; p<0.001) plasma levels in hepatitis C virus patients. Furthermore, multivariate regression analysis highlighted an inverse independent correlation between high oxysterol levels and low low-density lipoprotein cholesterol (p=0.01 for 7-β-hydroxycholesterol; p=0.02 for 7-ketocholesterol) in the hepatitis C virus group; in contrast, the non-alcoholic fatty liver disease group showed a direct correlation between oxysterol levels and low-density lipoprotein-cholesterol (p<0.001 for 7-β-hydroxycholesterol; p=0.002 for 7-ketocholesterol).Conclusion: These different correlations reveal profound differences in lipid dysmetabolism between chronic hepatitis C and non-alcoholic fatty liver disease patients.

The clinicopathological features of intraductal papillary neoplasms of the bile duct in a Chinese population

Jian Yang, Wentao Wang, Lunan Yan — 2011-09-19

Abstract: Background: Intraductal papillary neoplasms of the bile duct have been applied to certain types of papillary tumours occurring in the biliary tract. Although many cases have been sporadically reported, there remain controversies.Aims: To analyze the clinicopathologic characteristics and long-term survival of intraductal papillary neoplasms of the bile duct.Methods: The clinicopathologic data of 52 patients who underwent surgery for intraductal papillary neoplasms of the bile duct were retrospectively evaluated.Results: In our series, tumours located in intrahepatic and hilar bile duct, rather than in extrahepatic bile duct, were more commonly diagnosed as adenomas or borderline tumours (12/19 and 7/13 vs 6/20; P=0.046). And the gastric type was more commonly associated with adenomas or borderline tumour (85.7%), whilst the pancreaticobiliary type mainly comprised of noninvasive carcinoma or invasive carcinoma (93.8%). However, only the types of treatment (median survival: curative resection: 72 months and palliative groups: 12 months; P<0.001) and histologic grades (adenoma or borderline malignancy vs noninvasive carcinoma: P=0.018) were significantly associated with survival.Conclusion: Intraductal papillary neoplasms of the bile duct are rare type of biliary neoplasms, long-term survival may be achieved with complete resection. However, further studies are needed to clarify the relationship between these variables like location, cellular types and histologic grades.

Proper management and follow-up strategy of branch duct intraductal papillary mucinous neoplasms of the pancreas

2011-10-26

Abstract: Background and aim: It has been reported that main duct intraductal papillary mucinous neoplasms are more invasive and have a worse prognosis than branch duct intraductal papillary mucinous neoplasms. Therefore, an aggressive surgical approach has mainly been recommended for all MD-IPMNs. However, the surgical management of BD-IPMNs has been controversial and the consensus guidelines are not specific for an indicator of malignancy in BD-IPMNs. The objective of this study was to determine the proper management and follow-up strategy of BD-IPMNs.Methods: We monitored and analysed patients with presumed BD-IPMNs between March 1995 and March 2010.Result: The mean value of the initial cyst size in all patients with BD-IPMNs was 2.19cm. Amongst 194 patients with BD-IPMNs, 34 underwent immediate surgical resection, 152 were followed conservatively. Amongst the 152 conservatively managed patients, 18 (11.8%) underwent surgical resection after a median follow-up of 12.7 months (range, 3–48 months). In 132 patients who were managed conservatively without surgery, the mean incremental rate of cyst size growth was 0.0038cm/month during a median of 30.7 months of follow-up and there were no IPMN-related deaths.Conclusion: Amongst patients with BD-IPMNs, about 10% have surgery within approximately 1 year from the time of diagnosis because of the occurrence of new malignant stigmata. Therefore, a conservative approach without surgery and careful follow-up every 3 months or 6 months during the first year after diagnosis can be safely advocated in patients with BD-IPMNs larger than 10mm in size who have no risk factors for malignant IPMNs.

Volume of surgical activity and lymph node evaluation for patients with colorectal cancer in France

2011-11-28

Abstract: Background: The correct examination of lymph nodes is decisive for tumour classification into stage 2 and stage 3. The aim of this specialised population-based study was to investigate the influence of clinical factors and volume of surgical activity on lymph node assessment in France for patients diagnosed with localised colorectal cancer.Methods: From 1997 to 2004, French digestive cancer registries recorded a total of 4197 cases of colorectal cancer. The volume of surgical activity was appreciated by the annual number of digestive surgery admissions in 2004. The probability of having at least 12 lymph nodes examined after surgical resection was analysed using a multilevel logistic regression model.Results: Only 1900 patients had more than 12 lymph nodes examined (45.2%). The percentage of patients with at least 12 lymph nodes examined after tumour resection is directly associated with the volume of surgical activity within care centres for patients diagnosed between 1997 and 2000. This association was no longer significant during the second period study (2001–2004).Conclusion(s): This population-based study reports that only 55% of colorectal patients have a sufficient number of lymph nodes examined. This insufficient number of examined lymph nodes could be considered as a potential prospect for increasing treatment quality in cancer patients in France.

