Bloqueos Nerviosos. Bases Anatómicas del Dolor Somático Abdomino-Pélvico / Nerve Blocks. Anatomy of the Somatic Innervation of the Abdomino-Pelvic Cavity

El dolor abdominal es una de las sintomatologías que afectan con frecuencia la cavidad abdomino-pélvica. Dicha cavidad posee una inervación somática en la que intervienen del séptimo a doceavo nervios intercostales, ramos colaterales y terminales del plexo lumbar y el nervio pudendo; siendo objetivo de este trabajo la descripción anatómica del dolor abdominopélvico a través del plexo lumbar, nervios intercostales y nervio pudendo, sus diferentes patrones y variaciones de conformación, y las implicancias de éstas últimas en las distintas maniobras clínico-quirúrgicas. Se realizó un estudio descriptivo, observacional y morfométrico de la inervación somática de la cavidad abdomino-pélvica, en 50 preparaciones cadavéricas, fijadas en solución de formaldehído, de la Tercera Cátedra de Anatomía, Facultad de Medicina, Universidad de Buenos Aires, entre Agosto/2017-Diciembre/2019. La descripción clásica del plexo lumbar se encontró en 35 casos; la presencia del nervio femoral accesorio en ningún caso; así como también la ausencia del nervio iliohipogástrico en ningún caso; el nervio obturador accesorio se halló en 2 casos; el nervio genitofemoral dividiéndose dentro de la masa muscular del psoas mayor en 6 casos; el nervio cutáneo femoral lateral emergiendo únicamente de la segunda raíz lumbar en 6 casos y por último se encontró la presencia de un ramo del nervio obturador uniéndose al tronco lumbosacro en un caso. Los nervios intercostales y el nervio pudendo presentaron una disposición clásica en todos los casos analizados. Es esencial un adecuado conocimiento y descripción del plexo lumbar, nervios intercostales y nervio pudendo para un adecuado abordaje de la cavidad abdomino-pélvica en los bloqueos nerviosos.

SUMMARY: Abdominal pain is one of the symptoms that affect the abdominal-pelvic cavity. The abdominal-pelvic cavity has a somatic innervation involving the seventh to twelfth intercostal nerves, collateral and terminal branches of the lumbar plexus and the pudendal nerve. The objective of this work is the description of the lumbar plexus, intercostal nerves and pudendal nerve, its different patterns and structure variations, as well as its implications during pain management in patients. A descriptive, observational, and morphometric study of patterns and structure variations of the lumbar plexus, intercostal nerves and pudendal nerve was conducted in 50 formalin-fixed cadaveric dissections of the Third Chair of Anatomy at the School of Medicine in the Universidad de Buenos Aires from August 2017 to December/2019. The standard description of the lumbar plexus was found in 35 cases; accessory femoral nerve was not present in any of the cases; absence of the iliohipogastric nerve was also not found in any case, while the accessory obturating nerve was found in 2 cases; genitofemoral nerve dividing within the muscle mass of psoas in 6 cases; lateral femoral cutaneous nerve emerging only from the second lumbar root in 6 cases and finally, presence of a branch of the obturating nerve was found joining the lumbosacral trunk in one case. The pudendal and intercostal nerve patterns presented a typical pathway in all cases. Adequate knowledge and description of the lumbar plexus, intercostal nerves and pudendal nerve is essential for an adequate approach of the abdominal-pelvic cavity in nerve blocks.

Metastatic clear-cell renal carcinoma: an exceptional cause of ileocolonic intussusception in adults

Introduction: Intussusceptions in adults are rare, representing 1% to 5% of intestinal obstructions in this age group. This condition can be caused by benign and malignant lesions acting as lead points, the latter being the most frequent. Furthermore, the diagnosis is challenging due to the non-specific symptoms with variable duration. Case Presentation: A 43-year-old man, with a history of localized clear-cell renal carcinoma (ccRCC) treated 9 years earlier with a right radical nephrectomy, presented with bowel obstruction symptoms. An abdominal computed tomography scan showed an ileocolonic intussusception. Hence, the patient required a right hemicolectomy with ileotransverse anastomosis. The histopathological analysis showed a metastatic ccRC to the terminal ileum causing the intussusception. Discussion: Adult intussusceptions are rare. However, they should be considered in the differential diagnosis of patients with abdominal pain and symptoms of bowel obstruction. Metastases of renal cancer to the small bowel are uncommon and even more so in the form of intussusception. Definitive treatment must be tailored to the patient's condition and underlying cause. (AU)

