Neoplasia fusocelular - tumor de gist: presentación de un caso / Fusocellular neoplasia - gist tumor: presentation of a case

Los tumores del estroma gastrointestinal (TEGI) son las neoplasias mesenquimales más frecuentes del tracto digestivo con una frecuencia de 0,1 a 3 % de todas las neoplasias gastrointestinales. Son derivadas de las células intersticiales de Cajal, localizadas a lo largo del plexo mioentérico de la pared intestinal. Comprenden leiomisarcomas, leiomioblastomas, leimiomas, schwannomas. Están formadas por células fusiformes, en la mayoría, epitelioides o ambas. Se localizan predominantemente en estómago e intestino delgado. Inmunohistoquimicamente se detecta expresión de receptores KIT (antígeno CD117) que puede ser focal, variable o difusa. Involucran tumores benignos pero con potencial malignidad hasta sarcomas metastizantes. Su pronóstico se basa el tamaño y porcentaje de mitosis. La sintomatología depende del lugar de origen, en este caso como masa palpable abdominal y obstrucción intestinal. El tratamiento es la resección completa con márgenes limpios. En caso de metástasis preoperatoria, esta no cambia la conducta quirúrgica, debido a la posibilidad de obstrucción y sangrado. El Imatinib a dosis de 400 mg controla el crecimiento eventual de enfermedad residual. Se presenta el caso clínico de paciente con masa abdominal y cuadro de obstrucción intestinal que evoluciona a la perforación de un TEGI localizado en yeyuno proximal con cuadro peritoneal y absceso subfrenico. Se procede a resección intestinal con yeyuno yeyuno anastomosis resección completa. La histopatología reporta Tumor estronal gastrointestinal y la inmunohistoquimica Neoplasia Fusocelular. CONCLUSION: Los TEGI son de origen mesenquimal, comprenden espectro grande de tumores desde benignos, hasta carcomas altamente malignos. Los factores pronósticos se asocian al tamaño e índice mitótico del tumor. La inmunohistoquimica reporta su expresión para CD117. La resección quirúrgica completa es el pilar de tratamiento y en casos de resección incompleta o irresecabilidad puede usarse imatinib.

Gastrointestinal stromal tumors (GIST) are the most frequent mesenchymal neoplasms of the digestive tract with a frequency of 0.1 to 3% of all gastrointestinal neoplasms. They are derived from the interstitial cells of Cajal, located along the myoenteric plexus of the intestinal wall. They include leiomysarcomas, leiomioblastomas, leimiomas, schwannomas. They are made up of spindle cells, in the majority, epithelioids or both. They are located predominantly in the stomach and small intestine. Immunohistochemically, KIT receptor expression (CD117 antigen) is detected, and they can be focal, variable or diffuse. They involve benign but potentially malignancy tumors up to metastatic sarcomas. Their prognosis is based on the size and percentage of mitosis. The symptoms depend on the place of its origin. Treatment is complete resection with clean margins. In the case of preoperative metastases, this does not change the surgical approach, due to the possibility of obstruction and bleeding. Imatinib at a dose of 400 mg controls the eventual growth of residual disease. We present the clinical case of a patient with an abdominal mass and a small bowel obstruction that progresses to perforation of a GIST located in the proximal jejunum with a peritonitis and subphrenic abscess. Intestinal resection is performed with jejunum jejunoanastomosis and complete resection. Histopathology reports gastrointestinal stromal tumor and immunohistochemistry, Fusocellular neoplasia. Conclusion: GIST are of mesenchymal origin, they include a wide spectrum of tumors from benign to highly malignant sarcomas. Prognostic factors are associated with tumor size and mitotic index. Immunohistochemistry reports its expression for CD117. Complete surgical resection is the mainstay of treatment and in cases of incomplete resection or unresectability imatinib can be used.

