Fisiología respiratoria: fisiopatología de las enfermedades obstructivas / Pathophysiology of obstructive diseases

Las enfermedades obstructivas de la vía aérea pediátrica son muy frecuentes debido a los fenómenos mecánicos que están involucrados. En los niños más pequeños, la marcada resistencia de las vías aéreas pequeñas, determinada por la falta de tejido elástico y una caja torácica aún no bien desarrollada; tanto su estructura como la musculatura, facilitarán que cuadros infecciosos, mecánicos (cuerpo extraño) y compresivos, determinen que los flujos de aire se vean limitados y con ello la ventilación alveolar. La respuesta fisiológica con aumento del trabajo respiratorio es limitada y por lo tanto la fatiga muscular determinará hipoventilación con las consecuencias de hipoxemia e hipercapnia.

Obstructive diseases of the pediatric airway are very frequent due to the mechanical phenomena that are involved. The marked resistance of the small airways, such as the lack of elastic tissue and a thoracic cage that is not yet well developed, both in its structure and in the musculature, will make it easier for infectious, mechanical (foreign body), compressive and other conditions to determine that the flows of air are limited and with it the alveolar ventilation. The physiological response with increased work of breathing is limited and therefore muscle fatigue will determine hypoventilation, with the consequences of hypoxemia and hypercapnia.

A guide to managing disorders of the ear pinna and canal.

This review will help you troubleshoot everything from infections and foreign bodies to trauma and neoplasm.

The Pathophysiology of Small Intestinal Foreign Body Obstruction and Intraoperative Assessment of Tissue Viability in Dogs: A Review.

Small intestinal foreign body obstructions occur commonly in dogs, accounting for 80% of all canine intestinal obstructions. Such obstructions induce local aberrations in secretion, absorption, and intestinal motility that can precipitate devastating systemic consequences, including a systemic inflammatory response, sepsis, and multiorgan dysfunction. Radiographic diagnosis is poorly sensitive relative to ultrasonography for diagnosing the presence of obstructive foreign material. Emergent surgical intervention is indicated for dogs with obstructive foreign material due to an inability to assess the degree of compromise of the intestinal wall that may precipitate intestinal perforation and to mitigate progression of life-threatening electrolyte and acid-base imbalances secondary to sequestration and emesis. Intraoperatively, an enterotomy or resection and anastomosis may be required to remove the obstructive material. A number of subjective and objective techniques for assessing the viability of intestinal tissue have been described due to the poor accuracy associated with surgeon assessment of color, peristalsis, pulsation, bleeding, and mural thickness alone. Such techniques have the potential to alter the surgeon's decision-making regarding performance of an enterotomy or resection and anastomosis, potentially reducing morbidity associated with intestinal surgery.

Natural elimination of a video capsule after retention for 1 year in a patient with small bowel Crohn disease: A case report.

INTRODUCTION: Video capsule endoscopy (VCE) is a useful tool to differentiate small intestinal bleeding, inflammatory bowel disease, and other small bowel disease. The most common adverse effect of VCE is capsule retention; the incidence varies greatly depending on the underlying disease, which is known to increase from 1.5% in healthy individuals to 21% in patients with small bowel Crohn disease. We report this case on a patient who had asymptomatic capsule retention for 12 months and experienced natural elimination with medication. PATIENT CONCERNS: A 21-year-old woman presented to the hospital with chronic abdominal pain and persistent diarrhea for 2 years. DIAGNOSES: The patient was diagnosed with small bowel Crohn disease using VCE, and radiography revealed capsule retention. INTERVENTION: Symptoms of obstruction were not distinctive, it was decided to increase the dosages of azathioprine and infliximab to 50 and 500 mg (10 mg/kg), at 5 months after VCE. And at month 11 of capsule retention, she was admitted and started on a regimen of hydrocortisol 300 mg for 4 days and hydrocortisol injection 200 mg for 10 days. OUTCOMES: At month 12, abdominal radiography in the clinic confirmed that the capsule had been naturally retrieved. LESSONS: Capsule retention could be initially treated conservatively with medication and if the treatment fails, it is recommended to remove the capsule surgically. But in the case of the clinical condition of the patient is favorable without symptoms of bowel obstruction, the medication should be continued and the patient followed up.