Persistencia de uraco en paciente joven. Reporte de caso / Persistence of urachus in a young patient. Case report

Introducción. Durante el desarrollo embrionario normal, se espera que el denominado uraco o ligamento umbilical mediano se oblitere a las 32 semanas de gestación. Ante una obliteración incompleta surgen las diferentes anomalías, siendo las más frecuentes el quiste y la fístula urinaria umbilical. El objetivo de este artículo fue presentar el caso de una paciente joven, sin comorbilidades, con quiste de uraco. Caso clínico. Mujer indígena de 19 años que consultó por dolor leve en hipogastrio, asociado a síntomas urinarios y distensión abdominal. Se sospechó en primera instancia cólico renal, pero ante hallazgos ecográficos de masa infraumbilical y reactantes de fase aguda elevados, la impresión diagnóstica cambió a sepsis secundaria a absceso intraabdominal. Posterior a tomografía y cistoscopía con calibración uretral se identificó pequeño divertículo en cúpula vesical, que sugirió el diagnóstico de uraco persistente, por lo que la paciente fue llevada a intervención quirúrgica para su resección, con evolución favorable. Discusión. El quiste de uraco es una anormalidad infrecuente, en su mayoría asintomática y generalmente de hallazgo incidental en la población anciana, por lo que se requiere de imágenes y manejo multidisciplinar para su correcto diagnóstico y abordaje. Conclusión. Son pocos los casos de uraco persistente reportados, y mucho menos en el sexo femenino. Dada la posibilidad de complicaciones tardías es importante el seguimiento para su manejo. Este caso se ha controlado de manera ambulatoria por 2 años

Introduction. During normal embryonic development, it is expected that the so-called urachus or median umbilical ligament will be obliterated at 32 weeks of gestation. In the face of incomplete obliteration, the different anomalies of the urachus arise. The most frequent anomaly of the urachus is the cyst followed by the umbilical urinary fistula. The objective of this article was to present the case of a young patient without comorbidities with urachal cyst. Clinical case. A 19-year-old indigenous woman consulted for mild hypogastric pain associated with urinary symptoms and abdominal distension. Renal colic was suspected at first, but due to ultrasound findings of an infraumbilical mass and high acute phase reactants, the diagnostic impression changed to sepsis secondary to an intra-abdominal abscess. After tomography and cystoscopy with urethral calibration, a small diverticulum was identified in the bladder dome, suggesting a diagnosis of persistent urachus, for which the patient was taken to surgery for its resection, with favorable evolution. Discussion. The urachal cyst is a rare abnormality, mostly asymptomatic and usually incidental finding in the elderly population. Imaging and multidisciplinary management are required for its correct diagnosis and approach. Conclusion. There are few reported cases of persistent urachus and much less in females. Given the possibility of late complications, follow-up is important for its management, in this case we have carried out control for 2 years

Análise das gestações ectópicas íntegras tratadas com o protocolo de dose única de metotrexato / Analysis of unruptured ectopic pregnancies treated with single-dose methotrexate protocol

Objetivo: Avaliar o índice de sucesso do tratamento da gravidez ectópica com o protocolo de dose única do metotrexato e verificar sua correlação com variáveis clínicas e dados dos exames complementares. Métodos: É um estudo epidemiológico observacional, analítico, retrospectivo, de delineamento transversal. Foi realizado de janeiro de 2014 a agosto de 2020 em um hospital público, de ensino, em nível terciário, do Sul do Brasil. Em 73 casos com diagnóstico de gestação ectópica íntegra, foi utilizado o protocolo de dose única de metotrexato intramuscular, com a dose de 50 mg/m2 de superfície corporal. As variáveis do estudo foram relacionadas ao sucesso do tratamento e abordaram as características clínicas na admissão, dos exames complementares e do tratamento realizado. As variáveis foram comparadas por análise de regressão de Poisson. O nível de significância estabelecido foi de p < 0,05. Resultados: O índice de sucesso foi de 83,6%, e em nove casos foi necessária uma segunda dose da medicação. Nível de ß-hCG inicial superior a 5.000 mUI/mL foi relacionado a menor chance de sucesso (odds ratio ajustado de 0,20 [0,05-0,95]). Tamanho da imagem anexial, presença de líquido livre na cavidade abdominal e demais variáveis estudadas não afetaram a chance de sucesso do tratamento. Conclusão: O protocolo de dose única de metotrexato mostrou-se uma opção válida para o tratamento da gestação ectópica íntegra, notadamente quando o nível de ß-hCG inicial é inferior 5.000 mUI/mL.