Apendicitis subhepática con absceso subdiafragmático en paciente pediátrico sin malrotación intestinal: informe de un caso / Subhepatic appendicitis with subdiaphragmatic abscess in a pediatric patient without intestinal malrotation: case report

Introducción: Los cuadros de apendicitis aguda subhepática en niños son raros y no siempre se acompañan de malrotación intestinal, lo que dificulta el diagnóstico y manejo temprano. Caso clínico: Niño de 10 años de edad, con padecimiento de cinco días de evolución caracterizado por evacuaciones diarreicas, tratado con antibióticos. Posteriormente presentó vómito, dolor abdominal tipo cólico y fiebre de 39 °C. El abdomen se encontró blando y depresible, con escaso dolor en flanco derecho. El ultrasonido y la tomografía mostraron imagen compatible con absceso subdiafragmático. Se manejó con drenaje externo. Al no obtener respuesta se realizó laparotomía exploradora, encontrando apéndice inflamada, de 10 cm de longitud, en posición ascendente sobre la corredera parietocólica derecha y perforación del extremo distal a nivel subhepático. El paciente evolucionó con sepsis abdominal y choque séptico, requiriendo nueva intervención quirúrgica para drenaje de líquido serohemático. A los 40 días el paciente fue dado de alta. Conclusiones: La consideración anatómica del apéndice es importante, por las múltiples presentaciones clínicas, de las cuales 30 % son atípicas y el diagnóstico se enmascara ocasionando complicaciones como perforación y abscesos. Los casos de apendicitis aguda de localización subhepática son raros y por lo general se asocian a malrotación del intestino. El retraso del tratamiento relacionado con el cuadro atípico, ocasionado por la posición poco habitual del apéndice, implica estancia hospitalaria más prolongada y riesgo de incrementar la morbilidad y mortalidad.

BACKGROUND: Acute subhepatic appendicitis in children is an uncommon presentation. It is usually associated with intestinal malrotation. When these conditions are met, accurate diagnosis and early management decisions are delayed. CLINICAL CASE: We present the case of a 10-year-old male who had diarrhea without mucus or blood for 5 days. He was treated with antibiotics. Afterwards, he presented with vomiting, abdominal pain, and fever. Physical examination of the abdomen demonstrated a soft and depressible mass and pain in the lower right abdomen. Abdominal ultrasound and tomography reported image of subdiaphragmatic abscess. Percutaneous puncture and drainage were performed without results. Exploratory laparotomy was then performed, revealing a subhepatic perforation of the appendix. The patient evolved with abdominal sepsis and septic shock, resulting in a new surgical intervention for drainage of serohematic fluid. The patient improved and was discharged on day 40. DISCUSSION: It is very important to consider the position of the anatomic appendix during appendicitis because it contributes to the various clinical symptoms, of which 30% are atypical. Diagnosis is masked, leading to complications such as perforations and/or abscesses that extend the hospital stay. CONCLUSIONS: Acute subhepatic appendicitis in children is an uncommon presentation. It is usually associated with intestinal malrotation. Delay in treatment due to atypical symptoms caused by the abnormal position of the appendix conditioned complications that implied a prolonged hospital stay, with the risk of increasing morbidity and mortality of the patient.

A case of pyogenic liver abscess in a 10-year-old girl / 소아과

Pyogenic liver abscesses are rare in children. In pediatric patients, altered host defences seem to play an important role. However, pyogenic liver abscess also occurs in healthy children. We experienced a case of pyogenic liver abscess in a healthy immunocompetent 10-year-old-girl. The patient presented two distinct abscesses: one subphrenic and the other intrahepatic. The intrahepatic abscess resolved with percutaneous drainage and 3 weeks of parenteral antibiotic therapy but the subphrenic abscess which could not be drained needed prolonged parenteral antibiotic therapy in addition to oral antibiotic therapy. We performed follow-up serial CT scan of the abscess cavity to decide on the duration of antibiotic therapy. Here we present this case with a brief review of the literature.

