Diagnóstico, manejo y tratamiento de pacientes con peritonitis secundaria en una unidad de cirugía general / Diagnosis, management and treatment of patients with secondary peritonitis in a general surgery unit

La peritonitis es una inflamación aguda o crónica del peritoneo que generalmente tiene un origen infeccioso. Existen varios tipos, siendo la de tipo secundario la más frecuente. El término peritonitis secundaria se define como la inflamación localizada o generalizada de la membrana peritoneal causada por infección polimicrobiana posterior a la ruptura traumática o espontánea de una víscera o secundaria a la dehiscencia de anastomosis intestinales. Esta entidad se caracteriza por la presencia de pus en la cavidad peritoneal o de líquido; que, en el estudio microscópico directo, contiene leucocitos y bacterias. El tratamiento de esta patología constituye una urgencia y puede ser de tipo clínico y/o quirúrgico. El objetivo del manejo operatorio se basa en identificar y eliminar la causa de la infección, recoger muestras microbiológicas, realizar una limpieza peritoneal y prevenir la recidiva. El tratamiento clínico se ocupa de las consecuencias de la infección mediante la reanimación perioperatoria y el tratamiento antibiótico1. A pesar de los avances en diagnóstico, procedimientos quirúrgicos, terapia antimicrobiana y cuidados intensivos, la mortalidad asociada con la peritonitis secundaria grave es aún muy alta. El pronóstico y el manejo oportuno representan la clave para mejorar la sobrevida y reducir la mortalidad asociada a infecciones intraabdominales extensas2. Es importante establecer lineamientos en cuanto al diagnóstico, manejo antibiótico y pautas de tratamiento quirúrgico para disminuir la morbilidad y mortalidad asociada a esta enfermedad. Palabras clave: Peritonitis; Peritoneo; Cavidad Abdominal/cirugía; Cavidad Peritoneal; Líquido Ascítico/patología; Procedimientos Quirúrgicos Operativos.

Peritonitis is an acute or chronic inflammation of the peritoneum that generally has an infectious origin. There are several types, with secondary peritonitis being the most frequent. The term secondary peritonitis is defined as localized or generalized inflammation of the peritoneal membrane caused by polymicrobial infection following traumatic or spontaneous rupture of a viscus or secondary to dehiscence of intestinal anastomoses. This entity is characterized by the presence of pus in the peritoneal cavity or fluid which, on direct microscopic examination, contains leukocytes and bacteria. The treatment of this pathology constitutes an emergency and can be clinical and/or surgical. The aim of operative management is based on identifying and eliminating the cause of the infection, collecting microbiological samples, performing peritoneal cleansing and preventing recurrence. Clinical management deals with the consequences of the infection by perioperative resuscitation and antibiotic treatment1 . Despite advances in diagnosis, surgical procedures, antimicrobial therapy and intensive care, mortality associated with severe secondary peritonitis is still very high. Prognosis and timely management represent the key to improving survival and reducing mortality associated with extensive intra-abdominal infections2. It is important to establish guidelines for diagnosis, antibiotic management and surgical treatment guidelines to reduce the morbidity and mortality associated with this disease.

Regulatory T cells isolated from endometriotic peritoneal fluid express a different number of Toll-like receptors / Células T reguladoras isoladas do fluido peritoneal de mulheres com endometriose expressam um número diferente de receptores do tipo Toll

ABSTRACT Objective To analyze and compare the expression of Toll-like receptors by regulatory T cells present in the peritoneal fluid of patients with and without endometriosis. Methods Regulatory T cells were isolated from peritoneal fluid of women with and without endometriosis, collected during surgery, and mRNA was extracted for analysis of Toll-like receptors expression by reverse-transcriptase polymerase chain reaction. Results Patients with endometriosis presented regulatory T cells expressing a larger number and variety of Toll-like receptors when compared to regulatory T cells from patients in the Control Group. Toll-like receptor-1 and Toll-like receptor-2 in regulatory T cells were expressed in both groups. All other expressed Toll-like receptors types were only found in regulatory T cells from the Endometriosis Group. Conclusion Patients with endometriosis had peritoneal regulatory T cells expressing various Toll-like receptors types.