Objective: The purpose of the present study is to evaluate the success rate of treatment of ectopic pregnancy with the single-dose methotrexate protocol and to verify its correlation with clinical variables and complementary exam data. Methods: This is a retrospective epidemiological observational analytical cross-sectional study. It was carried out from January 2014 to August 2020 in a tertiary level teaching hospital in southern Brazil. In 73 cases with a diagnosis of intact ectopic pregnancy, the intramuscular methotrexate single-dose protocol was applied with a dose of 50 mg/m2 of body surface. The study variables were related to the success of the treatment and addressed the clinical characteristics on admission, the complementary exams and the treatment performed. The variables were compared by Poisson regression analysis. The level of significance was set at p < 0.05. Results: The success rate was 83.6%, and in nine cases a second dose of the medication was necessary. An initial ß-hCG level greater than 5,000 mIU/mL was related to a lower chance of success (adjusted odds ratio of 0.20 [0.05- 0.95]). The size of the adnexal image, the presence of free fluid in the abdominal cavity and other variables studied did not affect the chance of a successful treatment. Conclusion: The methotrexate single-dose protocol proved to be a valid option for the treatment of intact ectopic pregnancy, notably when the initial ß-hCG level is below 5,000 mIU/mL.

Hallazgos quirúrgicos en pacientes con apendicitis agudadurante la pandemia COVID-1 / Surgical findings in patients with acute appendicitis duringthe COVID-19 pandemic

Objetivo: Caracterizar los hallazgos quirúrgicos en pacientes con apendicitis aguda durante la pandemia COVID-19. Métodos: se realizó un estudio retrospectivo, descriptivo, observacional de corte transversal en pacientes con apendicitis aguda operados por el Servicio de Cirugía I del Hospital Universitario de Caracas, durante el período marzo2020-marzo 2022. Resultados: Se incluyeron 83 pacientes, cuya edad promedio fue 28,2±15,3 años, la mayoría del sexo femenino. Los síntomas clínicos más frecuentes fueron: dolor abdominal, náuseas, vómitos y fiebre; la paraclínica indicó importante leucocitosis, y el ultrasonido fue positivo en algunos pacientes. El tiempo de espera para la cirugía fue de 10,4±7,99horas, la vía de abordaje más común fue la abierta, seguida de la laparoscópica; el tiempo quirúrgico promedio fue de116,5±42,3 minutos. Los principales hallazgos quirúrgicos fueron, en orden decreciente: apendicitis flegmonosa (casi la mitad de los casos), seguida de catarral, gangrenosa y perforación, con dos pacientes con apéndice normal; otros hallazgos fueron: líquido inflamatorio, mesoapéndice engrosado, y adherencias. Sólo hubo complicaciones en 5 pacientes (6,0 %). La condición al alta de los pacientes fue buena en el 97,0 %. Conclusión: Los hallazgos de esta serie, no difieren de los obtenidos en periodos de tiempo previos a la pandemia, es decir, más frecuentes apendicitis en fase flegmonosa y catarral, sobre el resto de las otras formas de presentación(AU)

