Enfrentamiento del paciente con dolor abdominal / Approach to the patient with abdominal pain

El dolor abdominal es una causa frecuente de consulta ambulatoria, sus causas son múltiples e incluyen patologías de riesgo vital u otras de bajo riesgo que requieren principalmente tratamiento y no requieren mayores estudios. La historia clínica y el examen físico son las herramientas principales para poder sospechar la etiología de la enfermedad que está causando el dolor abdominal. Es por esto que realizar una historia completa, haciendo preguntas dirigidas a confirmar o descartar sospechas diagnósticas, asociado a un examen físico completo y sistemático, es la principal forma de orientar el diagnóstico y estudio posterior del paciente. Conocer el cuadro clínico de las enfermedades que dentro de sus síntomas pueden presentar dolor abdominal, especialmente aquellas que son de riesgo vital permite poder diagnosticarlas con la rapidez que se requiere. Así mismo, es necesario reconocer aquellas enfermedades que son más frecuentes y que no requieren mayores estudios sino tratamiento básico, habitualmente ambulatorio. Existen personas que, por sus condiciones de salud o edad, pueden tener presentaciones atípicas de cuadros habituales o mayores riesgos de tener enfermedades infrecuentes o de mayor riesgo vital, que es importante reconocer al momento de la evaluación.

Abdominal pain is a common complaint in ambulatory medicine. It has multiples causes,including lifethreatening pathologies and other benign in which the need in treatment and no other tests. The clinical history and physical examination are the key to suspect the etiology of the underlying disease. A complete history includes make direct questions to confirm or discard the diagnostic suspects and with a complete and systematic physical examination are the main way to get the diagnosis and treatment of the patient. The clinician must know the syndromes which includes abdominal pain, especially those life-threatening which requires urgent treatment or surgery. Also needs to know the frequent benign syndromes that can be safely treated symptomatically with no further investigation. Older adults or patients with comorbidities may present with unusual causes of abdominal pain or may have an atypical presentation of common disorders. Also, may present more frequent serious etiologies that may require urgent interventions.

Dolor abdominal crónico en un niño con Blastocystis hominis: a propósito de un caso / Chronic abdominal pain in a child with Blastocystis hominis: case report

RESUMEN El Blastocystis sp. es un parásito frecuente en el humano, identificado por el laboratorio en muestras de heces fecales. Se presentó el caso de un paciente de 5 años atendido en consulta de Gastroenterología en el Hospital Pediátrico Docente Provincial Eliseo Noel Caamaño, de Matanzas, por presentar dolor abdominal, heces pastosas, náuseas y vómitos desde hacía un año. Llevó tratamiento con ranitidina, omeprazol y domperidona, sin mejoría clínica. Se realizó estudio coproparasitológico en muestras de heces fecales seriadas, con la presencia del Blastocystis hominis. Se indicó tratamiento con metronidazol, sin mejoría clínica, y posteriormente se indicó como alternativa la nitazoxanida. Se evaluó a los 15 días, sin sintomatología y con negativización de las heces fecales seriadas. Resulta frecuente el desconocimiento y la poca importancia que los profesionales sanitarios muestran ante esta infestación, aunque cada vez más se confirma la participación del parásito en manifestaciones clínicas (AU).

ABSTRACT Blastocystis sp. is a frequent parasite in humans, identified in the laboratory in samples of fecal feces. The case of a 5-year-old patient is presented; he assisted the consultation of Gastroenterology in the Provincial Teaching Pediatric Hospital Eliseo Noel Caamaño in Matanzas, suffering abdominal pain, mash feces, nauseas and vomits for one year, and was treated with ranitidine, omeprazole and domperidone without clinical improvement. A coproparasitological study was carried out in serial fecal feces samples with the presence of Blastocystis hominis. Treatment with metronidazole was indicated without clinical improvement and them, as an alternative, nitazoxanide was indicated. He was evaluated at 15 days without symptoms and with negative serial fecal feces. The ignorance and the little importance that health professionals show towards this infestation are frequent, although more and more frequently it is confirmed the participation of the parasite in clinical manifestations (AU).

