Mesenteric cystic lymphangioma in adults: a rare entity presenting as acute abdomen - a report of two cases

ABSTRACT Lymphangiomas are rare benign tumors that mainly involve the head and neck region in pediatric patients. Lymphangiomas of the small bowel mesentery in adults are rarer. We present two cases of mesenteric lymphangioma with acute abdominal pain on presentation. Case 1: A 38-year-old female presented with abdominal pain, vomiting, fever, and difficult evacuation. On abdominal examination, she had an ill-defined, tender lump, and radiological findings raised a possibility of perforation peritonitis. Thus, exploratory laparotomy was planned. Per-operatively, a mesenteric mass was found, which, on histopathological evaluation, was found to be a mesenteric lymphangioma involving the bowel. Case 2: A 27-year-old male presented with abdominal pain and difficult evacuation. Radiological evaluation revealed a multilobulated lesion involving the mesentery and with differential diagnoses of mesenteric fibromatoses and inflammatory pseudotumor. Histopathological assessment of the resected mass revealed a lymphangioma that was limited to the mesentery. Owing to their rarity and non-specific presentation, mesenteric lymphangiomas are often misdiagnosed on clinical examination and imaging. Thus, histopathological examination is the gold standard to reach a definitive diagnosis.

Aneurisma de arteria iliaca: una causa de dolor abdominal agudo de alto riesgo

El dolor abdominal de alto riesgo es una condición común en los servicios de emergencia y está asociado a una alta morbilidad y mortalidad, si no se diagnostica y trata de manera rápida y precisa. Un hombre con síntomas de cólico nefrítico se presentó en emergencia con dolor abdominal intenso y deterioro clínico. Después de una tomografía, se encontró una imagen aneurismática en la arteria iliaca común primitiva izquierda. El paciente fue trasladado a sala de operaciones para una reparación quirúrgica, pero falleció. El dolor abdominal de alto riesgo requiere un abordaje diagnóstico integral y tratamiento individualizado para prevenir complicaciones graves. El aneurisma de la arteria iliaca complicado es una causa potencialmente grave de dolor abdominal en hombres fumadores de edad avanzada con antecedentes de hipertensión y aterosclerosis.

Life-Threatening abdominal pain is a common condition in emergency departments and it is associated with high morbidity and mortality, if not promptly and accurately diagnosed and treated. A man with symptoms of renal colic presented to the emergency room with severe abdominal pain and clinical deterioration. After a CT scan, an aneurysmatic image was found in the left primitive iliac artery. The patient was taken to an operating room for surgical repair but died. Life-Threatening abdominal pain requires a comprehensive diagnostic approach and individualized treatment to prevent serious complications. The complicated iliac artery aneurysm is a potentially serious cause of abdominal pain in elderly male smokers with a history of hypertension and atherosclerosis.

Torsión primaria segmentaria del omento mayor: una causa infrecuente de abdomen agudo quirúrgico / Primary segmental torsion of the greater omentum: an uncommon cause of acute surgical abdomen

El abdomen agudo comprende un amplio grupo de enfermedades con alta incidencia en la práctica quirúrgica habitual. Se presenta el caso de un paciente masculino, de 23 años, con cuadro abdominal agudo, cuyo diagnóstico preoperatorio fue compatible con una apendicitis aguda; al efectuar la laparotomía exploratoria se constató torsión primaria y segmentaria del omento mayor. Esta es una afección de difícil diagnóstico preoperatorio, generalmente diagnosticada durante el acto quirúrgico porque fácilmente se confunde con otras enfermedades del abdomen agudo quirúrgico. Lo indicado en estos pacientes es la remoción del segmento involucrado por lo que se realizó omentectomía parcial y apendicectomía complementaria; el paciente presentó una evolución clínica favorable.

Acute abdomen comprises a wide group of diseases with a high incidence in routine surgical practice. We present a 23-year-old male patient with acute abdominal symptoms, whose preoperative diagnosis was compatible with acute appendicitis; primary and segmental torsion of the greater omentum was found when performing the exploratory laparotomy. This condition is difficult to diagnose preoperatively; it is generally evident during surgery because it is confused with other diseases of the acute surgical abdomen. The removal of the involved segment is indicated in these patients that is why partial omentectomy and complementary appendectomy were performed; the patient had a favourable clinical evolution.

Diffusion-weighted imaging versus non-contrast magnetic resonance imaging in the diagnosis of acute appendicitis during pregnancy

