Síndrome del dedo azul: de la piel a lo multisistémico / Blue digit syndrome: from skin to a multisystemic etiology

El signo del dedo azul (SDA) es una condición poco frecuente causada principalmente por la oclusión de la vasculatura periférica. Clínicamente puede manifestarse como una coloración azulada o eritrocianótica en uno o varios dedos en ausencia de traumatismo y condiciones propias de congelación. Las etiologías son múltiples e incluyen obstrucción del flujo arterial, disminución del flujo venoso y alteración en la viscosidad sanguínea. La importancia de reconocer el signo como motivo de consulta radica en encaminar un diagnóstico temprano e instaurar un tratamiento que evite la evolución natural de la enfermedad hacia la necrosis, amputación o muerte del paciente. Proponemos un algoritmo diagnóstico para reconocer los elementos de la historia clínica que guíen la etiología y los paraclínicos disponibles desde el Servicio de Urgencias.

Blue finger sign (BFS) is a rare condition caused mainly by occlusion of peripheral vasculature. Clinically it may manifest as a bluish, or erythrocyanotic discoloration of one or more fingers in the absence of trauma and freezing conditions. The etiologies are multiple and include arterial flow obstruction, decreased venous flow, and altered blood viscosity. The importance of recognizing the sign as a reason for consultation lies in the early diagnosis and the establishment of a treatment that finally avoids the natural evolution of the disease towards necrosis and finally amputation or death of the patient. We propose a diagnostic algorithm based on recognizing elements of the clinical history that guide the etiology and paraclinical available from the Emergency Department.

Tratamento combinado na dissecção de artéria mesentérica superior: desafio terapêutico / Combination treatment for superior mesenteric artery dissection: therapeutic challenge

Resumo A dissecção da artéria mesentérica superior é uma causa rara de dor abdominal, com quadro clínico variável. Seu diagnóstico é difícil, e não existe consenso sobre suas opções terapêuticas; elas variam em torno de tratamento conservador, correção aberta, endovascular ou combinada. Descrevemos o caso de um homem de 45 anos com dissecção isolada da artéria mesentérica superior, com quadro de dor abdominal persistente após tentativa de tratamento conservador. Ele foi submetido à revascularização cirúrgica aberta devido à localização e complexidade da dissecção. O tratamento com endarterectomia, arterioplastia com remendo de pericárdio bovino e acesso retrógrado para abertura da mesentérica com stent foi realizado com sucesso. A angina abdominal foi totalmente resolvida após estabilização do quadro. A combinação de abordagem aberta e endovascular deve ser considerada como terapia para casos de dissecção complexa isolada da artéria mesentérica superior.

Abstract Dissection of the superior mesenteric artery is a rare cause of abdominal pain, with a variable clinical picture. It is difficult to diagnose and there is no consensus on treatment options, which range from conservative treatment to open, endovascular, or combination repair. We describe the case of a 45-year-old man with isolated dissection of the superior mesenteric artery and persistent abdominal pain after conservative treatment had been attempted. He underwent open surgical revascularization due to the location and complexity of the dissection. Treatment consisting of endarterectomy, arterioplasty with bovine pericardium patch, and retrograde access to open the mesenteric artery with a stent was successful. Abdominal angina was completely resolved after the condition had stabilized. A combination of open and endovascular approaches should be considered as treatment for cases of isolated complex dissection of the superior mesenteric artery.

Isquemia mesentérica aguda: a propósito de un caso / Acute mesenteric ischemia: a purpose of a case

La isquemia mesentérica aguda (IMA) es consecuencia de la oclusión de la arteria mesentérica superior (AMS) por trombosis o embolia, y es considerada la más letal del síndrome de abdomen agudo. Se presenta el caso de paciente femenina de 69 años con clínica difusa y confirmación diagnóstica radiológica, El objetivo de este caso clínico es proporcionar una revisión bibliográfica actual del tema y facilitar la adecuada actuación ante este problema de salud de amplio compromiso sistémico, y de aparición no tan infrecuente. (AU)

Acute mesenteric ischemia (IMA) is a consequence of occlusion of the superior mesenteric artery (AMS) by thrombosis or embolism; and it is considered the most lethal of acute abdomen syndrome. The case of a 69 years old female patient with diffuse clinic and radiological diagnostic confirmation is presented. The objective of this clinical case is to provide a current bibliographic review of the topic and facilitate adequate action in the face of this health problem with a broad systemic commitment, and with no appearance so infrequent. (AU)

Trombosis segmentaria sigmoidea consecuente a neoplasia maligna de colon. A propósito de un caso interesante / Sigmoid segmental thrombosis consequent to colon malignant neoplasia. On the purpose of a case

RESUMEN Se presentó un caso de una paciente de 78 años de edad, procedente del municipio de Calimete, con antecedentes patológicos personales de infarto agudo miocárdico sin elevación del segmento ST e hipertensión arterial. Llegó a la Unidad de Cuidados Intensivos de Emergencia, de Colón con un estado toxico infeccioso severo. Fue intervenida quirúrgicamente con el diagnóstico presuntivo de una trombosis mesentérica. Se constató dicho diagnóstico complementario a una neoplasia maligna de colon sigmoides. Falleció producto a un shock séptico refractario a aminas. En la necropsia se reportaron hallazgos de interés.