Neuroendocrine tumor in a child with common variable immunodeficiency / Tumor neuroendócrino em criança com imunodeficiência comum variável

ABSTRACT Objective: To report a case of a child with primary immunodeficiency who at eight years developed digestive symptoms, culminating with the diagnosis of a neuroendocrine tumor at ten years of age. Case description: One-year-old boy began to present recurrent pneumonias in different pulmonary lobes. At four years of age, an immunological investigation showed a decrease in IgG and IgA serum levels. After the exclusion of other causes of hypogammaglobinemia, he was diagnosed with a Common Variable Immunodeficiency and started to receive monthly replacement of human immunoglobulin. The patient evolved well, but at 8 years of age began with epigastrium pain and, at 10 years, chronic persistent diarrhea and weight loss. After investigation, a neuroendocrine tumor was diagnosed, which had a rapid progressive evolution to death. Comments: Medical literature has highlighted the presence of gastric tumors in adults with Common Variable Immunodeficiency, emphasizing the importance of early diagnosis and the investigation of digestive neoplasms. Up to now there is no description of neuroendocrine tumor in pediatric patients with Common Variable Immunodeficiency. We believe that the hypothesis of digestive neoplasm is important in children with Common Variable Immunodeficiency and with clinical manifestations similar to the case described here in the attempt to improve the prognosis for pediatric patients.

RESUMO Objetivo: Relatar um caso de criança portadora de imunodeficiência primária que, aos oito anos, desenvolveu sintomas digestivos, culminando com o diagnóstico de tumor neuroendócrino aos dez anos de idade. Descrição do caso: Menino, com um ano de idade, começou a apresentar pneumonias de repetição em diferentes lobos pulmonares. Aos quatro anos, a investigação imunológica mostrou diminuição dos níveis séricos de IgG e IgA. Após exclusão de outras causas de hipogamaglobulinemia, teve diagnóstico de imunodeficiência comum variável, passando a receber reposição mensal de imunoglobulina humana. Evoluiu bem, porém, aos oito anos, começou com epigastralgia e, aos dez anos, diarreia crônica persistente e perda de peso. O quadro culminou com o diagnóstico de tumor neuroendócrino intestinal, de rápida progressão, com óbito do paciente. Comentários: A literatura tem chamado a atenção para tumores gástricos em adultos com imunodeficiência comum variável, alertando para a importância do diagnóstico precoce e da pesquisa de neoplasias digestivas. Até o momento, não há descrição de tumor neuroendócrino em pacientes pediátricos portadores de imunodeficiência comum variável. Acredita-se ser importante a hipótese de neoplasia digestiva diante de crianças com imunodeficiência comum variável e com manifestações clínicas semelhantes ao caso descrito, na tentativa de melhorar o prognóstico para pacientes pediátricos.

Pediatric appendicitis: age does make a difference / Apendicite em pediatria: a idade é importante

ABSTRACT Objective: To investigate the influence of patient age on the diagnosis and management of appendicitis, as well as to evaluate the rate of complications according to the age group. Methods: We undertook a retrospective analysis of 1,736 children who underwent laparoscopic appendectomy in our center between January 2000 and December 2013. Patients were divided in groups taken into account their age: group A were infants, group B were preschoolers, group C were those ones older than five years old, and group D were those ones younger than five years old. A p value of 0.05 was considered statistically significant. Results: We found higher incidence of misdiagnosis and atypical symptoms in the youngest patients. The rate of perforation was similar between group A and B (p=0.17). However, it was higher in group D than in group C (p<0.0001). The incidence of postoperative complications was higher in the youngest patients too (p=0.0002). Conclusions: The age does make a difference in acute appendicitis. Because of its unusual presentation in children younger than five years old, it is often misdiagnosed, which leads to an increased morbidity. Although clinical presentation varies between infants and preschoolers, no statistically significant differences were observed in the rate of perforated appendix or postoperative complications.