Objective: To characterize the surgical findings in patients with acute appendicitis during the COVID-19 pandemic. Methods: a retrospective, descriptive, observational cross-sectional study was carried out in patients with acute appendicitis operated on by the Surgery Service I of the Hospital Universitario de Caracas, during the period March 2020-March2022. Results: 83 patients were included, whose age average was 28.2 ± 15.3 years, most of them female. The most frequent clinical symptoms were: abdominal pain, nausea, vomiting and fever; paraclinical tests indicated significant leukocytosis, and ultrasound was positive in some patients. The waiting time for surgery was 10.4±7.99 hours, the most common approach was open, followed by laparoscopic.; the mean surgical time was 116.5±42.3 minutes. The main surgical findings were, in decreasing order: phlegmonous appendicitis (almost half of the cases), followed by catarrhal, gangrenous, and perforation, with two patients with a normal appendix; other findings were: inflammatory fluid, thickened mesoappendix, and adhesions. There were only complications in 5 patients (6.0%). The condition at discharge of the patients was good in 97.0 %. Conclusion: the findings of this series do not differ from those obtained in periods of time prior to the pandemic, that is,appendicitis in the phlegmonous and catarrhal phase is more frequent than the rest of the other forms of presentatio(AU)

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.

Síndrome post-colecistectomía: análisis de una cohorte prospectiva / Post-cholecystectomy syndrome: Descriptive analysis of a prospective cohort

Introducción. El síndrome post-colecistectomía fue descrito hace más de 70 años y se define como la presencia de síntomas gastrointestinales que pueden persistir después de la colecistectomía o aparecer como nuevos síntomas. Este síndrome, poco conocido, puede manifestarse desde pocos meses hasta varios años luego de la cirugía y ocurre entre 5 % y 40 % de los pacientes. Método. Estudio de cohorte prospectiva, que incluyó pacientes a quienes se les realizó colecistectomía laparoscópica en tres unidades quirúrgicas de Bogotá, D.C., Colombia, durante un período de ocho meses, con seguimientos periódicos durante dos años. El síndrome post-colecistectomía se definió como la presencia de al menos un síntoma gastrointestinal a partir del primer mes de la cirugía. Resultados. Se incluyeron 380 pacientes de los cuales 183 (48,2 %) desarrollaron el síndrome. La edad tuvo diferencia estadísticamente significativa entre aquellos que lo desarrollaron y los que no (p=0,024). La diarrea fue el único síntoma preoperatorio asociado al desarrollo del síndrome. El síndrome post-colecistectomía se encontró en el 42,1 % de los pacientes al primer mes de seguimiento y en el 17,4 % al segundo año. Conclusiones. El síndrome post-colecistectomía ocurre en un porcentaje importante de pacientes. En concordancia con la literatura, se encontró que la diarrea prequirúrgica es un factor de riesgo independiente para el desarrollo del síndrome. Se recomienda un adecuado seguimiento de los pacientes después de una colecistectomía

Introduction. Post-cholecystectomy syndrome (PCS) was described more than 70 years ago and is defined as the presence of gastrointestinal (GI) symptoms that may persist after cholecystectomy or can present as new symptoms. This little-known syndrome can appear from a few months to several years after surgery and occurs between 5% and 40% of patients. Method. Prospective cohort study, which included patients who underwent laparoscopic cholecystectomy in three surgical units in Bogotá, Colombia, during a period of eight months, with periodic follow-up for two years. PCS was defined as the presence of at least one GI symptom from the first month after surgery. Results. Three-hundred and eighty patients were included, of which 183 (48.2%) developed the syndrome. Age had a statistically significant difference between those who developed PCS and those who did not (p=0.024). Diarrhea was the only preoperative symptom associated with the development of PCS. Post-cholecystectomy syndrome was found in 42.1% at the first month of follow-up and in 17.4% at the second year. Conclusions. Post-cholecystectomy syndrome occurs in a significant percentage of patients. Consistent with the literature, preoperative diarrhea was found to be an independent risk factor for the development of the syndrome. Adequate follow-up of patients after cholecystectomy is recommended

Pancreatitis aguda: Puntos clave. Revisión argumentativa de la literatura / Acute pancreatitis: Key points. Argumentative review of the literature