SUMMARY OBJECTIVE: The aim of this study was to evaluate the diagnostic performance of diffusion-weighted imaging compared to non-contrast magnetic resonance imaging in the differential diagnosis of acute appendicitis in pregnant patients. METHODS: A total of 72 pregnant patients with the suspicion of acute appendicitis who underwent magnetic resonance imaging combined with diffusion-weighted imaging examinations were enrolled in this retrospective study. Magnetic resonance imaging images (non-contrast and diffusion-weighted imaging sequences) were evaluated. Moreover, apparent diffusion coefficient ratios were estimated. The diagnostic performances of magnetic resonance imaging and diffusion-weighted imaging findings were statistically analyzed on the basis of surgical and follow-up results. RESULTS: Of 72 pregnant patients, 10 (14%) had acute appendicitis on magnetic resonance imaging and diffusion-weighted imaging. Among 10 patients with acute appendicitis, three (3/10) had perforation. diffusion-weighted imaging findings had higher sensitivity (90 versus 60%), negative predictive value (98.41 versus 93.94%), and accuracy (98.61 versus 94.44%) ratios compared to non-contrast magnetic resonance imaging in the diagnosis of acute appendicitis. There was one false-negative result on diffusion-weighted imaging. Diffusion restriction facilitated the detection of appendicitis. The apparent diffusion coefficient ratios were lower in acute appendicitis than in the normal appendix (0.70±0.19 versus 0.96±0.16) (p<0.05). CONCLUSION: With a shorter scan time and higher diagnostic accuracy, diffusion-weighted imaging can be useful for the early diagnosis of acute appendicitis and for planning appropriate management.

Acute abdomen in intensive care unit: etiology, comorbidity and severity of 1,523 patients / Abdome agudo em unidade de terapia intensiva: etiologia, comorbidades e severidade de 1.523 pacientes

ABSTRACT BACKGROUND: Clinical features and outcomes of patients admitted to the intensive care unit due to acute abdomen are important to be investigated. AIMS: To evaluate the outcomes of critically ill subjects with acute abdomen according to etiology, comorbidity and severity. METHODS: Outcomes of 1,523 patients (878 women, mean age 66±18 years) consecutively admitted to a specialized gastrointestinal intensive care unit with different causes of acute abdomen from January 2012 to December 2019, were retrospectively evaluated according to etiology, comorbidity and severity. RESULTS: The most common causes of acute abdomen were obstructive and inflammatory, particularly large bowel obstruction (27%), small bowel obstruction (18%) and acute pancreatitis (17%). Overall mortality was 13%. Surgery was required in 34% of patients. Median length of stay in the hospital was 9 [1-101] days. On univariate analysis mortality was significantly associated with age, APACHE II, Charlson comorbidity index, requirement for surgery and malignancy (p<0.0001), but only APACHE II, Charlson comorbidity index and surgical interventional remained significant on multivariate analysis. CONCLUSIONS: Critically ill patients admitted to the intensive care unit with acute abdomen constitute a heterogeneous group of subjects with different prognosis. Mortality is more related to the severity of the disease, comorbidity and need for surgery than to the etiology of the acute abdomen.

RESUMO RACIONAL: As características clínicas e os desfechos dos pacientes internados na unidade de terapia intensiva devido ao abdômen agudo são importantes serem investigados. OBJETIVOS: Avaliar os desfechos de indivíduos gravemente doentes com abdômen agudo de acordo com etiologia, gravidade e comorbidade. MÉTODOS: Os desfechos de 1.523 pacientes (878 mulheres, média de idade 66±18 anos) que foram previamente admitidos em uma unidade de terapia intensiva especializada em doenças gastrointestinais, com diferentes causas de abdômen agudo entre janeiro de 2012 e dezembro de 2019, foram avaliados retrospectivamente segundo etiologia, comorbidade e gravidade. RESULTADOS: As causas mais comuns de abdômen agudo foram obstrutivas e inflamatórias, com destaque para obstrução em colon (27%), em intestino delgado (18%) e pancreatite aguda (17%). A mortalidade geral foi de 13%. A cirurgia foi necessária em 34%. A média de permanência no hospital foi de 9 [1-101] dias. Na análise univariada a mortalidade foi significativamente associada à idade, APACHE II, índice de comorbidade de Charlson, necessidade de abordagem cirúrgica e presença de malignidade (p<0,0001), mas apenas APACHE II, índice de comorbidade de Charlson e intervenção cirúrgica permaneceram significativos na análise multivariada. CONCLUSÕES: Pacientes internados na unidade de terapia intensiva com abdômen agudo constituem um grupo heterogêneo de indivíduos com prognóstico diferente. A mortalidade está mais relacionada com a gravidade da doença, comorbidade e necessidade de cirurgia do que com a etiologia do abdome agudo.

Duodenitis eosinofílica asociada a alergia alimentaria debutando como dolor visceral agudo en un adulto con vitíligo: reporte de un caso