ABSTRACT The authors present the case of a 78-years-old female patient from the municipality of Calimete, with personal pathological antecedents of acute myocardial infarct without ST segment elevation and arterial hypertension. She arrived to the Emergency Intensive Care Unit of Colon with a severe toxic-infectious status. She underwent a surgery with a presumptive mesenteric thrombosis. It was stated that diagnosis, complementary to a sigmoid colon malignant neoplasia. She died as a product of an amine-refractory septic shock. The autopsy showed findings of interest.

Isquemia mesentérica crônica: relato de caso / Chronic mesenteric ischemia: case report

RESUMO A isquemia mesentérica crônica é uma incomum doença dentre os eventos vasculares abdominais que gera difícil diagnóstico e dúvida com outras enfermidades viscerais. A sua epidemiologia não está bem estabelecida e o principal agente etiológico é a aterosclerose. O diagnóstico deve se embasar na suspeita clínica e exames complementares, como a arteriografia, que evidencia a oclusão arterial parcial ou total. Dentre as opções terapêuticas, existem a correção laparotômica ­ padrão ouro - e o tratamento endovascular. Este relato de caso apresenta uma paciente feminina, 62 anos, hipertensa e dislipidêmica, com dor abdominal, com quadro de isquemia mesentérica crônica, com manifestações clássicas da doença, que foi submetida a abordagem terapêutica de exceção, com tratamento híbrido (combinação de cirurgia aberta com endovascular), com boa resposta ao tratamento no seguimento a curto prazo. Palavras-chave: Isquemia mesentérica; Procedimentos endovasculares; Oclusão vascular mesentérica.

Isquemia mesentérica crónica en una anciana con demencia: un reto diagnóstico / Chronic mesenteric ischemia in an elderly woman with dementia: a diagnostic challenge

El dolor abdominal es una causa frecuente de consulta al servicio de urgencias y la población anciana no es ajena a esta situación. En este grupo de pacientes, la dificultad en el enfoque diagnóstico radica en sus características particulares, como múltiples enfermedades concomitantes, medicación múltiple, deterioro cognitivo y cuidadores con pobre información, situaciones que favorecen múltiples consultas que llevan a diagnósticos erróneos y tardíos. Una de las causas de dolor abdominal en los ancianos son las catástrofes vasculares, como la angina mesentérica, enfermedad poco frecuente y con gran mortalidad, dado que su diagnóstico y su tratamiento son tardíos por la presentación atípica en esta población. Se reporta el caso de una paciente con antecedentes de demencia vascular, que consultó por dolor abdominal crónico y a quien se le diagnosticó angina mesentérica crónica

Abdominal pain is a common cause of visit to the emergency room and the elderly population is prone to present this situation. In this group of patients the difficulty lies in its particular features, like multiple comorbidities and multiple medications, cognitive impairment and poorly informed caregivers, a situations that favors multiple consultations leading to inaccurate and delayed diagnoses. A cause of abdominal pain in the elderly includes vascular catastrophes, such as mesenteric angina, an infrequent disease associated high mortality because diagnosis and treatment are delayed by virtue of the atypical presentation in this population. We report the case of an elderly female with history of vascular dementia who consulted for chronic abdominal pain that was diagnosed as chronic mesenteric angina

Effect of protective solutions and hydroxyethyl starch in the attenuation of the injuries of ischemia and reperfusion of splanchnic organs

PURPOSE: Vogt´s antioxidant solution (red blood cells, Ringer's solution, sodium bicarbonate, mannitol, allopurinol and 50% glucose) or its modification including hydroxyethyl starch (HES) were tested for the prevention of splanchnic artery occlusion shock. METHODS: Seventy rats were distributed in treatment (3), control (1), and sham (3) groups. Ischemia and reperfusion were induced by celiac, superior mesenteric and inferior mesenteric arteries occlusion for 40 min, followed by 60 min reperfusion or sham procedures. Controls received saline, both treatment and sham groups received the Vogt's solution, modified Vogt's solution (replacing Ringer's solution by HES), or HES. Mean arterial blood pressure (MABP), ileal malondialdehyde (MDA) and plasmatic MDA were determined, and a histologic grading system was used. RESULTS: At reperfusion, MABP dropped in all I/R groups. Only HES treatment was able to restore final MABP to the levels of sham groups. Plasmatic MDA did not show differences between groups. Ileum MDA was significantly higher in the control and treatment groups as compared to the sham group. Histology ranking was higher in the only in control group. CONCLUSIONS: Hydroxyethyl starch was able to prevent hemodynamic shock but not intestinal lesions. Both treatments with Vogt's solutions did not show any improvement. .