Outcome after iatrogenic esophageal perforation.

OBJECTIVES: Iatrogenic perforations are the most common cause of esophageal perforation. We present our experience mainly based on a non-operative treatment approach as well as long-term outcome in these patients. MATERIALS AND METHODS: Twenty-one patients were treated for iatrogenic esophageal perforation at Oslo University Hospital, Ullevål from February 2007 to March 2014. The etiology of perforation was dilation of benign stricture in eight patients, either dilation, stenting or stent removal in four with malignant stenosis, during diagnostic endoscopy in four, removal of foreign body in two and by other causes in three patients, respectively. After median 82 months, 10 patients alive (47.6%) were sent questionnaires about dysphagia, HRQoL and fatigue. RESULTS: Median age at time of treatment was 66 years. Median in-hospital stay and mortality were 10.5 days and 4.8%, respectively. Initial treatment in 15 patients (71.4%) was non-surgical of whom one needed delayed debridement for pleural empyema. Initial treatment in six patients (28.6%) was surgical of whom three needed delayed stenting. Altogether 14 patients (66.7%) were stented. Eight (57.1%) had restenting. Median number of stents used was 1 (1-4). The stents were removed after median 36 days. The perforations healed after 2.5 months. After median 82 months, the patients reported reduced HRQoL. There was no significant difference regarding level of dysphagia and fatigue. CONCLUSIONS: We report satisfactorily short-term and long-term results of iatrogenic esophageal perforations. Mortality was low and HRQoL was deteriorated. Dysphagia and fatigue were comparable to a reference population.

Fish Bone Foreign Body: The Role of Imaging

Abstract Introduction Fish bone foreign body (FFB) impaction in the upper aerodigestive tract is a common cause for emergency department referral. Its management varies in both diagnosis and treatment paradigms. Fish bone foreign bodies are more commonly found in the oropharynx in cases of patients < 40 years old, and in the esophagus in cases of patients > 40 years old. Symptoms are typically non-indicative for the location of the FFB, with the exception of foreign body sensation at/superior to the cervical esophagus. A lack of findings during the physical examination is routinely followed by imaging, with computed tomography (CT) being the preferred modality. In practice, many patients undergo unnecessary imaging studies, including CT scans. Objectives To identify patients with suspected fish bone impaction who do not require CT imaging and can be safely discharged. Data Synthesis We have searched the PubMed database for the following medical subject headings (MeSH) terms: fish bone, fish foreign body AND oropharynx, hypopharynx, esophagus, flexible esophagoscopy, and rigid esophagoscopy. Our search in the English language yielded 32 papers. Case reports were included, since they highlighted rare and serious complications. Conclusion In patients > 40 years old suspected of fish bone impaction, noncontrast CT is recommended and should be urgently performed, even in the presence of ambiguous symptoms. However, in patients < 40 years old presenting within 24 hours from ingestion, imaging has little diagnostic value due to the low probability of esophageal fish bones. For this specific subgroup, in the absence of clinical findings, discharge without imaging studies may be considered safe. (AU)

Intraabdominal Gossypibomas with variable CT appearance: A case report.

A retained surgical sponge or gossypiboma is a rare and an underreported complication occurring most commonly after abdominal surgeries. The clinical presentation as well as the time of presentation is variable with about one third of patients being asymptomatic. The diagnosis is challenging because of marked variation in the presentation and imaging plays a crucial role in diagnosis. We report a 30-year old Asian woman with prior history of Caesarean section who presented with persistent abdominal pain since surgery and underwent imaging in December 2012. The case is interesting as she had two intraabdominal gossypibomas with different appearances on computerized tomography. One was suggested to be a retained foreign body while the other was initially misinterpreted as a solid ovarian mass. However, on ultrasound, both lesions showed similar appearance and the left lower abdominal solid mass was also suggested to be a retained foreign body which was then confirmed on laparotomy.

Odyssey of an accidently ingested sewing needle from mouth to mesentery of small bowel in a young female - Case Report.