RESUMO Objetivo: Investigar a influência da idade do paciente no diagnóstico e tratamento de apendicite, bem como avaliar a frequência de complicações dependendo da faixa etária. Métodos: Análise retrospectiva dos 1.736 pacientes pediátricos que foram submetidos à apendicectomia laparoscópica em nosso hospital de janeiro de 2000 a dezembro de 2013. Os pacientes foram divididos em grupos de acordo com sua idade: grupo A eram crianças, grupo B eram pré-escolares, grupo C eram maiores de cinco anos de idade e grupo D eram menores de cinco anos de idade. Considerou-se estatisticamente significante p-valor <0,05. Resultados: Encontramos maior incidência de diagnóstico incorreto e sintomas atípicos em pacientes mais novos. A taxa de perfuração foi semelhante entre os grupos A e B (p=0.17); foi maior, porém, no grupo D que no grupo C (p<0.0001). A incidência de complicações no pós-operatório também foi maior em pacientes mais novos (p=0.0002). Conclusões: A idade faz diferença em casos de apendicite aguda. Por causa da sua apresentação rara em crianças menores de cinco anos, é frequentemente diagnosticada incorretamente, o que aumenta a morbidade. Apesar de sua apresentação clínica variar entre lactentes e pré-escolares, não foram observadas diferenças estatisticamente significativas na proporção de apêndices perfurados nem na de complicações pós-operatórias.

Dificultades en el diagnóstico de enteritis lúpica: presentación de un caso / Lupus enteritis: report of one case

In lupus enteritis, circulating pathological immune complexes and thrombosis of intestinal vessels may occur, resulting in acute abdominal pain. We report a 24-year-old woman without a history of systemic lupus erythematosus (SLE), admitted for abdominal pain. An exploratory laparotomy found an appendicitis along with ascites. An appendectomy was performed, and the patient was discharged from the hospital two days later. Three days after discharge, the patient was admitted to another hospital due to the persistence of abdominal pain. An abdominal computed tomography scan showed diffuse mesenteric congestion, concentric bowel loops (double halo or target sign) and the presence of free fluid in the peritoneal cavity. Suspecting a rheumatic disorder, the diagnosis of SLE was confirmed by immunological studies. The patient was treated with pulses of methylprednisolone with good results.

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.

Impact of the appendiceal position on the diagnosis and treatment of pediatric appendicitis / Impacto da posição do apêndice sobre o diagnóstico e tratamento de apendicite da infância

ABSTRACT Objective: To investigate how symptoms vary according to the appendiceal position in pediatric patients and to demonstrate that the laparoscopic approach is safe and effective in any appendiceal location by comparing each location to another. Methods: The medical records of 1,736 children aged 14 or younger who underwent laparoscopic appendectomy over a period of 14 years were analyzed retrospectively. Patients were divided according to the position of the appendiceal tip into four groups: anterior, pelvic, retrocecal and subhepatic. The Kruskal-Wallis and chi-square tests were used with the Bonferroni correction, with a significant p<0.05. Results: The appendiceal location was anterior in 1,366 cases, retrocecal in 248 cases, pelvic in 66 cases and subhepatic in 56 cases. There were no significant differences between the groups in terms of patient age and gender. Abdominal pain was the only symptom with statistically significant differences between the groups. The rate of perforated appendicitis was higher in the subhepatic and pelvic positions. Intraoperative complications and conversions were not statistically significant. Technical difficulties and operative time were higher in subhepatic position. The rate of postoperative complications was similar between the different locations, except for bowel obstruction, which was higher in pelvic appendicitis. Conclusions: The clinical symptoms of appendicitis hardly ever change with the position of the appendix. The laparoscopic approach is safe and effective, regardless the appendiceal location.