La duodenitis eosinofílica tiene una prevalencia entre 5,1 a 8,2 por 100000 personas. Se desconocen los mecanismos moleculares subyacentes de la enfermedad, pero la hipersensibilidad (alergias estacionales y alimentarias) juega un papel importante en su patogénesis, la predisposición alérgica se encuentra en el 25-35% de los casos. El diagnóstico incluye manifestaciones clínicas, hallazgos imagenológicos y evidencia histológica de infiltración eosinofílica >20 eosinófilos por campo de alto poder. Realizamos un informe de caso clínico y revisión de literatura. Hombre de 25 años con vitíligo que consulta a urgencias refiriendo síntomas de dispepsia, vómitos y dolor abdominal de máxima intensidad, en el examen médico se localiza dolor abdominal superior, con paraclínicos normales excepto un recuento de eosinófilos >2000 células/ul, la ecografía abdominal fue normal, la endoscopia superior reveló pangastritis eritematosa y duodenitis con pliegues rígidos y engrosados, la colonoscopia mostró hemorroides grado I. Coproscópico seriado negativo para parásitos, IgE total, IgA e IgG en rango normal, se reportó IgG positivo a Toxoplasma gondii, perfil de autoinmunidad negativo. En los siguientes 4 días aumenta el dolor abdominal y el recuento de eosinófilos, con endoscopia control y tomografía abdomino-pélvica contrastada que muestran duodeno edematizado con reflujo biliar severo, reporte histopatológico con duodenitis crónica atrófica y con pruebas para alergenos alimentarios positivo a cereales (centeno, soja, cebada), Manihot esculenta, plátano verde, tomate, leche de vaca, naranja y piña. Se indicó dieta restrictiva e inhibidor de la bomba de protones (pantoprazol), control ambulatorio a los 45 días de resolución de los síntomas con recuento de eosinófilos en sangre normal. Se presenta un caso de duodenitis eosinofílica relacionada con alergia alimentaria con mecanismos IgE independientes en un varón joven con vitíligo, que debutó con cuadro clínico inusual de dolor visceral agudo y reflujo biliar, que se resolvió con dieta de eliminación y pantoprazol sin uso de corticoides.

Background: Eosinophilic duodenitis has a prevalence of 5.1 to 8.2 per 100000 persons. The underlying molecular mechanisms are unknown, but hypersensitivity (seasonal and food allergies, asthma, eczema) response plays a major role in its pathogenesis, allergic predisposition can be found up-to 25-35% of cases. The diagnosis includes clinical manifestation, imaging findings and histological evidence of eosinophilic infiltration >20 eosinophils per high-power field. This is a clinical case report. a 25-years old man with vitiligo consult to emergency department referring dyspepsia symptoms, vomiting and abdominal pain of maximal intensity, in the medical exam upper abdominal pain was found, blood laboratories were unremarkable except a high net eosinophil-count >2000 cells/ul, abdominal ultrasound were normal, upper endoscopy revealed duodenitis with rigid and thickened folds, colonoscopy show hemorrhoids grade I. Coproscopy exam was negative for parasites, total IgE, IgA and IgG were in normal range, a positive IgG to Toxoplasma gondii was reported, autoimmunity panel was negative. In the following 4 days the abdominal pain and eosinophils count increase, a new abdomin-pelvic tomography was done showing thickened duodenum with a new endoscopy showing marked edema in duodenum with severe biliary reflux with biopsies describing an atrophic chronic duodenitis. Allergy tests -skin prick and patch tests- were done resulting positive to cereals (rye, soy, barley), Manihot esculenta, green banana, tomato, cow milk, orange and pineapple. A restrictive diet and protons pump inhibitor was indicated, ambulatory control at 45 days after show symptoms resolution with a normal blood eosinophils count. Here is reported a case of eosinophilic duodenitis related to food allergy in a young man with vitiligo debuting with an unusual clinical presentation of acute visceral pain and biliary reflux which resolved with elimination diet and pantoprazole without use of corticoids, with both, IgE and non-IgE mechanisms playing important roles explaining food sensitization.

Apendicitis aguda traumática. Reporte de caso / Traumatic acute appendicitis. A case report

RESUMEN Se presenta el caso de un hombre de 37 años sin antecedentes de dolor abdominal, o padecimiento de alguna enfermedad, que recibió un golpe directo con objeto romo (bate de béisbol) en el cuadrante inferior derecho del abdomen. Asistió a consulta con dolor abdominal selectivo en fosa ilíaca derecha, de aproximadamente 29 horas de evolución, que comenzó después de un trauma abdominal cerrado. Al examen físico se constata signo de Blumberg positivo, punto de McBurney doloroso con hiperestesia cutánea y cierto grado de defensa muscular. En los exámenes complementarios se comprueba leucocitosis y predominio de neutrófilos, con desviación a la izquierda. Se decidió realizar laparotomía exploratoria y se constató en el transoperatorio apendicitis aguda flegmonosa. La etiología traumática en la apendicitis aguda es un diagnóstico por exclusión que debe ser considerado en condiciones específicas.

ABSTRACT We present a 37 year-old man with no antecedents of abdominal pain, or suffering from other illnesses who received a direct blow with a blunt object (baseball bat) in the right lower quadrant of the abdomen. The patient was seen in consultation with a selective abdominal pain in his right iliac fossa, with approximately 29 hours of evolution that began after a closed abdominal trauma. A positive Blumberg sign, a painful McBurney's point with cutaneous hyperesthesia and certain grade of muscular defense were verified on physical exam. Leukocytosis and prevalence of neutrophils with left deviation were proven on complementary exams. An exploratory laparotomy was decided and a phlegmonous acute appendicitis was verified during the periprocedural period. Traumatic etiology in acute appendicitis is a diagnosis for exclusion that should be considered under specific conditions.

