Sometimes, the presentation of some diseases can be fulminating. The authors present the case of a 51-year- old male brought to the emergency department visibly drunk and complaining of abdominal pain. Immediately, the diagnosis of hemorrhagic shock due to an accentuated drop of the hemoglobin level was made. After stabilization, he underwent a computed tomography of the abdomen, revealing a hepatocellular carcinoma with rupture of the Glisson capsule and massive intraperitoneal hemorrhage. With this case, the authors want to bring attention to a rare first presentation of hepatocellular carcinoma with a catastrophic result.

Classicamente a hepatite viral está associada ao vírus dahepatite A, B ou C, podendo ser também causada por outrosvírus. Apesar de não ser endémica em Portugal, reporta-seo caso esporádico de uma doente com hepatite aguda, cujodiagnóstico se confirmou hepatite E. Os autores chamam aatenção para uma causa rara de hepatite, devendo ser umdiagnóstico a considerar após exclusão de causas mais frequentes.

Objective: Arterial Hypertension (AHT) is one of the main causes of morbidity and mortality in the world. Generally defined as an increase in blood pressure (BP), it is characterized by hemodynamic changes that have implications for diagnosis, risk stratification and therapy. In this study we intend to characterize the hemodynamic response to orthostatism in a group of treated hypertensive patients using impedance cardiography (ICG). Design and method: Resistant hypertensive patients without heart failure, ischemic heart disease, valvular heart disease or dysrhythmia were prospectively selected. All patients underwent ICG in the supine position and in orthostatism. After ICG, they were classified into patterns: vasoconstrictor (systemic vascular resistance (SVR) > 2500 dyn.s.cm-5.m2), hyperdynamic (cardiac index (CI) > 4.2 l / min / m2 and / or heart rate HR > 80 cycles / min), hypervolemic (thoracic fluid (CFT) > 34 1 / kOhm) or balanced (hemodynamic parameters below the established limit values). All patients underwent transthoracic echocardiography to exclude major morphologic changes. Results: We included 178 patients, 56.1% males, age 63 ± 11 years, medicated with 4 ± 1 antihypertensives. In ICG, 56.5% were vasoconstrictors, 11.8% hyperdynamic, 33.4% hypervolemic and 22.9% had a balanced hemodynamic profile. In the supine position the patients had systolic blood pressure 134 ± 18, diastolic blood pressure 79 ± 11, HR 69 ± 10, indexed ejection volume 42 ± 9, pre-ejection period 95 ± 15 ms, ejection time 333 ± 17 ms, systolic time ratio 0.28 ± 0.06, RVSI 2687 ± 621, cardiac index 2.8 ± 0.4 and CFT 32 ± 5. In the orthostatic position some of these values were significantly higher: diastolic blood pressure 82 ± 12 (p < 0.001), HR 73 ± 12 (p < 0.001), pre-ejection period 119 ± 23 (p < 0.001), systolic time ratio 0.41 ± 0.11 (p < 0.001). The indexed ejection volume 39 ± 9 (p < 0.001), ejection time 301 ± 46 (p < 0.001) and CFT 28 ± 3 (p < 0.001) were significantly lower. Conclusions: Although polymedicated, most patients had an unbalanced hemodynamic profile. The analysis of the impedance waveform with postural modification can be used to clarify the response to orthostatism and to better characterise the hemodynamic phenotype.

Objective: The prevalence of arterial hypertension (AHT) in Portuguese adult population is higher than 40%. Historically defined by sustained elevation of blood pressure (BP), AHT results from hemodynamic changes characterized by cardiac output, systemic vascular resistance and/or arterial compliance abnormalities, with significant implications for diagnosis, risk stratification and treatment. Impedance cardiography (ICG) is a noninvasive method for hemodynamic profile evaluation. It allows to access risk and optimize therapy. In this study we analyzed the resistant hypertensive patients with controlled blood pressure values in order to evaluate and characterize their hemodynamic profile by ICG. Design and method: Resistant hypertensive patients without heart failure, ischemic heart disease, valvular heart disease or dysrhythmia were prospectively selected. After ICG were classified as: vasoconstrictor (systemic vascular resistance (SVR) > 2500dyn.s.cm-5.m2), hyperdynamic (cardiac index (CI) > 4.2l/min/m2 and/or heart rate (HR) > 80 cycles/min), hypervolemic (thoracic fluid (TFC) > 341/kOhm) or balanced (hemodynamic parameters below the established limit values). All patients underwent transthoracic echocardiography to exclude major changes. In this sub-analysis of patients from the IMPEDDANS study we included only those who, according to international recommendations, had office and outpatient blood pressure values within the therapeutic goals. Results: From 178 initial patients, 52 were included, 57.7% male, with 63 ± 9 years old, under 4 ± 1 antihypertensive agents. The mean hemodynamic values were: systolic blood pressure (BP) 125 ± 12, diastolic BP 75 ± 6, HR 69 ± 11, SVR 2756 ± 527, CI 2.8 ± 0.5, TFC 32 ± 4. According to the hemodynamic profile 63.7% appear to be vasoconstrictors, 13.5% hyperdynamic, 28.7% hypervolemic and 22.9% balanced. Conclusions: These results suggest that, despite polymedicated and with arterial pressure within the recommended values, the majority of patients were not hemodynamically stabilized, confirming that BP is an hemodynamic variable supported by several processes, tendentially redundant, in which inhibition of one element tends to favor the activation of another. ICG is, therefore, an useful method in the evaluation of hypertensive individuals, capable of contributing to adequate therapeutic optimization.