RESUMO Objetivo: Investigar como os sintomas variam de acordo com a posição do apêndice em pacientes pediátricos e demonstrar que a laparoscopia é segura e eficaz em qualquer posição do apêndice, comparando-as. Métodos: Os prontuários de 1.736 pacientes pediátricos com idade ≤14 anos submetidos à apendicectomia laparoscópica em um período de 14 anos foram analisados retrospectivamente. Os pacientes foram divididos de acordo com a posição do apêndice: anterior, pélvica, retrocecal e sub-hepático. Os testes de Kruskal-Wallis e do qui-quadrado foram usados com a correção de Bonferroni, sendo significante p<0,05. Resultados: A posição do apêndice era anterior em 1.366 casos, retrocecal em 248 casos, pélvica em 66 casos e sub-hepática em 56 casos. Não houve diferenças significativas entre os grupos quanto às variáveis idade e sexo. A dor abdominal foi a única variável com diferenças estatisticamente significantes entre os grupos. A taxa de apêndice perfurado foi superior nas posições sub-hepática e pélvica. As complicações intraoperatórias e a taxa de conversão não foram estatisticamente significativas. As dificuldades técnicas e o tempo cirúrgico foram superiores em posição sub-hepática. A taxa de complicações pós-operatórias foi semelhante entre as diferentes posições, exceto a obstrução intestinal, que foi superior em posição pélvica. Conclusões: Os sintomas da apendicite dificilmente variam com a posição do apêndice. A laparoscopia é segura e eficaz, independentemente da posição do apêndice.

Proposta de escore preditor de desfechos para abdome agudo / Outcomes prediction score for acute abdomen: a proposal

RESUMO Objetivo: estabelecer a correlação entre dados objetivos coletados na avaliação inicial e os desfechos nos casos de dor abdominal aguda. Métodos: estudo retrospectivo, de caso controle, em que foram revisados prontuários de pacientes atendidos em um serviço de urgência e emergência no ano de 2016, diagnosticados com dor abdominal e pélvica. Resultados: de 2.352 prontuários avaliados, 330 foram considerados válidos para o estudo. Destes pacientes, 235 (71,2%) receberam alta e os 95 (28,8%) restantes foram internados, submetidos à cirurgia ou morreram. A análise estatística demonstrou que sexo masculino, idade ≥50 anos, temperatura axilar >37,3ºC, anemia, leucocitose >10.000/mm3, neutrocitose acima de 7.700/mm3, linfopenia <2.000/mm3 e hiperamilasemia são variáveis isoladamente associadas a pior desfecho. Conclusão: a presença de três ou mais das variáveis avaliadas aumenta fortemente a chance de um paciente sofrer os desfechos de cirurgia ou morte, sendo a chance de óbito tanto maior quanto maior o número de variáveis presentes.

ABSTRACT Objective: to establish a correlation between objective data collected at the initial evaluation and the outcomes in cases of acute abdominal pain. Methods: we conducted a retrospective, case-control study in which we reviewed medical records of patients treated at an emergency room in 2016, diagnosed with abdominal and pelvic pain. Results: of the 2,352 medical records evaluated, we considered 330 valid for the study. Of these patients, 235 (71.2%) were discharged and the remaining 95 (28.8%) were hospitalized, submitted to surgery, or died. The statistical analysis demonstrated that male gender, age ≥50, axillary temperature >37.3ºC, anemia, leukocytosis >10,000/mm3, neutrophil count above 7,700/mm3, lymphocyte count less than 2,000/mm3 and hyperamylasemia were variables in independently associated with worse outcome. Conclusion: the presence of three or more of the evaluated variables greatly increases the chances of a patient suffering the outcomes of surgery or death, the chance of death being greater the greater the number of variables present.