Advances in the application of transvaginal ultrasound in the diagnosis and treatment of ectopic pregnancy / 中国基层医药

Ectopic pregnancy is one of the most common acute abdominal diseases in gynecology. A ruptured ectopic pregnancy can lead to hemorrhagic shock, which is life-threatening. Therefore, early diagnosis and early treatment are extremely critical for preserving fertility and achieving good prognosis in patients with ectopic pregnancy. The available diagnostic methods of ectopic pregnancy include laboratory tests such as progesterone test, human chorionic gonadotropin test and ultrasound examination. Ultrasound examination can help determine the location of uterine and adnexal masses, gestational sacs, and germ, all of which are directly related to the final diagnosis regarding ectopic pregnancy. Ultrasound examination includes abdominal ultrasound and transvaginal ultrasound. Transvaginal ultrasound accesses to the focal tissue closer than abdominal ultrasound, and it does not require a full bladder. These advantages make clinical practice of transvaginal ultrasound easier for both physicians and patients. However, application of transvaginal ultrasound in the diagnosis of ectopic pregnancy requires further investigation to guide the early diagnosis and treatment of ectopic pregnancy. .

Practice and progress of interventional ultrasound in the diagnosis and treatment of acute abdomen / 国际外科学杂志

Acute abdominal pain is one of the most frequent complaints of patients presenting to the emergency department. Timely diagnosis and correct treatment affect the prognosis of patients. Traditional diagnosis mostly depends on physical examination and radiology. In terms of treatment, some patients need exploratory laparotomy. In recent years, with the development of interventional ultrasound, new techniques such as contrast-enhanced ultrasound, ultrasound-guided biopsy, drainage have been gradually applied to the diagnosis and treatment of surgical acute abdomen, especially the surgeon-performed interventional ultrasound, which has effectively improved the diagnostic efficiency and broadened the treatment choice. In this article, we aim to review and evaluate the application and progress of interventional ultrasound in the diagnosis and treatment of surgical acute abdomen.

Mannheim's peritonitis index in the prediction of postoperative outcome of peritonitis / O índice de peritonite de mannheim na predição do desfecho pós-operatório da peritonite

ABSTRACT Objective: evaluate the effectiveness of MPI to predict mortality in patients with peritonitis in Santa Casa de Misericordia de Vitoria Hospital (HSCMV). Methods: a longitudinal observational cohort retrospectively study, with a sample of 75 patients diagnosed with peritonitis between January 2010 to December 2 of 2015, in HSCMV and with all the necessary criteria for the calculation of IPM. Results: we found a profile of the patients, 33 female and 42 male, mean age 42 years, 11 deaths and 14.67% mortality percentage. Comparing the MPI variables into two groups (survivors and deceased) was found that older than 50 years, presence of malignancy and patients with organ dysfunction have statistical significance for mortality, with p<0.05. The MPI ranged between 4-41 points, with average of 21.2 points. However, among the dead, the score ranged from 23 to 41, with a mean of 32.8. Therefore, the cutoff point of 27 points was established by evaluating the best value of Kappa concordance index, and through it were calculated: 90.90% sensitivity and specificity of 78.13% by the ROC curve. Conclusion: based on these results, it was established that the MPI was effective in estimating the risk of death when the index reaches values = 27 points. Categorizing patients into different risk groups helps in determining a better prognosis and defining operative risk, thus contributing to the choice of the surgical procedure nature.

RESUMO Objetivo: avaliar a efetividade do índice de peritonite de Mannheim (IPM) para predizer mortalidade em pacientes com peritonite no Hospital Santa Casa de Misericórdia de Vitória (HSCMV). Método: Coorte longitudinal, observacional retrospectivo, com amostra de 75 pacientes diagnosticados com peritonite entre janeiro de 2010 a 02 de dezembro de 2015 no HSCMV, com todos os critérios necessários para o cálculo do IPM. Resultados: Encontrou-se um perfil dos pacientes, sendo 33 do sexo feminino e 42 do masculino, idade média de 42 anos, 11 óbitos e percentual de mortalidade de 14,67%. Comparando as variáveis do IPM em dois grupos (sobreviventes e falecidos), constatou-se que idade maior do que 50 anos, presença de malignidade e pacientes com disfunção de órgãos tiveram significância estatística para mortalidade, com p<0,05. O IPM variou entre 4 e 41 pontos, com média de 21,2 pontos. No entanto, entre os falecidos o escore variou de 23 a 41 pontos, com média de 32,8. Sendo assim, foi estabelecido o ponto de corte de 27 pontos através da avaliação do melhor valor do Índice Kappa de concordância, e através dele foram calculados: sensibilidade de 90,90% e especificidade de 78,13% através da curva ROC. Conclusão: Com base nesses resultados, foi visto que o IPM foi eficiente em estimar o risco de morte, sendo esse identificado quando o índice atinge valores = 27 pontos.