Very short cycles of postconditioning have no protective effect against reperfusion injury. Experimental study in rats / Ciclos muito curtos de pós-condicionamento não protegem contra lesão de reperfusão. Estudo experimental em ratos

Introduction: Ischemic postconditioning has been recognized as effective in the prevention of reperfusion injury in situations of ischemia and reperfusion in various organs and tissues. However, it remains unclear what would be the best way to accomplish it, since studies show great variation in the method of their application. Objective: To assess the protective effect of ischemic postconditioning on ischemia and reperfusion in rats undergoing five alternating cycles of reperfusion and ischemia of 30 seconds each one. Methods: We studied 25 Wistar rats distributed in three groups: group A (10 rats), which underwent mesenteric ischemia (30 minutes) and reperfusion (60 minutes); Group B (10 rats), undergoing ischemia (30 minutes) and reperfusion (60 minutes), intercalated by postconditioning (5 alternating cycles of reperfusion and ischemia of 30 seconds each one); and group C - SHAM (5 rats), undergoing only laparotomy and manipulation of mesenteric artery. All animals underwent resection of an ileum segment for histological analysis. Results: The mean lesions degree according to Chiu et al. were: group A, 2.77, group B, 2.67 and group C, 0.12. There was no difference between groups A and B (P>0.05). Conclusion: Ischemic postconditioning was not able to minimize or prevent the intestinal tissue injury in rats undergoing ischemia and reperfusion process when used five cycles lasting 30 seconds each one. .

Introdução: O pós-condicionamento isquêmico tem sido reconhecido como eficaz na prevenção das lesões de reperfusão em situações de isquemia e reperfusão em vários órgãos e tecidos. Entretanto, não está ainda claro qual seria a melhor maneira de realizá-lo, já que as publicações mostram grande variação de método no seu emprego. Objetivo: Avaliar o efeito protetor do pós-condicionamento isquêmico na isquemia e reperfusão intestinal em ratos, através de cinco ciclos alternados de 30 segundos de isquemia e 30 segundos de reperfusão. Métodos: Foram estudados 25 ratos Wistar, distribuídos em três grupos: grupo A (10 ratos), em que se realizou isquemia (30 minutos) e reperfusão (60 minutos) mesentérica; grupo B (10 ratos), isquemia e reperfusão, seguidos de pós-condicionamento isquêmico com 5 ciclos alternados de reperfusão e reoclusão, de 30 segundos cada; e grupo C (5 ratos), controle (SHAM). Ao final, ressecou-se um segmento do intestino delgado para análise histológica. Avaliaram-se os resultados pela classificação de Chiu et al. e procedeu-se ao tratamento estatístico. Resultados: As médias dos graus de lesão tecidual segundo a classificação de Chiu et al. foram: no grupo A, 2,77; no grupo B, 2,67; e no grupo C, 0,12. A diferença entre o resultado do grupo A com o resultado do grupo B não teve significância estatística (P>0,05). Conclusão: O pós-condicionamento isquêmico não foi capaz de minimizar ou prevenir a lesão tecidual intestinal de ratos submetidos ao processo de isquemia e reperfusão mesentérica quando utilizados cinco ciclos com duração de 30 segundos cada. .

Mesenteric lymph reperfusion after superior mesenteric artery occlusion shock exacerbates endotoxin translocation in brain

PURPOSE: To determine the role of mesenteric lymph reperfusion (MLR) on endotoxin translocation in brain to discuss the mechanism of brain injury subjected to superior mesenteric artery occlusion (SMAO) shock. METHODS: Twenty-four rats were randomly assigned to MLR, SMAO, MLR+SMAO and sham groups. MLR was performed by clamping the mesenteric lymph duct (MLD) for 1 h and then allowing reperfusion for 2 h in the MLR group; SMAO involved clamping the superior mesenteric artery (SMA) for 1 h, followed by reperfusion for 2 h in the SMAO group; occlusion of both the SMA and MLD for 1 h was followed by reperfusion for 2 h in the MLR+SMAO group rats. RESULTS: SMAO shock induced severe increased levels of the endotoxin, lipopolysaccharide receptor, lipopolysaccharide-binding protein, intercellular adhesion molecule-1 and tumor necrosis factor-α. Concurrently, MLR after SMAO shock further aggravates these deleterious effects. CONCLUSION: Mesenteric lymph reperfusion exacerbated the endotoxin translocation in brain; thereby increased inflammatory response occurred, suggesting that the intestinal lymph pathway plays an important role in the brain injury after superior mesenteric artery occlusion shock. .

Mesenteric lymph reperfusion exacerbates spleen injury caused by superior mesenteric artery occlusion shock

The intestinal lymph pathway plays an important role in the pathogenesis of organ injury following superior mesenteric artery occlusion (SMAO) shock. We hypothesized that mesenteric lymph reperfusion (MLR) is a major cause of spleen injury after SMAO shock. To test this hypothesis, SMAO shock was induced in Wistar rats by clamping the superior mesenteric artery (SMA) for 1 h, followed by reperfusion for 2 h. Similarly, MLR was performed by clamping the mesenteric lymph duct (MLD) for 1 h, followed by reperfusion for 2 h. In the MLR+SMAO group rats, both the SMA and MLD were clamped and then released for reperfusion for 2 h. SMAO shock alone elicited: 1) splenic structure injury, 2) increased levels of malondialdehyde, nitric oxide (NO), intercellular adhesion molecule-1, endotoxin, lipopolysaccharide receptor (CD14), lipopolysaccharide-binding protein, and tumor necrosis factor-α, 3) enhanced activities of NO synthase and myeloperoxidase, and 4) decreased activities of superoxide dismutase and ATPase. MLR following SMAO shock further aggravated these deleterious effects. We conclude that MLR exacerbates spleen injury caused by SMAO shock, which itself is associated with oxidative stress, excessive release of NO, recruitment of polymorphonuclear neutrophils, endotoxin translocation, and enhanced inflammatory responses.