Primary adenosquamous carcinoma of the cecum

Hiroka Kondo, Jun Matsumoto, Kensuke Adachi — 2011-10-03

A 78-year-old woman presented with anaemia and a positive faecal occult blood test. Routine work-up disclosed no abnormalities except for reduced haemoglobin levels (8.6g/dl). Total colonoscopy revealed a type 1-like tumour in the cecum (A), and friable epithelium was seen after indigo carmine dye (B). Subsequently, she underwent a laparoscopic ileocecal resection with a regional lymphadenectomy.

Comment to “Rumination syndrome: When the lower oesophageal sphincter rises”

François Mion, Sabine Roman — 2011-11-03

We read with interest the short report of Gourcerol et al. on the physiopathology of the rumination syndrome. Using concomitant high resolution oesophageal manometry, intra-luminal impedance and video-fluoroscopy, they give rather convincing evidence of intra-thoracic displacement of the lower oesophageal sphincter (LES) during rumination episodes.

Comment to “Rumination syndrome: When the lower oesophageal sphincter rises”

Guillaume Gourcerol, Pierre Dechelotte, Philippe Ducrotte, Anne Marie Leroi — 2011-12-05

We read with great interest the comments of Mion et al., who raised the question of transient relaxations of lower oesophagus sphincter (TLESRs) as a possible mechanism involved in rumination episodes . According to the authors, this is supported by the concomitant elevation of the LES, the common-cavity phenomena, and presence of gastric material in the oesophagus. So far, this possibility cannot be ruled out using current technology, although few points do not support such a hypothesis.

Multiple sterile liver abscesses: An unusual presentation mimicking metastatic disease

Metesh Nalin Acharya — 2011-10-26

A 57-year-old man with diabetes mellitus and alcohol-related liver disease presented with a 2-day history of nausea, vomiting and reduced appetite. On examination, he was apyrexial with right upper quadrant tenderness. Laboratory tests revealed microcytic anaemia (haemoglobin 8.9g/dL, MCV 79fL), and elevated white blood cell count (15.8×109/L), C-reactive protein (248mg/L), alkaline phosphatase (416IU/L) and gamma-glutamyltransferase (151IU/L). Blood cultures were sterile. Abdominal ultrasound scan (Fig. 1A) showed multiple, large, mixed echoic lesions (the largest 11cm in diameter), predominantly within the right lobe of the liver. Hepatic metastases were considered, but staging CT scan (Fig. 1B) did not detect a primary neoplasm and tumour markers were within normal limits. CT-guided drainage yielded sterile pus with marked neutrophilia. The patient received intravenous co-amoxiclav and metronidazole, with regression of the hepatic abscesses at one-month follow-up (Fig. 2A and B).

Successful management of a symptomatic splenic haemangioma by radiofrequency ablation

Xiaowu Zhang, Jiayin Yang, Lunan Yan — 2011-11-02

Splenic haemangioma (SH) is a rare benign disorder, although spontaneous rupture with massive haemorrhage can occur in these patients . Traditional treatment most often consists of splenectomy. Radiofrequency ablation (RFA) is a thermal treatment technique which has been successfully used for the treatment of hepatic haemangioma; however, it has not been reported for treatment of SH. A 43-year-old man presented to our department with a 2-month history of left upper quadrant pain. All laboratory data were within normal limits except for thrombocytopenia (PLT 72×109/L). Magnetic resonance imaging showed a single tumour with a diameter of 2.3cm in the spleen (Fig. 1), Preoperative evaluation led to the diagnosis of SH. The patient underwent laparoscopy through insertion of 2 trocars, which demonstrated a solid mass in the capsule of the anterior border of the spleen. To minimize the risk of bleeding, intraoperative needle biopsy was not performed. One cluster electrode (Cool-tip, Valleylab) was positioned within the centre of the haemangioma (Fig. 2a). A 12-min RFA was performed and the haemangioma was completely ablated (Fig. 2b). The estimated intraoperative blood loss was about 30ml. The patient tolerated the procedure well and was discharged the next day in good condition. After two-month follow-up he has returned to a normal vigorous lifestyle with complete resolution of the abdominal pain.