Draining of subphrenic abscess into pericardial cavity - an incidental finding

The direct extension of a subphrenic abscess into the pericardial cavity is a rare finding. We report a 13 year old boy with Past History of Abdominal surgeries presenting with Right Upper quadrant pain, fever, chest pain and shortness of breath. An abdominal USG diagnosed a subphrenic abscess and an EGG demonstrated diffuse ST and T wave changes depictive of Acute Pericarditis. Echo guided drainage of thick pus from the pericardial cavity was performed which followed USG guided drainage of subphrenic abscess and finally Exploratory Laparotomy and drainage of subphrenic abscess + Mediastonotmy and Pericardiostomy + diaphragmatic repair was performed

Litiasis pulmonar secundaria a fístula colecistopleural / Secondary pulmonary lithiasis following cholecystopleural fistual

La litiasis pulmonar secundaria a fístula colecistopleural es una entidad infrecuente en la evolución de la colelitiasis que genera un potencial riesgo de vida para el paciente. Solo se ha publicado un caso en la bibiliografía angloparlante donde fue necesria una resección pulmonar para su tratamiento

A Case of Respiratory Failure Caused by Gastropleural Fistula: A Case Report / 대한구급학회지

Gastropleural fistula is a very rare disorder, caused by various conditions, such as trauma and postoperative complication, subphrenic abscess, malignancy, hiatal hernia. The major causes of the gastropleural fistula have changed from trauma and subphrenic abscess to postoperative complication of malignant disorders. We report a case of empyema that developed respiratory failure caused by gastropleural fistula in a middle age woman with review of related articles.

A Case of Subphrenic Abscess with Ileal Fistula Caused by Metastatic Adenocarcinoma of Unknown Origin / 대한소화기학회지

Usual sources of subphrenic abscess with intestinal fistula are previous abdominal operation, inflammatory bowel disease and malignancy. Reported cases of intestinal fistula caused by adenocarcinoma were complicated by direct invasion. In this report, a 70-year-old male had a subphrenic abscess with intestinal fistula and the cause was a metastatic adenocarcinoma of unknown origin. As far as we know, this has not been reported previously in the literatures. The abscess went on chronic course for six months because intermittent administration of antibiotics modified its clinical presentation. The fistulous tract between the abscess and ileum was demonstrated by tubogram via the drainage catheter in abscess. The patient underwent surgical treatment because the cause of fistula was obscure. Invasion of the ileum by metastatic adenocarcinoma was diagnosed by the histologic examination of surgical specimen. Therefore, when a fistula develops without any apparent cause, there is a possibility of malignancy, and surgical approach must be considered. An early surgical approach will prevent the delay in treatment and reduce the mortality.

Subphrenic abscess complicating burn injury

A patient in whom a right subphrenic abscess developed as sequale to burn sepsis is described, drainage of the abscess through right sub-costal incision was done and revealed 500 cc of pus of the same bacteriology as the wound and blood, eventually resulted in cure

Subphrenic Abscess Due to Retained Gauze / 대한흉부외과학회지

Eighty-four-year old man who had lapalotomy for stomach ulcer perforation 35 years ago was admitted for left lower chest discomfort. Chest X-ray and CT showed a large mass with air fluid level in left lower lung field. The tentative diagnosis was infected bronchogenic cyst. After a thoracotomy, the mass was confirmed as elevated diaphragm and subphrenic abscess with a foreign body, retained surgical gauze. The pus and gauze were located between stomach and diaphragm. His hospital course was smooth and uneventful, he was discharged with good outcome on postoperative day 9.

Non - operative management of perforated peptic ulcer

The aim of this study was to see the morbidity and mortality in peptic ulcer perforation cases by non-operative management in selected cases. Design: The cases were selected on the basis of structured protocol. Setting: This study was carried out in the Department of Surgery of Khulna Medical College Hospital located in southern Bangladesh over a period of 10 years. Subjects: The patients were diagnosed as perforated peptic ulcer clinically and radiologically. All patients in this series had pneumoperitoneum in plain x-ray abdomen. They included 54 patients of peptic ulcer perforation cases had the following parameters: early presentation [<12 hours], soft abdomen with minimum tenderness and relatively younger patients. All patients were chosen who were haemodynamically stable. Ultrasonography was done in doubtful cases and also to see the amount of free fluid inside the abdominal cavity. Methodology: After diagnosis, all patients were managed in a similar fashion-like nil by mouth, continuous gastric aspiration, application of intravenous fluids and antibiotics and antiulcer therapy. In the selected 54 patients, male: female were 49:05. Nine had history of NSAID intake. There was no mortality. Morbidity analysis showed that three had hepatic abscess, four had pelvic abscess, six took prolonged time for improvement, in two cases conservative treatment had to be abandoned and laparotomy was done in the same hospital admission. Non-operative procedure is a safe and effective measure for the management of perforated peptic ulcer in selected cases