RESUMO Objetivo Analisar e comparar a expressão de receptores do tipo Toll por células T reguladoras presentes no líquido peritoneal de pacientes com endometriose. Métodos Células T reguladoras foram isoladas do líquido peritoneal de mulheres com e sem endometriose, coletadas durante a cirurgia, e o RNAm foi extraído para análise da expressão de receptores do tipo Toll por reação em cadeia da polimerase com transcriptase reversa. Resultados Pacientes com endometriose apresentaram células T reguladoras expressando maior número e variedade de Toll por células quando comparadas com T reguladoras de pacientes do Grupo Controle. Receptores do tipo Toll-1 e receptores do tipo Toll-2 foram expressos em ambos os grupos. Todos os outros tipos de receptores Toll foram encontrados expressos apenas em células T reguladoras do grupo com endometriose. Conclusão Pacientes com endometriose apresentaram células T reguladoras peritoneais expressando vários tipos de receptores tipo Toll.

Canine cavitary effusion: a retrospective study of 304 cases in Brazil / Efusões cavitárias caninas: estudo retrospectivo de 304 casos no Brasil

The objective of this study was to determine the frequency of different categories of specific and general classification in canine cavitary effusions (CE), as well as their association with the underlying etiologies. The laboratorial and clinical data from 304 cases of canine CE were retrospectively assessed. In 32.9% (100 cases), at least one of the specific classification categories was established, with a subtotal predominance of neoplasia (42%), bacterial serositis (24%) and hemorrhage (16%). Neoplasia was confirmed by effusion cytology in 57.5% of the cases with histopathological confirmation. From the cases in which the specific classification was not obtained, 35.8% were classified as modified transudate, 30.4% as pure transudate, 21.1% % as exudate and 12.7% was not included in any general category. The most common causes of effusion among these cases were hypoproteinemia and/or hipoalbuminemia (HPHA) (25.8%), hepatopathy (22.5%), cardiac insufficiency (15.5%) and cytologically undetected cases of neoplasia (12.4%). In conclusion, HPHA, hepatopathy and neoplasia represents important etiologies for canine CE development. Classification of effusions, solely based on [TP] and TNCC, might be an inaccurate diagnostic tool of effusions. New laboratorial classification methods for canine CE should be researched.(AU)

O objetivo deste estudo foi determinar a frequência de diferentes categorias de classificação específica e geral em efusões cavitárias (EC) caninas, bem como sua associação com as etiologias subjacentes. Os dados laboratoriais e clínicos de 304 casos de EC canina foram avaliados retrospectivamente. Em 32,9% (100 casos), pelo menos uma das categorias específicas de classificação foi estabelecida, com predomínio subtotal de neoplasia (42%), serosite bacteriana (24%) e hemorragia (16%). A neoplasia foi confirmada pela citologia da efusão em 57,5% dos casos com confirmação histopatológica. Dos casos em que a classificação específica não foi obtida (204 casos), 35,8% foram classificados como transudato modificado, 30,4% como transudato puro, 21,1% como exsudato e 12,7% não foram incluídos em nenhuma categoria geral. As causas mais comuns de efusão nestes casos foram hipoproteinemia e/ou hipoalbuminemia (HPHA) (25,8%), hepatopatia (22,5%), insuficiência cardíaca (15,5%) e casos de neoplasia citologicamente não detectados (12,4%). Em conclusão, HPHA, hepatopatia e neoplasia representam importantes etiologias para o desenvolvimento da EC canina. A classificação geral de efusões, baseada exclusivamente em proteína e celularidade, pode ser uma ferramenta diagnóstica imprecisa. Novos métodos de classificação laboratorial para ECs caninas devem ser pesquisados.(AU)

Peritonitis bacteriana espontánea en el paciente con cirrosis hepática / Spontaneous bacterial peritonitis in the patient presenting with hepatic cirrhosis