Foreign body (FB) ingestion is one of the most common complaint in the emergency room and, extra-intestinal migration of penetrating sharp FBs is one of the most overlooked aspect of medical research. We report a case of accidental ingestion of a sewing needle which was recovered from the mesentery. The 28-year-old female presented to our hospital with abdominal pain and one-month's history of needle ingestion. Initially laparoscopy was performed, which was inconclusive. Afterward, through laparotomy, the needle was successfully removed from the mesentery of small bowel.

Outcome after accidental food bolus-induced esophageal perforation.

OBJECTIVES: Food bolus-induced esophageal perforation is much more seldom than iatrogenic and emetic esophageal rupture. We present results from a non-operative treatment approach as well as long-term functional outcome. MATERIALS AND METHODS: Medical records of 10 consecutive patients with food bolus-induced esophageal perforation from October 2007 to May 2015 were retrospectively registered in a database. Six patients developed perforation related to endoscopic removal of impacted food, and four during esophageal passage of bone, meat or bread. Treatment was sealing the perforation by stenting (n = 7) with (n = 4) or without (n = 3) chest tube drainage, chest tube drainage (n = 1), observation (n = 1) and gastroesophageal resection (n = 1) because of concomitant emesis of gastric effluent. After median 51 months nine patients reported about dysphagia, fatigue and health-related quality of life. RESULTS: Ten patients aged median 62.5 years (range 30-85) stayed in our hospital for 12 days (5-68 days). There was no treatment-related mortality. Nine patients were alive 63 months (18-126) after perforation. Five needed restenting (leakage, migration, impacted stent), two had drainage of a mediastinal abscess, one patient developed a transient esophagobronchial fistula. Dysphagia score was 0 (0-1). One patient developed dysphagia for some solid food. Scores for fatigue and HRQoL was similar to a Norwegian reference population. CONCLUSION: Treatment mainly with a non-operative approach occurred without mortality. Complications were handled by restenting and abscess drainage. Functional result for dysphagia was excellent. Interesting results on fatigue and HRQoL must be interpreted with caution because of a limited patient material.

Cervical Esophagotomy for Foreign Body Extraction: A Case Report and Extensive Literature Review of the Last 20 Years.

BACKGROUND Voluntary and involuntary ingestion of foreign bodies is a common condition; in most cases they pass through the digestive tract, but sometimes they stop, creating emergency situations for the patient. We report a case of meat bolus with cartilaginous component impacted in the cervical esophagus, with a brief literature review. CASE REPORT A 64-year-old man came to our attention for retention in the cervical esophagus of a piece of meat accidentally swallowed during lunch. After a few attempts of endoscopic removal carried out previously in other hospitals, the patient has been treated by us with a cervical esophagotomy and removal of the foreign body, without any complications. We checked the database of PubMed, Scopus, and the Cochrane Library from January 2007 to January 2017 in order to verify the presence of randomized controlled trials, clinical trials, retrospective studies, and case series regarding the use of the cervical esophagotomy for the extraction of foreign bodies impacted in the esophagus. CONCLUSIONS The crucial point is to differentiate the cases that must be immediately treated from those requiring simple observation. Endoscopic treatment is definitely the first therapeutic option, but in case of failure of this approach, in our opinion, cervical esophagotomy could be a safe, easy, viable, durable approach for the extraction of foreign bodies impacted in the cervical esophagus. Our review does not have the purpose of providing definitive conclusions but is intended to represent a starting point for subsequent studies.

Paint in the Pipe: An Unusual Foreign Body.

BACKGROUND: Foreign bodies in the airway can be a diagnostic and therapeutic challenge. CASE CHARACTERISTICS: 30-month-old girl with complaints of noisy and fast breathing following fall over a pile of sand. Sand was suctioned out by direct bronchoscopy. The child improved initially but condition worsened in next four days with marked stridor and wheeze. OBSERVATION: Imaging revealed elongated sharp radiodense opacity in the cervical region, suggestive of foreign body. At repeat bronchoscopy, paint material was removed from the airway, leading to recovery. MESSAGE: Paint material mixed in the sand can adhere to the walls of the airway, and cause persistent symptoms of obstruction.