Tratamiento quirúrgico de la isquemia mesentérica crónica, revisión de la literatura y presentación de un caso / Surgical treatment of chronic mesenteric ischemia: Literature review and case presentation

Los problemas vasculares mesentéricos son infrecuentes pero, cuando se presentan, pueden ser catastróficos. La isquemia mesentérica crónica es una entidad caracterizada por la obstrucción de los vasos mesentéricos; se manifiesta por dolor abdominal después de las comidas, desnutrición y miedo a comer. La mortalidad de la isquemia aguda es de 50 a 70 %. El manejo quirúrgico es la terapia de elección con excelentes resultados. El objetivo del tratamiento de la isquemia mesentérica crónica es solucionar los síntomas con un procedimiento efectivo y duradero, disminuyendo el riesgo de isquemia aguda. El tratamiento óptimo aun es discutido aunque la cirugía abierta se considera el método de referencia del manejo; no obstante, se asocia a una morbimortalidad importante. Presentamos el caso de un paciente con una isquemia mesentérica crónica, que se manejó con cirugía abierta y excelente resultado clínico y nutricional. Se hace una revisión extensa de la literatura científica actual.

Mesenteric vascular problems are infrequent, but may be catastrophic. Chronic mesenteric ischemia (CMI) is a morbid disease that results from progressive stenotic disease of the mesenteric vessels. CMI presents with postprandial abdominal pain, inanition, fear of food And weight loss. Untreated,The mortality in acute intestinal ischemia is high (50%-70%). Vascular reconstruction is remarkably successful in relieving the symptoms of chronic intestinal ischemia . The goal of treatment for CMI is a safe and effective revascularization that provides the patient with immediate and durable relief of symptoms, minimal procedural risk, and protection from morbidity and mortality associated with intestinal ischemia. Optimal treatment for patients with CMI remains controversial and challenging. Open surgical revascularization is still considered the standard of care, but may be associated with significant morbidity and mortality. We presented a patient with severe abdominal pain after meals, repeatedly. Angiography revealed severe stenosis and occlusion of the super mesenteric artery (SMA). Endovascular treatment was initially unsuccessful, after that we did a open bypass with full clinical and nutritional recovery.

Ischemia-reperfusion histopathology alterations of the rabbit intestinal wall with and without ischemic preconditioning / Alterações histopatológicas da parede intestinal de coelhos na isquemia-reperfusão com e sem precondicionamento isquêmico

PURPOSE: To evaluate the histopathology alterations of the intestinal mucosa of rabbits submitted to mesenteric artery ischemia and reperfusion with and without ischemic preconditioning. METHODS: Two groups of ten male New Zealand white rabbits body (weight 2.2-3.0, average 2.5 kg). For mesenteric ischemia induction in all animals the small bowel and mesentery were cut 30cm and 60cm far from the gastroduodenal pyloric transition before the proximal mesenteric artery occlusion. In the Group 1 animals, the proximal mesenteric artery was occluded for 45 min with an atraumatic vascular clamp, followed by reperfusion for 30 min. In the Group 2 the 45 min ischemic phase was preceded by three cycles of ischemia (2 minutes each) alternated with three cycles of reperfusion (2 minutes each). For istopathology study small bowel biopsies were obtained before ischemia (control), after 45 min of mesenteric ischemia and at 30 min. of mesenteric artery reperfusion. RESULTS: In the Group I animals, the followings histopathology grade results were observed: t1, mean 2,8; t2, mean 3,3. Using the Kruskal-Wallis non-parameter test, differences between t0 and t1 and t0 and t2 were significants (p<0.05), but not significant between t1 and t2 (p>0.05). In the Group 2 animals histopathology grade results were: t1 mean 2,6 and t2, mean 2,1. Differences between t0 and t1, t0 and t2 were significant (p<0.05). It was not observed differences (p>0.05) between results of t1 in both groups but histopathology injury observed in Group 1 t2 biopsies were higher (p<0.05) than observed in the same period (t2) of Group 2 animals. CONCLUSION: Microscopic examination of the biopsies revealed significant evidence of preconditioning protection against small bowel wall ischemia-reperfusion injury.