Dolor y distensión abdominal: abordaje diagnóstico a distintas edades / Abdominal pain and distention: diagnostic approach at different ages

Fluctuating abdominal pain and bloating suggest gastrointestinal origin with multiple causes. In adults, patients fulfilling the Rome criteria for irritable bowel syndrome (IBS) have a low probability of neoplasms or intestinal inflammatory diseases. In these patients it is cost effective to request fecal calprotectin and celiac disease serology. Due to the high probability of nocebo effect, the diagnosis of sensitivity to non celiac and food allergies should require a blind rechallenge. It is recommended to evaluate other non ominous diagnostic options in a second stage if there is not good control of symptoms. In adults that do not fulfil the criteria of IBS or in adults older than 50 it is often necessary to request more studies, including endoscopic examinations. In children, abdominal pain and bloating occur frequently in the context of excessive consumption of sugar (including fructose, lactose and sorbitol). In infants it can occur in the context of congenital malformations, infant colics and food allergies. An active search for symptoms and signs of alarm is recommended. In their absence the performance of an endoscopic study is low. The use of celiac disease serology is also recommended, but the use of fecal calprotectin has the limitation that normal values are not present below age 4, so its use is not recommended under that age.

El dolor abdominal y la distensión abdominal fluctuantes sugieren origen gastrointestinal, con múltiples causas. En adultos, los pacientes que cumplen criterios de Roma para Síndrome de Intestino Irritable (SII) tienen una baja probabilidad de neoplasias o enfermedades inflamatorias intestinales (EII). En estos pacientes, es costoefectivo solicitar calprotectina fecal y serología de enfermedad celiaca. Por la alta probabilidad de efecto nocebo, el diagnóstico de sensibilidad al gluten no celiaca (SGNC) y alergias alimentarias debería requerir un rechallenge ciego. Es recomendable evaluar otras opciones diagnósticas no ominosas en una segunda etapa, si no hay buen control sintomático. En adultos que no cumplen criterios de SII o en adultos mayores de 50 años, suele requerirse más cantidad de estudios, incluyendo endoscópicos. En niños, el dolor abdominal y distensión ocurren frecuentemente en el contexto de consumo excesivo de azúcares (incluyendo fructosa, lactosa y sorbitol). En lactantes puede ocurrir también en el contexto de malformaciones congénitas, cólicos del lactante y alergia alimentaria. Se recomienda la búsqueda activa de signos y síntomas de alarma. En su ausencia el rendimiento del estudio endoscópico es bajo. También se recomienda el uso de serología de enfermedad celíaca, pero el uso de calprotectina fecal tiene la limitación de ausencia de valores de normalidad hasta los 4 años, por lo que su uso no se recomienda bajo esa edad.

Hernia paraesofágica mixta con mal rotación de estómago / Mixed paraesophageal hernia with bad gastric rotation

Las hernias hiatales, son defectos anatómicos en el hiato diafragmático. Las de tipo "paraesofágicas" son frecuentes, se sabe que atentan contra la vida de una manera potencial, ya que presentan un alto riesgo de complicación de vólvulo y encarcelación lo que incrementa con la edad. Objetivo: establecer una ruta diagnóstica para mejorar el abordaje clínico de esta patología. Caso Clínico: niño de 4 años, con historia de dolor abdominal de 3 meses de evolución en región mesogástrica, que se acompaña de palidez hiporexia y estreñimiento. Laboratorio: hemoglobina 4.3g/dl, hematocrito 13.9%, diagnóstico de anemia, diagnóstico por endoscopía: hernia hiatal tipo III (mixta), mal rotación de estómago. Se trató con funduplicatura Nissen y posteriormente con dilataciones esofágicas. Conclusión: La hernia hiatal es la anormalidad más frecuente del tracto digestivo alto, las de tipo paraesofágico son infrecuentes y debe ser incluida como diagnóstico diferencial en niños con repetidos episodios de infección respiratoria o vómitos a repetición. El estudio diagnóstico de elección es el esofagograma con medio de contraste.

Quiste epitelial esplénico como causa infrecuente de dolor abdominal. reporte de caso / Splenic epithelial cyst as an unusual cause of abdominal pain. a case report

Se reporta el caso de una joven con esplenomegalia, que consulta por dolor abdominal crónico en hipocondrio izquierdo. Los estudios mostraron un quiste tabicado de gran tamaño, con desplazamiento de órganos. Se realizó una esplenectomía total, confirmándose al estudio histopatológico, un quiste epitelial esplénico

We report the case of a girl with splenomegaly, who consults for chronicabdominal pain in the left hypochondrium. The studies showed a largecyst with organ displacement. A total splenectomy was performed, confirmingto the histopathological study, a splenic epithelial cyst.