Tomografía abdominal sin contraste oral: evaluación de su rendimiento en el dolor abdominal agudo no traumático / Abdominal tomography without oral contrast: evaluation of its performance in acute non-traumatic abdominal pain

RESUMEN Objetivo: evaluar el rendimiento diagnóstico de la tomografía abdominal sin medio de contraste oral en pacientes con dolor abdominal. Materiales y métodos: se incluyeron tomografías de pacientes con dolor abdominal entre el 1 de septiembre y 31 de diciembre del 2015 en el Hospital Universitario San Vicente Fundación. Se analizó el desempeño de las tomografías con o sin contraste oral y se consideró como prueba de referencia el resultado diagnóstico definitivo en la intervención quirúrgica o por diagnóstico clínico. Se calculó la sensibilidad, especificidad y los valores predictivos positivos y negativos con intervalos de confianza del 95 %. Resultados: fueron evaluadas un total de 128 tomografías de abdomen, 91 con contraste oral y 37 sin él. La tomografía sin contraste oral tuvo una sensibilidad y especificidad muy similar a la que sí lo tenía, con valores de 84 % y 91,6 %, respectivamente. Conclusión: el rendimiento global de la tomografía con contraste oral fue similar a la que no lo tenía, con valores cercanos al 90 %. La adquisición de la tomografía con contraste oral tomó casi 3 veces más tiempo que el requerido en los estudios sin contraste oral.

SUMMARY Objective: Evaluate the diagnostic performance of abdominal tomography without oral contrast medium in patients with abdominal pain. Materials and methods: Abdominal tomographies of patients with abdominal pain were included, between September 1 and December 31, 2015 at the Hospital Universitario San Vicente Fundación. For the analysis of the tomographies with or without oral contrast, the definitive diagnostic result in the surgical intervention or by clinical diagnosis was considered as a reference test. We calculated the sensitivity, specificity and positive and negative predictive values with their respective 95% confidence intervals for tomography with and without oral contrast. Results: 128 abdominal tomographies, 91 with oral contrast and 37 without this type of contrast were evaluated. The tomography without oral contrast had a sensitivity and specificity very similar to the tomography with contrast, with values of 84% and 91.6%, respectively. Conclusion: The performance of the tomography with oral contrast was similar to the tomography without oral contrast, with values close to 90%. The acquisition of tomography with oral contrast took almost 3 times longer than that required in the studies without oral contrast.

Enterite mesentérica como complicação rara do lúpus eritematoso sistêmico / Mesenteric enteritis as a rare complication of systemic lupus erythematosus

A dor abdominal no paciente com lúpus eritematoso sistêmico tem amplo espectro clínico, variando desde condições inespecí- ficas, como diarreia e vômitos, até eventos de importante morbi- mortalidade, como o abdome agudo inflamatório e/ou perfura- tivo. A seguir, descreve-se um caso de paciente do sexo feminino, de 23 anos, internada por dor abdominal associada a vômitos e à diarreia crônica e progressiva. Foi diagnosticada com lúpus eritematoso sistêmico há 2 anos. Durante a internação, evoluiu com quadro de abdome agudo, e foi realizada tomografia compu- tadorizada de abdome, revelando importante edema de parede intestinal difuso. Isso, somado a alterações clínico-laboratoriais, permitiu o diagnóstico de enterite lúpica. Foi realizado tratamen- to conservador, com corticoterapia e terapia de suporte com correção de distúrbios eletrolíticos severos, sendo iniciado ciclo- fosfamida, com resolução dos sintomas gastrintestinais.

Abdominal pain in patients with systemic lupus erythematosus has a broad clinical spectrum, ranging from nonspecific symp- toms, such as diarrhea and vomiting, to events of significant morbidity and mortality, such as acute inflammatory and/or per- forating abdomen. This article describes a case of a 23-year-old female patient hospitalized for abdominal pain, associated with vomiting and progressive chronic diarrhea. She was diagnosed with systemic lupus erythematosus 2 years ago. During hospita- lization, the patient progressed with acute abdomen, and an ab- dominal computed tomography scan was performed, revealing major diffuse intestinal wall edema. This, added to clinical and laboratories alterations, allowed the diagnosis of lupus enteritis. A conservative treatment with corticotherapy and supportive therapy with correction of severe electrolyte disturbances were initiated, as well as the prescription of cyclophosphamide, with resolution of gastrointestinal symptoms.

Vólvulo de vesícula biliar, a propósito de un caso / Gallbladder Volvulus: a case report

RESUMEN Introducción: el vólvulo de la vesícula biliar se define como la torsión del órgano sobre su mesenterio a lo largo del eje del conducto y arteria cística, es una enfermedad rara, que ocurre con mayor frecuencia en mujeres ancianas. Presentación del caso: se trata de una paciente femenina de 46 años de edad, de color de piel blanca, con antecedentes patológicos personales de úlcera duodenal, que practica hábitos tóxicos como el fumar y la ingestión de café. No se ha sometido con anterioridad a procederes quirúrgicos. Acude a cuerpo de guardia de Cirugía General del Hospital Clínico Quirúrgico Provincial Abel Santamaría Cuadrado de Pinar del Río con dolor en hipocondrio derecho, de leve intensidad y de aproximadamente 24 horas de evolución, acompañado de náuseas y dos vómitos con restos de alimentos. Se le diagnostica vólvulo de vesícula biliar, por lo cual recibe tratamiento quirúrgico. Conclusiones: el vólvulo de vesícula biliar, enfermedad infrecuente de gran similitud clínica a otras patologías de abdomen agudo, hace muy complejo su diagnóstico preoperatorio. No obstante, el advenimiento de las nuevas técnicas imagenológicas maniobradas por especialistas capacitados, junto con la correcta aplicación del método clínico epidemiológico facilitaron la capacidad diagnóstica que permitiera a los cirujanos tomar la decisión terapéutica acertada para el paciente, con resultados satisfactorios.