La peritonitis bacteriana (PBE) o infección espontánea del líquido ascítico (IELA) es una de las infecciones que afecta frecuentemente a los pacientes con cirrosis, se puede ver en otras entidades que evolucionan con ascitis, como el síndrome nefrótico, la carcinomatosis peritoneal y la insuficiencia cardíaca. Se realizó el presente trabajo para evaluar el comportamiento de esta complicación en nuestro medio. Se estudió a todos los pacientes con cirrosis hepática que ingresaron descompensados, con ascitis moderada a severa, en el Servicio de Gastroenterología del Hospital Clinicoquirúrgico "Hermanos Ameijeiras" desde septiembre de 2002 hasta febrero de 2007. Se halló que de una muestra de 70 pacientes, 26 cumplían los criterios diagnósticos de PBE (37,1 por ciento de incidencia). Dentro de los subtipos espontáneos de peritonitis, 15 enfermos (57,6 por ciento) presentaron peritonitis bacteriana espontánea con cultivo positivo, 7 (26,9 por ciento) con cultivo negativo y 4 (15,3 por ciento), bacteroascitis sintomática. No se presentaron casos de bacteroascitis asintomática, polimicrobiana, de peritonitis bacteriana secundaria ni empiema bacteriano espontáneo. El dolor abdominal ocupó el primer lugar entre las manifestaciones clínicas, con 23 pacientes (88,4 por ciento), seguido de la fiebre con 18 (69,2 por ciento) y la encefalopatía hepática, en tercer lugar, con 10 (38,4 por ciento). No se presentaron casos asintomáticos. Los gérmenes más frecuentemente aislados en los cultivos fueron Escherichia coli, en 10 enfermos (52,6 por ciento), Klebsiella en 4 (21 por ciento) y Pneumococcus, en 3 (15,7 por ciento)

The spontaneous bacterial peritonitis (SBP) or spontaneous infection of ascetic fluid (SIAF) is one of the infections affecting frequently to patients presenting with cirrhosis, it may be present in other entities evolving with ascites like the nephrotic syndrome, peritoneal carcinomatosis and the heart failure. The aim of present paper was to assess the behavior of this complication in our environment. All the admitted decompensated patients presenting with hepatic cirrhosis and a moderate to severe ascites were studied in the Gastroenterology Service of "Hermanos Ameijeiras" Clinical Surgical Hospital from September, 2002 to February, 2007. From a sample of 70 patients, 26 of them fulfilled the diagnostic criteria of SBP (37.1 percent of incidence). Within the spontaneous subtypes of peritonitis, 15 patients (57.6 percent) had spontaneous bacterial peritonitis with positive culture, 7 (26.9 percent) with negative culture and 4 (15.3 percent) had symptomatic and poly-microbial bactero-ascites. There were not cases of spontaneous bacterial empyema. Abdominal pain occupied the first place among the clinical manifestations with 23 patients (88.4 percent), followed by fever with 18 patients (69.2 percent) and hepatic encephalopathy in the third place with 10 patients (38.4 percent). There were not asymptomatic cases. The more frequent germs isolated in cultures were Escherichia coli in 10 patients (52.6 percent), Klebsiella in 4 patients (21 percent) and Pneumococcus in 3 patients (15.7 percent)

Inmunocitoquímica para líquidos de pleura y peritoneo: estandarización de la técnica en el Hospital de San Jose / Immunocytochemistry for pleural and peritoneal fluids: standardization of the technique at the San Jose Hospital

El objetivo de esta investigación fue estandarizar y crear un protocolo para una técnica de inmunocitoquímica en líquidos pleural y peritoneal, procedimiento de gran utilidad como ayuda diagnóstica cuando no se sabe con certeza donde se encuentra el tumor primario. Incluye la obtención del líquido para determinar mediante el procedimiento tradicional si es positivo para malignidad, el método de procesamiento y el desarrollo de la técnica inmunocitoquímica.

Abdominal tuberculosis.

Tuberculosis can involve any part of the gastrointestinal tract and is the sixth most frequent site of extrapulmonary involvement. Both the incidence and severity of abdominal tuberculosis are expected to increase with increasing incidence of HIV infection. Tuberculosis bacteria reach the gastrointestinal tract via haematogenous spread, ingestion of infected sputum, or direct spread from infected contiguous lymph nodes and fallopian tubes. The gross pathology is characterized by transverse ulcers, fibrosis, thickening and stricturing of the bowel wall, enlarged and matted mesenteric lymph nodes, omental thickening, and peritoneal tubercles. Peritoneal tuberculosis occurs in three forms : wet type with ascitis, dry type with adhesions, and fibrotic type with omental thickening and loculated ascites. The most common site of involvement of the gastrointestinal tuberculosis is the ileocaecal region. Ileocaecal and small bowel tuberculosis presents with a palpable mass in the right lower quadrant and/or complications of obstruction, perforation or malabsorption especially in the presence of stricture. Rare clinical presentations include dysphagia, odynophagia and a mid oesophageal ulcer due to oesophageal tuberculosis, dyspepsia and gastric outlet obstruction due to gastroduodenal tuberculosis, lower abdominal pain and haematochezia due to colonic tuberculosis, and annular rectal stricture and multiple perianal fistulae due to rectal and anal involvement. Chest X-rays show evidence of concomitant pulmonary lesions in less than 25 per cent of cases. Useful modalities for investigating a suspected case include small bowel barium meal, barium enema, ultrasonography, computed tomographic scan and colonoscopy. Ascitic fluid examination reveals straw coloured fluid with high protein, serum ascitis albumin gradient less than 1.1 g/dl, predominantly lymphocytic cells, and adenosine deaminase levels above 36 U/l. Laparoscopy is a very useful investigation in doubtful cases. Management is with conventional antitubercular therapy for at least 6 months. The recommended surgical procedures today are conservative and a period of preoperative drug therapy is controversial.