OBJETIVO: Avaliar as alterações histopatológicas da mucosa intestinal de coelhos submetidos a isquemia-reperfusão com e sem precondicionamento isquêmicol. MÉTODOS: Foram estudados dois grupos de dez coelhos Nova Zelândia machos com pesos variáveis entre 2,2 e 3,0 kg (média de 2,5 kg) de peso corpóreo. Para indução da isquemia, em todos os animais, o intestino delgado e o mesentério foram seccionados 30 cm e 60 cm após a transição pilórica gastroduodenal, antes da oclusão da artéria mesentérica cranial. Nos animais do Grupo 1, a artéria mesentérica proximal foi ocluida por pinçamento atraumático durante 45 min., seguido de reperfusão por 30 min. No Grupo 2, foi realizado precondicionamento por três ciclos de 2 min. de oclusão mesentérica intercalados com três ciclos de 2 min. de reperfusão, seguido de oclusão mantida por 45 min e reperfusão de 30min. como no Grupo I. Para estudo histopatológico, foram obtidas biópsias da parede intestinal antes da isquemia (t0-controle), após 45 min. de isquemia (t1) e após 30 min. de reperfusão (t2). RESULTADOS: No Grupo I foram observados os seguintes graus de lesões: t1, média de 2,8 e t2, média 3,3, Foram significantes as diferenças entre t0 e t1 e t0 e t2, mas não foram significantes as variações entre t1 e t2 (p>0,05). No Grupo 2, obteve-se em t1,média de 2,6 e t2, média 2,1. Foram significantes (p<0,05) as diferenças entre t0 e t1, t0 e t2 e entre t1 e t2. . Não ocorreu diferença significante (p>0,05) entre os resultados de t1 nos dois Grupos, mas foram significantes (p<0,05) as diferenças entre os resultados histopatológicos das biopsias de t2 dos Grupos 1 e 2. CONCLUSÃO: O precondicionamento isquêmico reduziu significantemente a degeneração histopatológica determinada pela reperfusão pós-isquêmica da parede intestinal.

Isquemia mesentérica crónica, tratamiento quirúrgico: reporte de dos casos / Chronic mesenteric ischemia: report of two cases

Chronic mesenteric ischemia is uncommon and often not recognized by clinicians. We report two patients with the disease. A 61 years old female with a two years history of abdominal pain, diarrhea, anorexia and weight loss. A mesenteric arteriography showed a critical stenosis of the celiac artery. The patient was operated and a retrograde bypass from the iliac to the mesenteric artery was placed. Digestive symptoms ceased and the patient gained weight. A 49 years old smoker female, with a two years history of abdominal pain and weight loss, without diarrhea. A doppler ultrasonography of abdominal arteries showed a critical stenosis of the celiac artery. The angiography confirmed the stenosis and disclosed also a complete occlusion of the common hepatic artery. The patient was operated placing anterograde aortic-mesenteric and aortic- hepatic bypasses. During the follow up, the patient is in good conditions.

La isquemia mesentérica crónica es una enfermedad que pone en riesgo la vida, que puede provocar la muerte por inanición o infarto mesentérico. El diagnóstico se realiza tardíamente debido a la inespecificidad de sus síntomas. El método diagnóstico no invasivo de elección es la ecografía doppler, por el cual se determina la presencia de estenosis u oclusión de las arterias viscerales comprometidas. La arteriografía se utiliza para definir la anatomía de las lesiones y planificar la cirugía. El tratamiento de elección sigue siendo la revascularización. Presentamos dos pacientes tratadas en nuestro servicio con buenos resultados, las que presentaban historia de síntomas abdominales inespecíficos y baja de peso. En la primera paciente, con antecedentes de hipercolesterolemia, su estudio demostró ateromatosis calcica difusa de aorta abdominal, ilíacas comunes, tronco celíaco, renales y mesentérica superior; se le realizó bypass ilíaco-mesentérico superior. En la segunda paciente, con antecedentes de tabaquismo crónico, su estudio demostró lesiones críticas de tronco celíaco y arteria mesentérica superior e inferior, se le realizó bypass aorto-mesentérico superior y aorto-hepático común. En los controles, ambas pacientes presentan alza de peso sostenida y se mantienen asintomáticas.

Ischemia-reperfusion histopathology alterations of the rabbit intestinal wall with and without exclusion of the collateral mesenteric circulation supply / Alterações histopatológicas da parede intestinal de coelhos na isquemia-reperfusão com e sem exclusão da circulação mesentérica colateral