ABSTRACT Introduction: gallbladder volvulus is defined as the twisting of the organ over its mesentery along the axis of the duct and cystic artery; it is a rare disease, which more frequently occurs in older women. Case report: a 46 year-old, white skin color female patient, with personal pathological history of duodenal ulcer, having smoking and coffee ingestion habits, who has not previously undergone surgical procedures, she comes to the emergency room of the General Surgery Department at Abel Santamaria Cuadrado Provincial General Hospital in Pinar del Río referring pain in right hypochondriac region, of slight intensity and of approximately 24 hours of evolution; accompanied by nausea and two vomits with food remains. He is diagnosed with gallbladder volvulus, undergoing surgical treatment. Conclusions: gallbladder volvulus, an infrequent entity of great clinical similarity to other pathologies of the acute abdomen, makes a very complex pre-surgical diagnosis; nevertheless, the introduction of new imaging techniques performed by trained specialists, together with the accurate application of the clinical epidemiological method facilitated the diagnostic capacity, allowing the surgeons to take a correct and timely therapeutic decision for the patient and with satisfactory results.

Application of perioperative nutritional support in enhanced recovery after surgery / 中国医师杂志

Objective:To explore the value and advantages of perioperative nutritional support in enhanced recovery after surgery (ERAS).Methods:The clinical data of patients admitted to Jinjiang City Hospital for acute abdomen and undergoing surgery from April 2018 to January 2021 were collected. They were divided into two groups: the enhanced recovery after surgery group (ERAS group, 78 cases) and the traditional perioperative management group (CPM group, 75 cases). The nutritional risk assessment of NRS2002 was performed on admission to the two groups. The postoperative inflammatory indexes, nutrition and rehabilitation related indexes were compared between the two groups.Results:There was no significant difference in preoperative NRS 2002 score, operation method, operation time and blood loss between ERAS group and CPM group ( P>0.05). There was no significant difference in C-reactive protein (CRP), albumin (Alb) and prealbumin (PA) between ERAS group and CPM group before operation ( P>0.05). The ALb and PA of the two groups on the first day after operation were significantly lower than those before operation, and the CRP levels on the first, third, fifth and seventh day after operation were higher than those before operation( P<0.05), with significant difference. The CRP level of ERAS group was lower than that of CPM group on the third day after operation, with significant difference ( P<0.05). On the 7th day after operation, the levels of Alb and PA in ERAS group were higher than those in CPM group ( P<0.05). The recovery time of gastrointestinal function and hospitalization days in ERAS group were significantly reduced, and the total cost of hospitalization was significantly less than that in CPM group ( P<0.05). Conclusions:Perioperative effective nutritional support is helpful to accelerate the recovery of patients with acute abdomen. The application of enhanced recovery after surgery can effectively improve the nutritional status of patients with acute abdomen, reduce the incidence of complications and improve the clinical outcome of patients.

Application of minimally invasive technique in the diagnosis and treatment of acute abdomen / 国际外科学杂志

Acute abdomen is often a general term for abdominal diseases with acute abdominal pain as the main manifestation. Common clinical acute abdomen includes acute appendicitis, acute cholecystitis, acute cholangitis, acute pancreatitis, gastrointestinal perforation, intestinal obstruction and other diseases, its characteristics are great changes, rapid progress, high misdiagnosis rate, high postoperative complication rate and high mortality rate, accurate diagnosis and early treatment can obtain a good prognosis. With our in-depth understanding of the occurrence and development of acute abdomen diseases and the development of evidence-based medicine, minimally invasive technology plays a pivotal role in the diagnosis and treatment of common acute abdomen. Laparoscopy on diagnosis can clarify disease diagnosis to a large extent. For those who cannot undergo surgery, decompression and drainage under endoscopy provides a diversified plan for treatment decisions. In addition, minimally invasive techniques are also used in etiological treatment and complications. Disease, prevention of recurrence in all aspects, Minimally invasive technology is beneficial to the etiological treatment of biliary pancreatitis, appendicitis and cholangitis, and endoscopic technology is more consistent with the minimally invasive concept in the treatment of complications.