Postoperative Bile Duct Stricture

PURPOSE: Postoperative biliary stricture is rare, but can result in a dreadful condition unless it is properly treated. This study was undertaken to assess the clinical features of a postoperative biliary stricture and to evaluate the outcome of reconstructive methods according to the stricture locations and types. METHODS: From 1984 to 2001, 28 cases (M=16, F=12) of postoperative biliary stricture, which resulted from surgical injury and had subsequent reconstructive procedures performed in department of surgery of Seoul National University Hospital, during the period of 1984 to 2001, were retrospectively reviewed. Clinical features such as the symptom, type of surgery causing the stricture, laboratory finding, diagnostic modality, interval between the operation and symptoms and the type of stricture were reviewed and clinical outcomes of the reconstructive procedures were also analyzed. The mean follow-up period was 45.9 months (2~157). RESULTS: The most common symptoms of stricture was jaundice. 57.1% of patients showed symptoms within postoperative 6 months and 64.3% showed symptoms within 1 year. A cholecystectomy was most common surgical procedure that caused a postoperative biliary stricture. Bismuth type I was most common type of stricture (52.2%). Bilioenteric anastomosis (Roux-en Y hepaticojejunostomy) showed most excellent result among the many reconstructive methods. One case of an interventional balloon dilatation has maintained a good condition for 3 years after the procedure. The postoperative complications comprises bile leakage, a subphrenic abscess, an incisional hernia, am intrahepatic duct stone, recurrent pyogenic cholangitis. There were 2 cases of postoperative mortality. CONCLUSION: Roux-en Y hepaticojejunostomy is considered to the procedure of choice for a postoperative biliary stricture. An interventional balloon dilatation is expected to show good result with more cases and adequate indications.

Abordaje posterior extraseroso de Ochsner / Posterior extraperitoneal approach the Ochsner method

Objetivo: Mostrar la experiencia en la Fundacion Santa Fé de Bogotá con el abordaje extraseroso con resección de la duodécima costilla para el drenaje de los abscesos subfrénicos. Métodos: Se realiza una revision retrospectiva de las historias clínicas de los pacientes sometidos a drenaje de abscesos subfrénicos por la técnica de Ochsner en el periodo comprendido entre enero de 1995 y diciembre de 2001. Se revisaron datos demográficos, la causa del absceso, métodos díagnósticos, procedimientos quirúrgicos y/o radiológicos, el grado de severidad de la enfermedad calculado por el indice APACHE II en el momento de la cirugía, complicaciones de la cirugía, gérmenes detectados en los cultivos, complicaciones no relacionadas con el procedimiento y los días de hospitalización antes y después de la cirugía. Resultados: Cinco pacientes fueron sometidos a 6 procedimientos de Ochsner por 4 abscesos subfrénicos izquierdos y uno bilateral. Dos pacientes presentaron abscesos por pancreatitis aguda y tres por fístulas gástricas. Todos los díagnósticos se realizaron por TAC. El indice APACHE se pudo calcular en 4 pacientes y la medíana fué de 3,5. A todos se les habia practicado por lo menos un procedimiento abdominal previo y en 3 un drenaje percutáneo fallido. Solo hubo una complicación por el procedimiento y fue la apertura accidental del díafragma. Escherichia coli y Pseudomona sp fueron los principales gérmenes identificados. En todos los pacientes el tratamiento fue efectivo para el drenaje del absceso y la medíana de la hospitalización antes de la cirugía fue de 47 días y de 21 días de postoperatorio. Conclusiones: El drenaje posterior de los abscesos subfrénicos por la tecnica de Ochsner es un procedimiento seguro en quienes el drenaje percutáneo fue fallido y se ofrece como altemativa en aquellos casos en los que el drenaje percutáneo no este indicado.