p53 Immunostaining in benign and malignant effusions

To evaluate p53 immunostaining as a marker of malignancy in pleural and peritoneal effusions and to compare the results with HE staining. Design: Pleural and peritoneal effusion samples were obtained from patients suffering from benign and malignant diseases. H and E staining and p53 immunostaining were performed on smears prepared from these samples. Setting: The samples were obtained from patients admitted in Mayo Hospital, Services Hospital, Gulab Devi Chest Hospital and Institute of Nuclear Medicine and Oncology [INMOL]. Subjects: One hundred cases having either pleural or peritoneal effusions were selected. Fifty of these cases were positive for malignant cells on H and E staining. Fifty cases contained only mesothelial cells. Main outcome measures: To compare the specificity and sensitivity of p53 immunostaining with HE stain as a diagnostic marker of malignancy. Out of the 50 malignant cases, 31 [62%] were found to be p53 positive. None of the benign cases showed positive staining. p53 was found to have a specificity of 100%, sensitivity of 62%, a positive predictive value of 100% and a negative predictive value of 72.4%. Conclusions: p53 is a highly specific and moderately sensitive marker of malignancy

The role of quantitative methods in the cytopathological diagnosis in serous effusions / O papel de métodos quantitativos no diagnóstico citopatológico de derrames cavitários

Uma revisäo crítica dos métodos quantitativos é feita focando suas aplicaçöes na prática laboratorial. Limitaçöes da citopatologia convencional também é discutida. Perspectivas do alcance diagnóstico e prognóstico dos métodos quantitativos säo apresentados

Cytological study of serous effusions with the aid of tumour markers.

Clinicocytological evaluation with the help of tumour markers was done in 25 cases presenting with serous effusions. The main aim was to differentiate between reactive mesothelial cells and malignant cells, type the tumour cells in effusions with the aid of tumour markers--carcino-embryonic antigen (CEA), epithelial membrane antigen (EMA), cytokeratin and vimentin. It was observed that immunocytochemistry has complemented conventional cytology in diagnosis of carcinoma specially in cases labelled as suspicious of malignancy. EMA was found to be the most reliable epithelial marker and very useful in differentiating carcinoma cells from reactive mesothelial cells.

Neoplasias malignas en efusiones pleurales peritoneales y pericardicas: aspectos citomorfológicos (1991-1996) / Malignant neoplasias un pleural peritoneal and pericardit effusiones: cytomorphologic aspects (1991-1996)

Se estudiaron 1530 citologías de efusiones pleurales, peritoneales y pericárdicas, procesadas en la Sección de Citopatología Instituto Anatomopatológico "J.A. O'Daly" de la Universidad Central de Venezuela. Se revisaron además las historias clínicas de los pacientes y se hizo correlación de los hallazgos citológicos con los histológicos. Se encontraron 107 efusiones neoplásicas predominando los derrames pleurales (61,68 por ciento), seguidos por los peritoneales (41,12 por ciento), y en proporción los pericárdicos (0,93 por ciento). El sexo femenino predominó en las lesiones metastásicas pleurales y peritoneales. Los adenocarcinomas pulmonares constituyeron la primera causa de efusión pleural, y los de ovario en la peritoneal. Con este procedimiento se evidenció una alta sensibilidad y especificidad. Los resultados sugieren que el estudio de las efusiones constituye una herramienta diagnóstica en el estudio de un paciente con neoplasia de primario conocido o desconocido

Ventajas del ratón híbrido F1 para la produccción de anticuerpos monoclonales / Advantages of F1 hybrid mice for the production of monoclonal antibodies