Primary pelvic hydatid cyst in a postmenopausal female: a surgical challenge

Primary pelvic hydatid cysts are a rare entity and are often overlooked as a differential diagnosis of a pelvic-space-occupying lesion particularly in non-endemic regions. Unpreparedness and a hasty decision on the surgical approach may end in life-threatening complications and systemic dissemination of the disease. We report the case of a 55-year-old postmenopausal woman with a history of two previous unsuccessful surgeries to remove pelvic cystic lesions due to dense adhesions between the surrounding gut wall, bladder, and the cyst wall. Clinical and imaging findings failed to diagnose the nature of the cysts, and a laparotomy was contemplated. On the third surgical attempt, the clinical suspicion was considered and by meticulous dissection the cysts were removed thoroughly without undue complications. In the postoperative follow-up period there was no sign of disease recurrence or dissemination.

Síndrome de Bouveret: A propósito de un caso / BOUVERET´S SYNDROME: CASE REPORT

El íleo biliar es una causa poco frecuente de obstrucción intestinal. Puede manifestarse de formas variadas según el sitio de obstrucción y las características del paciente. Cuando la obstrucción se localiza a nivel duodenal, bloqueando el paso del contenido gástrico, se trata de una entidad denominada síndrome de Bouveret

Gallstone ileus is an uncommon cause of intestinal obstruction. It can manifest itself in various shapes according to the site of obstruction and the patient´s characteristics. When the obstruction is located at the duodenum, blocking the passage of gastric contents, it is an entity called Bouveret´s syndrome

Caso Clínico: Mucocele Apendicular / Case Report: Appendicular Mucocele

INTRODUCCIÓN: El mucocele apendicular es una entidad clínica rara que con poca frecuencia se considera en el diagnóstico diferencial del dolor localizado en el cuadrante inferior derecho del abdomen. CASO CLÍNICO: Se trata de un paciente masculino de 38 años de edad que acude al servicio de emergencia por dolor abdominal de 2 días de evolución referido a FID. Al examen físico se evidenció un abdomen blando, depresible, doloroso a la palpación superficial y profunda en FID con la presencia de una masa de 6 x 4 cm aproximadamente. La biometría reveló leucocitosis y predominio de segmentados. EVOLUCIÓN: Se realizó una laparotomía exploratoria en la que se encontró un apéndice cecal con aumento de su diámetro, engrosado y traslúcido de 8 x 4 cm por lo que se procedió a realizar una apendicetomía por la técnica habitual. El resultado de la biopsia tuvo como resultado un quiste mucinoso de apéndice cecal. CONCLUSIÓN: El mucocele apendicular es una patología poco frecuente que debe ser considerada dentro del diagnóstico diferencial del dolor abdominal por las múltiples complicaciones derivadas de un abordaje inadecuado y su potencial de malignidad.(au)

BACKGROUND: Appendicular mucocele is a rare condition not usually considered as a differential diagnosis in patients with lower-right quadrant abdominal pain. CASE REPORT: It is about a 38 years-old male patient who attended to Emergency department because of a 2 days evolution abdominal pain located at right iliac fosse (RIF). Abdomen was soft, depressible and caused pain during superficial and deep palpation at RIF, where a 6 x 4 cm mass was noticed. A blood biometry revealed leukocytosis and neutrophilia. EVOLUTION: An exploratory laparotomy was performed and a translucent swollen of 8 x 4 cm caecal appendix was found, so an appendectomy was performed too. Biopsy reported an appendicular mucinous cyst. CONCLUSION: Appendicular mucocele is an infrequent pathology that must be considered as a differential diagnosis of abdominal pain because of its multiple complications that could be secondary to an inadequate approach and its malignity potential. (au)