PURPOSE: To evaluate the histopathology alterations of the intestinal mucosa of rabbits submitted to different times of mesenteric artery ischemia and reperfusion with and without celiac artery collateral circulation supply. METHODS: Two groups of eight male New Zealand white rabbits (weight 2.2-3.5 kg) were used in this study. In the Group 1 animals, the proximal mesenteric artery was occluded for 60 min with an atraumatic vascular clamp, followed by reperfusion for 60 min. In the Group 2 animals the small bowel and mesentery were cut 30cm and 60cm far from the gastroduodenal pyloric transition before the proximal mesenteric artery occlusion. Small bowel biopsies were obtained before ischemia (control), after 30 min and 60 min of mesenteric ischemia and at 30 and 60 min. of mesenteric artery reperfusion. RESULTS: In the Group I animals, the followings histopathology grade results were observed: t1, mean 0.4 + 0.29; t2, mean 1.9 ± 0.38; t3, 1.9 ± 0.33; t4, 1.2 ± 0.36 and t5, 1.2 ± 0.32. Differences between t0 and t2 and between t3 and t4 were statistically significant (p<0.05). Differences between t2 and t3 and t4 and t5 were not significant (p>0.5). In the Group II animals, it was observed: t1, mean 1.6 ± 0.33; t2, 2.4 ± 0.36; t3, 3.0 ± 0.35; t4 3.4 ± 0.31; t5, 3 ± 031. Differences between t0 and t1, t1 and t2, and t2 and t3 were significant (p<0.05). Differences between histopathology grades results of samples t1 to t5 in Group 1 and 2 were statistically significant (p<0.5). CONCLUSION: Microscopic examination of the biopsies revealed significant evidence of worse small bowel wall ischemia-reperfusion lesions by exclusion of the celiac artery collateral circulation supply.

OBJETIVO: Avaliar as alterações histopatológicas da mucosa intestinal de coelhos submetidos à isquemia-reperfusão com e sem exclusão da circulação mesentérica colateral. MÉTODOS: Foram estudados dois grupos de oito coelhos Nova Zelândia machos com pesos variáveis entre 2,2 e 3,5 kg de peso corpóreo. Nos animais do Grupo 1, a artéria mesentérica proximal foi ocluida por pinçamento atraumático durante 60 min, seguido de reperfusão por 60 min. No Grupo 2 o intestino delgado e o mesentério foram seccionados 30 cm e 60 após a transição pilórica gastroduodenal antes da oclusão da artéria mesentérica cranial. Biópsias da parede intestinal foram obtidas antes da isquemia (controle), após 30 e 60 min. de isquemia. RESULTADOS: No Grupo I foram observados os seguintes graus de lesões: t1,média de 0.4 + 0.29; t2, média 1.9 ± 0.38; t3, 1.9 ± 0.33; t4, 1.2 ± 0.36 e t5, 1.2 ± 0.32. As diferenças entre t0 e t2 e entre t3 e t4 foram significantes (p<0.05). As diferenças entre t2 e t3 e t4 e t5 não foram significantes (p>0.5). No Group II observou-se: t1, média de 1.6 ± 0.33; t2, 2.4 ± 0.36; t3, 3.0 ± 0.35; t4 3.4 ± 0.31; t5, 3 ± 031. As diferenças entre t0 e t1, t1 e t2, e t2 e t3 foram significantes (p<0.05). As diferenças entre os resultados histopatológicos das biopsies de t1 a t5 dos Grupos 1 e 2 foram significantes (p<0.5). CONCLUSÃO: A exclusão da circulação mesentérica colateral agravou significantemente a degeneração histopatológica na isquemia-reperfusão da parede intestinal.

Regeneração do fígado de ratos após oclusão parcial da drenagem venosa hepática / Hepatic regeneration after parcial oclusion of hepatic vein drainage in rats

INTRODUÇÃO: A regeneração hepática é um mecanismo para superar a perda de tecido funcional do fígado. Este processo é estudado através de diferentes métodos. OBJETIVO: Avaliar o efeito da oclusão parcial da drenagem venosa hepática sobre a regeneração do fígado remanescente de ratos submetidos à hepatectomia parcial. MÉTODO: Foram colhidas biópsias de fígado em 30 ratos Wistar machos, e a seguir realizada hepatectomia a dois terços. Os animais foram divididos em três grupos: um grupo controle e dois grupos de estudo, submetidos a diferentes graus de estenose da veia hepática direita. Após 96 horas do estímulo para regeneração hepática, todos submeteram-se à outra biópsia hepática. Analisaram-se os fragmentos por imunoistoquímica para os marcadores Ki-67 e fator de von Willebrand. Para a leitura das amostras utilizou-se o sistema SAMBA 4000. A deposição de colágeno foi avaliada pela coloração tricrômico de Masson. RESULTADOS: A proliferação celular dos animais submetidos à hepatectomia parcial e estenose moderada ou severa da veia hepática direita persistiu mais elevada quando comparada ao grupo controle. O Índice de Marcação para o Ki-67 foi significativamente mais elevado após a hepatectomia nos grupos submetidos à oclusão parcial da veia hepática, tanto moderada quanto severa. A expressão de fator de von Willebrand estava diminuída após a hepatectomia parcial nos três grupos. Houve pouco depósito de colágeno no tecido hepático nos animais dos dois grupos com estenose da veia hepática direita. CONCLUSÃO: A oclusão parcial da drenagem venosa hepática em ratos submetidos à hepatectomia parcial prolonga o tempo de proliferação de células hepáticas quando comparado aos animais com veias de calibre normal. Como consequência, também houve atraso na restauração da matriz extracelular e na formação de novos vasos sinusoidais.