Fueron apareados ratones hembras IOR/Hab con machos BALB/c para producir ratones híbridos F1 con características reproductivas y peso corporal superior al parenteral BALB/c. Las células del hibridoma anti-T3 fueron inyectadas intraperitonealmente en los ratones F1 y produjeron tumores ascíticos ricos en anticuerpos monoclonales. Ratones BALB/c e hibridos F1 de 20-22 g fueron tratados con 0,3 ml de adyuvante incompleto de Freund, seis días antes de la inoculación de 1 x 10- células del hibridoma. Los ratones F1 produjeron dos veces más fluido ascítico que los ratones BALB/c a iguales niveles de anticuerpo monoclonal. Se sugiere el uso de ratones hibridos F1 por ser mejores productores de fluidos asciticos ricos en anticuerpo monoclonal y por lo tanto, resulta menos costoso el procedimiento

Diagnóstico da ascite: importância da determinaçäo do antígeno carcinoembrionário no líquido peritoneal / Diagnosis of ascites: importance of determination of the carcinoembryonic antigen in peritoneal fluid

A ascite freqüentemente tem como causa a carcinomatose peritoneal. Daí a importância do diagnóstico etiológico dos derrames peritoneais. O exame citopatológico, método tradicionalmente utilizado para atingir este objetivo, tem como limitaçäo uma baixa sensibilidade, quando aplicados critérios rígidos em sua interpretaçäo para torná-lo mais específico. Para avaliar, no diagnóstico diferencial da ascite, a importância da determinaçäo do antígeno carcinoembrionário no líquido peritoneal, foram analisados prospectivamente 43 pacientes com derrame peritoneal com diferentes etiologias. Conclui-se que sua determinaçäo é de importância para sugerir a natureza neoplásica do fluido peritoneal

Diagnostic significance of cytologic pattern of pleural and peritoneal effusions

This is a study of 100 pleural and peritoneal effusions aspirated from 96 patients. Several causes of effusion were found including exudative and transudative diseases. The three commonest causes of pleuro-peritoneal effusions were liver cirrhosis [28%], tuberculosis [27%], malignancy [25%] and other diseases [20%]. It was found that there is a certain cellular pattern of effusion in each disease. The cellular pattern was found to be of value for the clinician in the diagnosis of malignant and non-malignant effusions when these cellular changes are correlated with clinical and laboratory data

Evoluçäo do carcinoma mamário: novos parâmetros imunopatológicos de avaliaçäo, estudo experimental em camundongos (MuMT): IV. Correlaçäo entre hemograma, esplenograma e células do fluído ascítico / Course of mammary carcinoma: new immunopathological parameters of evaluation, experimental study in mice (MuMT): IV. Correlation between hemogram, splenogram and ascitic fluid cells

Células da hematopoie esplênica (esplenograma), do hemograma e do líquido ascítico de camundongos inoculados intraperitonialmente com MuMT (carcinoma de Ehrlich), foram estudadas isoladamente pelos autores, nos trabalhos anteriores I, II e III. O presente trabalho estuda comparativamente os resultados obtidos, estabelecendo uma correlaçäo entre as variaçöes observadas nas diferentes linhagens celulares

Evoluçäo do carcinoma mamário: novos parâmetros imunopatológicos de avaliaçäo; estudo experimental em camundongos (MuMT), III. Líquido ascítico / Course of breast carcinoma: new immunopathological parameters of evaluation; experimental study in mice (MuMT), III. Ascitic fluid

Cem camundongos Swiss fêmeas inoculados por via intraperitonial com células tumorais de MuMT (carcinoma de Ehrlich, forma ascítica) e sacrificados diariamente, em grupos de cinco animais, durante os 20 dias de experimentaçäo. A formaçäo do líquido ascítico foi constatada a partir do 3§ dia (0,28 ml), aumentando para 0,48 ml no 6§ dia, e atingindo o máximo de 15,28 ml próximo ao 20§ dia (morte dos animais). A proporçäo de células tumorais variou acentuadamente no decorrer dos 20 dias da experimentaçäo. As células encontradas no 2§ dia se apresentaram 95% lisadas e as células íntegras inexistentes. Ao contrário, no fim da experimentaçäo constatou-se 6% de células lisadas e 85% de células íntegras. Nos primeiros dias a lise predominante foi a de tipo citotóxico, desencadeada pelas plaquetas, linfócitos T e monócitos. Entre o 6§ e 10§ dia a lise foi devida aos granulócitos. A lise por mecanismo näo citotóxico foi inversa ao porcentual de polimorfonucleares neutrófilos, diminuindo de 80% nos primeros 12 dias para 33% no 18§ dia