Gastrectomía total paliativa / Total palliative gastrectomy

El cáncer gástrico ya sea por el compromiso ganglionar extenso (invasión sobre N2), por la extensión local (invasión pancreática, colonial, o hepática) o por las metástasis (hepáticas o peritoneales) frecuentemente permite sólo cirugía de carácter paliativo. Entre los años 1985 y 2000, 51 pacientes (35 hombres y 16 mujeres) con carcinoma gástrico en estadio IV fueron sometidos a una gastrectomía total. La edad media fue de 62,1 años, rango de 34 a 83 años. Se realizó gastrectomía total con omectomía mayor y menor sin intentar linfadenectomía superior a N1. El 37,3 por ciento de los pacientes presentarom complicaciones postoperatorias. El tiempo de hospitalización postoperatoria fue de 17,2 por ciento días en promedio, con un rango entre 9 y 36 días. Cuatro pacientes fallecieron en el postoperatorio (7,8 por ciento). Entre las complicaciones quirúrgicas destacan 4 fístulas de la anastomosis esofagoyeyunal (7,8 por ciento) y 4 abscesos subfrénicos (7,8 por ciento). La sobrevida a un año, 2 y 3 años fue de 52 por ciento, 20 por ciento y 0 por ciento, respectivamente. La sobrevida media fue de 4,7 meses ( rango: 3-34 meses). La resección tumoral es el mejor tratamiento en pacientes que clínicamente se encuentran en estadio IV. La gastrectomía total mejora la calidad de vida en estos pacientes

Absceso subfrénico primario. Presentación de un caso clínico y revisión bibliográfica / Primary subphrenic abscess: case report and revision of the literature

Los autores presentan el caso de un paciente de sexo femenino de 85 años de edad que presentó un cuadro de taquipnea, con ictericia de piel y mucosas, deshidratación e hipotensión arterial. Se realizó una ecografía abdominal constatando la presencia de una colección en el espacio subfrénico izquierdo. Fue sometida a una laparotomía exploradora transperitoneal donde se constató la presencia de un absceso subfrénico. Se realizó esplenectomía, lavado y drenaje de cavidad abdominal. La paciente presenta un cuadro de sepsis abdominal y falleció a las 2 semanas. Se realiza una revisión bibliográfica acerca del tema

A Case of Hepatosubphrenic Fistula Treated by Histoacryl(R) Injection by ERCP / 대한소화기내시경학회지

Acute hepatic failure, liver infarction, abscess, intrahepatic biloma, and multiple intrahepatic aneurysms could be complicated after transcatheter arterial embolization (TAE) in a patient with hepatocellular carcinoma. Conservative managements such as nutritional support and control of sepsis for gastrointestinal fistula have been recommended for the last few decades. Histoacryl(R) has been applied to treat gastrointestinal fistula. We report a case of liver abscess after TAE followed by hepatosubphrenic abscess in a patient with hepatocellular carcinoma. The fistula between liver abscess and subphrenic abscess was occluded with Histoacryl(R) injection by ERCP. Endoscopic nasobiliary drainage and percutaneous drainage were performed respectively. Both abscesses were treated, but the patient died of hepatic failure.

Perforated Meckel's diverticulum presenting as subphrenic abscess.

Meckel's diverticulum is known to present with myriad complications. However, its perforation followed by development of subphrenic abscess has not been reported in literature. We report this complication in an eleven-month-old child.

An unusual paratyphoid fever.

Salmonella typhi is known to produce acalculous cholecystitis and related gall bladder perforation. Following is a documentation of a patient of sub-phrenic abscess and gall bladder perforation which was possibly a result of Salmonella paratyphi A.