A 21−year−old woman underwent an ultra− sound−guided liver biopsy as part of a pre− operative kidney transplantation protocol. Her background included chronic renal failure due to glomerulonephritis and he− patitis C. One hour after the procedure, she experienced acute epigastric pain and melena, without hemodynamic compro− mise. Her hemoglobin level decreased from 8.9 g/dl to 7.7 g/dl (normal range 13.5 ±15.0 g/dl). An ultrasound examina− tion demonstrated free peritoneal fluid and a large quantity of echogenic material in the gallbladder. The following day, she developed nausea, vomiting, worsening pain, and jaundice. Serum amylase was 600 U/l (normal: below 130 U/l), total bi− lirubin 11.5 mg/dl (normal: 0.2 ±1.0 mg/ dl). She received three units of packed red blood cells. Computed tomography and magnetic resonance cholangiopancreato− graphy (MRCP) revealed edematous pan− creatitis, a dilated gallbladder, and clots inside the common bile duct and gallblad− der. Endoscopic retrograde cholangiopan− creatography confirmed that there were blood clots obstructing the major duode− nal papilla (Figure 1), and the cholangio− gram demonstrated irregular filling de− fects throughout the bile ducts and gall− bladder (Figure 2). Endoscopic sphincter− otomy was carried out, and a large and hy− pertensive amount of fresh blood clot was drained with a basket and a balloon cathe− ter. A hepatic angiogram did not show any evidence of further active bleeding. The patient s condition and jaundice initially improved, but 5 days later, recurrent ab− dominal tenderness over the right upper quadrant, fever, and leukocytosis were no− ted. Ultrasound revealed a distended gall− bladder containing echogenic materials. A cholecystectomy was performed, confirm− ing blood clots and purulent fluid inside the gallbladder. The patient was dis− charged home after a course of antibiotics, and has remained well in the last 18 months. The average time observed between a liver biopsy and the onset of hemobilia is ap− proximately 5 days [1]. Angiography can be useful both to confirm the diagnosis and to attempt treatment by embolizing the bleeding vessel [2]. Ultrasound can de− tect clots in the dilated bile ducts and gall− bladder. MRCP shows a negative magnetic signal in the biliary duct and gallbladder, corresponding to blood clots. When the blood clots completely obstruct the duo− denal papilla, as observed in the patient described here, jaundice and biliary pan− creatitis may subside; this observation has also been reported by other authors [3, 4]. Acute cholecystitis has also been de− scribed after liver biopsy [5]. In the present case, the distended gallbladder full of large blood clots was not able to empty itself even after sphincterotomy and wide bili− ary drainage, and cholecystectomy was necessary to manage this complication.

A 34-year-old woman presented in hypovolemic shock from GI bleeding (hematemesis and melena). The initial Hb was 8.6 g/dL (normal: 12-16 g/dL). There was a history of multiple episodes of variceal hemorrhage caused by portal hypertension as a result of schistosomiasis. Emergency EGD revealed a large volume of blood in the stomach and active (spurting) hemorrhage from a large fundal varix (A). Application of an endoclip at the point of rupture of the varix promptly arrested the bleeding (B). When EGD was repeated 3 days later, the clip was still in place.

We evaluated antimicrobial susceptibility patterns of microorganisms isolated from intraabdominal infection of Brazilian patients, by agar dilution, agar diffusion, and E test. Among the strictly anaerobes, 57.7% were resistant to penicillin, 28.2% to clindamycin, and 9.9% to metronidazole. The majority of Escherichia coli and Staphylococcus were sensitive and resistant to almost all drugs, respectively. Half of Candida samples were resistant to itraconazole. Our data reinforce the importance of this kind of study to support rational antimicrobial therapy.

Endoscopic mucosal resection (EMR) is an alternative approach for the curative treatment of early gastric cancer [1]. Endoscopic clipping devices have been developed to counter complications such as perforation [2].