BACKGROUND: Hepatic regeneration is a mechanism to overcome the loss of liver functional tissue. This process has been studied through different methods. AIM: To evaluate the effect of the partial occlusion of the hepatic venous drainage on the regeneration of the remainder livers in rats submitted to partial hepatectomy. METHOD: Liver biopsies from 30 male Wistar rats were collected, and after they were submitted two-third hepatectomy. The animals were divided in three groups: a control group and two study groups, which were submitted to different degrees of the right hepatic vein stenosis. After 96 hours of the stimulation for regeneration all rats were submitted to another hepatic biopsy. The analysis of the fragments was performed by immunohistochemistry for the Ki-67 and von Willebrand factor markers. The reading of the samples was done using the SAMBA 4000 system. Collagen deposition was evaluated by the trichromic Masson's staining. RESULT: The cellular proliferation of the animals submitted to partial hepatectomy and stenosis of the right hepatic vein persists higher when compared to control group. The Label Index for Ki-67 was significantly higher post-hepatectomy in groups submitted to hepatic vein partial occlusion. The expression of von Willebrand factor was strongly decreased after the hepatectomy in all groups. There was little deposit of collagen in the hepatic tissue of animals with hepatic vein stenosis. CONCLUSION: Partial occlusion of the hepatic venous drainage in rats submitted to partial hepatectomy prolongs the time of hepatic cells proliferation when compared to the animals with vein of normal caliber. Consequently, there will be also a delay in the restoration of the extracellular matrix and in the formation of new sinusoidal vessels.

Avaliação do pós-condicionamento isquêmico no tratamento da isquemia mesentérica: estudo experimental em ratos / Evaluation of ischemic postconditioning effect on mesenteric ischemia treatment: experimental study in rats

OBJETIVO: Avaliar o efeito do pré e pós-condicionamento isquêmico sobre a lesão tecidual na mucosa intestinal de ratos submetidos ao processo de isquemia e reperfusão mesentérica. MÉTODOS: Foram estudados 30 ratos Wistar, distribuídos em três grupos: grupo A, em que se realizou isquemia (30 minutos) e reperfusão (60 minutos) mesentérica; grupo B, isquemia e reperfusão mesentérica precedidos pelo pré-condicionamento isquêmico por três ciclos de isquemia e reperfusão com duração de dois minutos cada; grupo C, isquemia e reperfusão mesentérica e, precedendo o início da reperfusão, foi realizado o pós-condicionamento isquêmico por três ciclos de reperfusão e isquemia com duração de dois minutos cada. Ao final, ressecou-se um segmento do intestino delgado para análise histológica. Avaliaram-se os resultados pela classificação de Chiu et al. e procedeu-se ao tratamento estatístico. RESULTADOS: As médias dos graus de lesão tecidual segundo a classificação de Chiu et al. foram: no grupo A, 3,5; grupo B, 1,2; grupo C, 1. A diferença entre o resultado do grupo A com os resultados dos grupos B e C foi considerada estatisticamente significativa (P < 0,05). CONCLUSÃO: O pré e pós-condicionamento isquêmico foram capazes de minimizar, com intensidade semelhante, a lesão tecidual na mucosa intestinal de ratos submetidos ao processo de isquemia e reperfusão mesentérica.

OBJECTIVE: To assess the preconditioning and postconditioning effect on intestinal mucosal lesions in rats undergone mesenteric ischemia and reperfusion procedure. METHODS: Thirty Wistar rats were studied and divided into three groups: Group A, 10 rats undergone mesenteric ischemia (30 minutes) and reperfusion (60 minutes); Group B, 10 rats undergone mesenteric ischemia and reperfusion preceded by ischemic preconditioning for three cycles of ischemia and reperfusion for two minutes each; Group C, 10 rats undergone mesenteric ischemia and reperfusion and, preceding the beginning of reperfusion, ischemic postconditioning was performed for three cycles of reperfusion and ischemia for two minutes each. Then, a segment of small intestine was resected for histological analysis. We assessed the results by Chiu et al. score and the statistical analysis was performed. RESULTS: According to Chiu et al. score, the means of lesion degree were: In the group A, 3.5; Group B, 1.2; Group C, 1. The difference between group A with the groups B and C was considered statistically significant (P < 0.05). CONCLUSION: Ischemic pre- and postconditioning were capable of minimizing - in a similar intensity - the tissue injury on the intestinal mucosa of rats undergone mesenteric ischemia and reperfusion process.

Comparison of the effects of lactated Ringer solution with and without hydroxyethyl starch fluid resuscitation on gut edema during severe splanchnic ischemia