Application of minimally invasive technique in the treatment of acute obstructive suppurative cholangitis / 国际外科学杂志

Acute obstructive suppurative cholangitis (AOSC) is one of the common surgical acute abdomen. It often causes the increase of intrabiliary pressure due to biliary obstruction, resulting in various clinical symptoms. The onset is urgent and the disease progresses quickly. It is the primary cause of death of benign biliary diseases. Timely biliary decompression and bile drainage are the key to treat AOSC and save the lives of patients. With the continuous progress of the concept of enhanced recovery after surgery and minimally invasive technical means, minimally invasive technical means such as endoscopic retrograde cholangiopancreatography, ppercutaneous transhepatic catheterizde drainage and endoscopic ultrasound guided biliary drainage have gradually become the preferred treatment for AOSC, playing a more and more important role in the treatment of AOSC. Combined with relevant research literature and the author′s personal experience in the treatment of AOSC with these technologies, this paper introduces the application value, advantages and disadvantages of the above three minimally invasive technologies in the treatment of AOSC.

Miomectomía durante el embarazo: leiomioma gigante con degeneración / Miomectomy during pregnancy: giant leiomyoma with degeneration

Resumen ANTECEDENTES: Los leiomiomas son los tumores pélvicos más comunes, con múltiples presentaciones clínicas a lo largo de la vida de la mujer. Es inusual que aparezcan durante el embarazo y que ameriten tratamiento quirúrgico, sobre todo por abdomen agudo secundario a degeneración. OBJETIVO: Aportar y exponer el proceso de diagnóstico, tratamiento quirúrgico y desenlace obstétrico en una paciente con un leiomioma gigante con degeneración asociado al embarazo. CASO CLÍNICO: Paciente de 34 años, primigesta, con 22.1 semanas de embarazo. Acudió a Urgencias con abdomen agudo, fiebre y daño ventilatorio secundario a un leiomioma gigante que ocupaba la totalidad del abdomen y comprimía las estructuras abdominales y torácicas. Debido al deterioro clínico se decidió la intervención quirúrgica para extraer los dos miomas: el mayor de 35 x 20 cm y 9150 g. La evolución posoperatoria fue favorable lo mismo que el control prenatal. La finalización del embarazo fue por cesárea electiva a las 38.1 semanas, sin complicaciones maternas ni perinatales. CONCLUSIÓN: La miomectomía durante el embarazo es un procedimiento seguro para disminuir la morbilidad y la mortalidad materna y fetal en casos seleccionados.

Abstract BACKGROUND: Leiomyomas are the most common pelvic tumors, with multiple clinical presentations throughout a woman's life. It is unusual for them to appear during pregnancy and to merit surgical treatment, especially for acute abdomen secondary to degeneration. OBJECTIVE: To provide and expose the process of diagnosis, surgical treatment and obstetric outcome in a patient with a giant leiomyoma with pregnancy-associated degeneration. CLINICAL CASE: A 34-year-old primigravida patient, 22.1 weeks pregnant. She came to the emergency department with acute abdomen, fever and ventilatory impairment secondary to a giant leiomyoma that occupied the entire abdomen and compressed abdominal and thoracic structures. Due to the clinical deterioration, surgery was decided to remove the two fibroids: the larger one measuring 35 x 20 cm and weighing 9150 g. The postoperative evolution was favorable. The postoperative evolution was favorable as well as the prenatal control. The pregnancy was terminated by elective cesarean section at 38.1 weeks, without maternal or perinatal complications. CONCLUSION: Myomectomy during pregnancy is a safe procedure to reduce maternal and fetal morbidity and mortality in selected cases.

Síndrome de Valentino: una causa no común de abdomen agudo. Reporte de un caso / Valentino Syndrome: an uncommon cause of acute abdomen. Case Report.

INTRODUCCIÓN: El síndrome de Valentino es la perforación de una úlcera péptica a nivel gástrico o duodenal, en donde el paciente se presenta de forma atípica, con un cuadro clínico sugerente de apendicitis aguda, asociado a peritonitis localizada. Al ser una entidad con escasos reportes a nivel mundial y con ningún caso documentado en el Ecuador, es fundamental difundir el presente caso clínico para conocimiento de la comunidad médico-científica. CASO CLÍNICO: Paciente masculino de 63 años, acudió a servicio de emergencia con dolor abdominal de 12 horas de evolución localizado en fosa iliaca derecha asociado a signos de irritación peritoneal y descompensación hemodinámica, sugestivo de peritonitis. Se realizó laparotomía exploratoria. EVOLUCIÓN: En el procedimiento quirúrgico no se evidenciaron cambios inflamatorios en el apéndice y tras la exploración de la cavidad abdominal se encontró una úlcera gástrica perforada; se realizó rafia primaria en dos planos, apendicectomía incidental, más lavado de cavidad abdominal. Paciente con recuperación exitosa, se indicó alta médica al séptimo día de hospitalización. CONCLUSIÓN: La perforación de una úlcera péptica puede generar un cuadro clínico de dolor en fosa ilíaca derecha, que puede confundirse con una apendicitis aguda debido a su similitud clínica. El equipo médico debe considerar al Síndrome de Valentino como un diagnóstico diferencial importante durante la evaluación del paciente que llega a la emergencia con cuadro clínico de dolor abdominal sugestivo de apendicitis aguda.

BACKGROUND: Valentino's syndrome is secondary to a perforated peptic ulcer, which could be located in the stomach or the duodenum, patients present with clinical features that suggest acute appendicitis, with localized peritonitis. There are few case reports about this syndrome worldwide and no one submitted in Ecuador. It is essential to transmit this clinical case for the knowledge of the medical- scientific community. CASE REPORT: A 63-year-old male patient came to the emergency department with abdominal pain, located in the right iliac fossa, that began 12 hours ago, associated to peritoneal irritation signs and hemodynamic decompensation; suggestive of peritonitis. An exploratory laparotomy was performed. EVOLUTION: During exploratory laparotomy, no inflammatory changes were identified in the appendix. After abdominal cavity exploration, a perforated gastric ulcer was found. Primary raffia was stitched in two planes, incidental appendectomy and lavage of the abdominal cavity were performed. The patient had a successful recovery; and was discharged after 7 days at hospitalization. CONCLUSION: The perforation of a peptic ulcer can generate right iliac fossa pain, simulating acute appendicitis due to its clinical similarity. The medical team should consider Valentino's Syndrome as an important differential diagnosis during the evaluation of a patient that arrives to the emergency room with abdominal pain, suggestive of appendicitis.

Apendicitis aguda por hidatidosis apendicular: reporte de caso y revisión de la literatura / Acute appendicitis caused by echinococcus granulosus: report of a case and literature review

RESUMEN La apendicitis aguda es considerada la causa más común de emergencia quirúrgica en adultos jóvenes; y su asociación con infecciones parasitarias es rara. De éstas, la localización apendicular del quiste hidatídico, es extremadamente rara; y hasta la fecha solo existen reportes en Irán, India, Túnez, Chile y Perú. Se presenta el caso de un paciente varón de 52 años, natural de Puno, sin antecedentes patológicos, que ingresa con un cuadro clínico típico de apendicitis aguda, y que, al ser intervenido quirúrgicamente, se aprecia al apéndice con una tumoración quística, compatible con un quiste hidatídico complicado de Echinococcus granulosus. Posteriormente, se constatan otros tres quistes hidatídicos intrabdominales. No existió antecedente quirúrgicoo traumático, por lo que se considera una localización primaria intraabdominal diseminada, que incluía al apéndice, hígado y peritoneo.

ABSTRACT Acute appendicitis is the most frequent surgical emergency instance in young adults; and its association with parasitic infections is rare. Of these particular cases, appendix location of hydatid cyst is extremely rare; and there have been published reports of such cases only in Iran, India, Tunisia, and Peru. We present the case of a 52-year old male subject born in Puno, with no relevant past medical history, who was admitted with a clinical condition typically consistent with acute appendicitis. When this patient underwent surgery, the appendix was found showing a cystic mass, compatible with complicated Echinococcus granulosus hydatid cyst. Later on, three additional intraabdominal hydatid cysts were identified. There was no surgical or trauma past history, so it was concluded this condition corresponded to disseminated primary intraabdominal location of hydatid disease, including the appendix, liver, and peritoneum.

Enteritis eosinofílica, una causa extraña de abdomen agudo. reporte de caso clínico / Eosinophilic enteritis, a strange cause of acute abdomen Clinical case report

La enteritis eosinofílica, es una patología rara, caracterizada por infiltración de eosinófilos en una o más capas histológicas en diferentes niveles del tracto gastrointestinal, siendo el estómago e intestino delgado los más afectados; su cuadro clínico, inespecífico, caracterizado por dolor abdominal, náusea, vómito, diarrea o estreñimiento, pérdida de peso y ascitis, con presencia o ausencia de eosinofilia en la biometría. Reporte de caso Paciente masculino de 51 años de edad, acudió a emergencia por distensión abdominal y náusea, al examen físico en la palpación intenso dolor y distención abdominal, percusión timpánico y abolición de ruidos hidroaéreos. La analítica reportó leucocitosis con neutrofilia, radiografía de abdomen íleo adinámico, en la ecografía abdominal presencia de imágenes tubulares con aspecto de diana, asociado a líquido libre purulento en fosa ilíaca derecha y fondo de saco vésico rectal. Un cuadro clínico compatible con abdomen agudo de resolución quirúrgica, se realizó laparotomía exploratoria (AU);

The eosinophilic enteritis is a rare pathology, characterized by infiltration of eosinophils in one or more histological layers at different levels of the gastrointestinal tract, the stomach and small intestine being the most affected; its nonspecific clinical picture, characterized by abdominal pain, nausea, vomiting, diarrhea or constipation, weight loss and ascites, with the presence or absence of eosinophilia in the biometry. Enteritis eosinofílica, una causa extraña de abdomen agudo. reporte de caso clínico Eosinophilic enteritis, a strange cause of acute abdomen year-old male patient came to the emergency room due to abdominal distention and nausea, to physical examination on palpation, intense abdominal pain and distention, tympanic percussion and abolition of air-fluid sounds. Laboratory analysis reported leukocytosis with neutrophilia, abdominal ileus adynamic radiography, abdominal ultrasound presence of tubular images with a target appearance, associated with free purulent fluid in the right iliac fossa and rectal vesicum fundus. A clinical picture compatible with an acute abdomen with surgical resolution, an exploratory laparotomy was performed (AU);