The type of fluid used during resuscitation may have an important impact on tissue edema. We evaluated the impact of two different regimens of fluid resuscitation on hemodynamics and on lung and intestinal edema during splanchnic hypoperfusion in rabbits. The study included 16 female New Zealand rabbits (2.9 to 3.3 kg body weight, aged 8 to 12 months) with splanchnic ischemia induced by ligation of the superior mesenteric artery. The animals were randomized into two experimental groups: group I (N = 9) received 12 mL·kg-1·h-1 lactated Ringer solution and 20 mL/kg 6 percent hydroxyethyl starch solution; group II (N = 7) received 36 mL·kg-1·h-1 lactated Ringer solution and 20 mL/kg 0.9 percent saline. A segment from the ileum was isolated to be perfused. A tonometric catheter was placed in a second gut segment. Superior mesenteric artery (Q SMA) and aortic (Qaorta) flows were measured using ultrasonic flow probes. After 4 h of fluid resuscitation, tissue specimens were immediately removed for estimations of gut and lung edema. There were no differences in global and regional perfusion variables, lung wet-to-dry weight ratios and oxygenation indices between groups. Gut wet-to-dry weight ratio was significantly lower in the crystalloid/colloid-treated group (4.9 ± 1.5) than in the crystalloid-treated group (7.3 ± 2.4) (P < 0.05). In this model of intestinal ischemia, fluid resuscitation with crystalloids caused more gut edema than a combination of crystalloids and colloids.

The ischemic preconditioning and postconditioning effect on the intestinal mucosa of rats undergoing mesenteric ischemia/reperfusion procedure

PURPOSE: To evaluate the effect of the ischemic preconditioning and the ischemic postconditioning over the tissue injury in the intestinal mucosa of rats undergoing the procedure of mesenteric ischemia and reperfusion. METHODS: Thirty Wistar rats were studied, divided in three groups: group A, undergoing mesenteric ischemia (30 minutes) and reperfusion (60 minutes); group B, mesenteric ischemia and reperfusion preceded by ischemic preconditioning; group C, mesenteric ischemia and reperfusion and, before the beginning of reperfusion, the ischemic postconditioning was performed. At the end, a segment of the small intestine was dissected for histological analysis. The results were evaluated using the CHIU et al.6 classification followed by the statistic treatment. RESULTS: The mean values of the tissue injury levels were: group A, 3.5; group B, 1.2; and group C, 1. The difference between the result of group A with the results of groups B and C was considered statistically significant (p < 0,05). CONCLUSION: The ischemic preconditioning and postconditioning are able to minimize the tissue injury in the intestines of rats that underwent the procedure of mesenteric ischemia and reperfusion.

OBJETIVO: Avaliar o efeito do pré e pós-condicionamento isquêmico sobre a lesão tecidual na mucosa intestinal de ratos submetidos ao processo de isquemia e reperfusão mesentérica. MÉTODOS: Foram estudados 30 ratos Wistar, distribuídos em três grupos: grupo A, em que se realizou isquemia (30 minutos) e reperfusão (60 minutos) mesentérica; grupo B, isquemia e reperfusão mesentérica precedidos pelo pré-condicionamento isquêmico; grupo C, isquemia e reperfusão mesentérica e, precedendo o início da reperfusão, foi realizado o pós-condicionamento isquêmico. Ao final, ressecou-se um segmento do intestino delgado para análise histológica. Avaliaram-se os resultados pela classificação de CHIU e col.6 e procedeu-se o tratamento estatístico. RESULTADOS: As médias dos graus de lesão tecidual foram: grupo A, 3,5; grupo B, 1,2; grupo C, 1. A diferença entre o resultado do grupo A com os resultados dos grupos B e C foi considerada estatisticamente significativa (p < 0,05). CONCLUSÃO: O pré e pós-condicionamento isquêmico foram capazes de minimizar a lesão tecidual na mucosa intestinal de ratos submetidos ao processo de isquemia e reperfusão mesentérica.

Oclusão aterosclerótica da aorta abdominal com fluxo arterial para os membros inferiores mantido pela artéria mesentérica inferior - relato de caso / Aterosclerotic oclusion of the abdominal aorta with arterial flow to the inferior limbs mantained by the inferior mesenteric artery -case report

Objetivo: relatar o caso de um paciente portador de oclusão aterosclerótica da aorta abdominal cuja vascularização dos membros inferiores era mantida por colaterais mesentéricas com reenchimento retrógrado da aorta distal. Método: as informações foram obtidas por meio de revisão do prontuário, entrevista com o paciente, registro fotográfico dos métodos diagnósticos aos quais o paciente foi submetido e revisão da literatura. Considerações finais: o caso relatado e publicações levantadas trazem à luz a discussão da terapêutica de uma situação complexa que é a doença oclusiva aortoilíaca e evidenciam que, embora adotada em uma minoria de casos, quando bem executada e em pacientes adequadamente selecionados, a endarterectomia aórtica é capaz de obter resultados satisfatórios e duradouros no que diz respeito ao alívio sintomático e melhoria da qualidade de vida.

Aim: to report the case of a patient with atherosclerotic occlusion of the abdominal aorta with the arterial flow to lhe inferior limbs maintained by mesenteric collaterals with retrograde peifusion ofthe distal aorta. Method: the necessary data was obtained by medical chart review, interview with the patient, photographic register of the image diagnose exams that were performed and literature review. Final comments: the case reported and reviewed data put onfocllS the old malter about the management of a complex situation that is the aortoiliac occlusive disease and show that even! thought choused in a minority of cases, when well executed and on properly selected patients, the aortic endarterectomy is capable to provide satisfactory and long-term results on symptoms reliving and quality of life improvement.