Introducción. La pancreatitis aguda es una condición gastrointestinal común que se asocia a una importante morbimortalidad. Se estima que su incidencia es de 34 por cada 100.000 habitantes, afecta principalmente a adultos a partir de la sexta década de la vida y en nuestra región es debida en la mayoría de los casos a cálculos biliares. Métodos. Se hizo una revisión de los aspectos fundamentales de esta patología, común y potencialmente mortal. Resultados. El diagnóstico requiere del hallazgo de manifestaciones clínicas, aumento de las enzimas pancreáticas en suero y, en ocasiones, el uso de imágenes diagnósticas. Se puede clasificar en leve, moderada y severa, lo cual es fundamental para determinar la necesidad de tratamiento y vigilancia en una unidad de cuidados intensivos. Conclusión. En la actualidad los pilares de manejo de la pancreatitis aguda son la terapia temprana con líquidos, tratamiento del dolor, inicio precoz de la vía oral y resolución del factor etiológico desencadenante. En presencia de complicaciones o un curso severo de enfermedad, pueden requerirse manejo antibiótico e intervenciones invasivas

Introduction. Acute pancreatitis is a common gastrointestinal condition that is associated with significant morbidity and mortality. It is estimated that its incidence is 34 per 100,000 inhabitants, it mainly affects adults from the sixth decade of life, and in our region, most of the cases are secondary to gallbladder stones. Methods. We present a review of the fundamental aspects of this disease, common and potentially fatal. Results. Diagnosis requires finding clinical manifestations, increased serum pancreatic enzymes, and sometimes the use of diagnostic imaging. It can be classified as mild, moderate and severe, which is essential to determine the need for treatment and monitoring in an intensive care unit. Conclusion. Currently, the pillars of management of acute pancreatitis are early fluid therapy, pain management, early oral food intake, and resolution of the etiology. In the presence of complications or a severe course of the disease, antibiotic management and invasive interventions may be required

Causa rara de dolor abdominal recurrente; coexistencia del síndrome de Wilkie y el síndrome del cascanueces / A rare cause of recurrent abdominal pain; the coexistence of Wilkie's syndrome and nutcracker syndrome

El síndrome del cascanueces es un síndrome que presenta síntomas clínicos como hematuria, proteinuria ortostática, congestión pélvica, varicocele del lado izquierdo, hipertensión y dolor en fosa renal. Estos síntomas se producen por la compresión de la vena renal izquierda entre la aorta y la arteria mesentérica superior. En el síndrome de Wilkie, la tercera porción del duodeno está comprimida entre la arteria mesentérica superior y la aorta abdominal, lo que provoca diversos síntomas gastrointestinales. La coexistencia de estos dos síndromes constituye una afección rara y se incluye como casos clínicos en la bibliografía. En este artículo, se presentan los resultados clínicos y radiológicos de un paciente de 17 años que presentaba dolor abdominal recurrente debido al síndrome de Wilkie, acompañado del síndrome del cascanueces que le provocaba proteinuria, por lo que el paciente fue derivado a los consultorios externos de reumatología pediátrica con un diagnóstico preliminar de fiebre mediterránea familiar.

Nutcracker syndrome is a syndrome that has clinical symptoms such as hematuria, orthostatic proteinuria, pelvic congestion, left-sided varicocele, hypertension, and flank pain. These symptoms occur because of the compression of the left renal vein between the aorta and the superior mesenteric artery. In Wilkie's syndrome, the third part of the duodenum is compressed between the superior mesenteric artery and the abdominal aorta, causing various gastrointestinal symptoms. The coexistence of these two syndromes is a rare condition and is included as case reports in the literature. This article presents the clinical and radiological results of a 17-year-old male patient who had recurrent abdominal pain due to Wilkie's syndrome, which was accompanied by nutcracker syndrome that caused proteinuria, and for this reason, the patient was referred to the Pediatric Rheumatology outpatient clinic with a preliminary diagnosis of familial Mediterranean fever.

A case of dimethylformamide poisoning caused by skin contact / 中华劳动卫生职业病杂志

In this paper, the clinical data of a case of accidental poisoning of dimethylformamide in a traffic accident was analyzed. The patient was trapped in the driving room, his limbs were soaked in dimethylformamide for a long time, and dimethylformamide was inhaled at the same time. After 4 days of treatment in a local hospital, he was transferred to the Department of Poisoning & Occupational Diseases, Emergency Medicine of Qilu Hospital of Shandong University for treatment. The main clinical manifestation of the patient was liver damage and intractable abdominal pain, which was cured by active treatment.

The relationship between genetic polymorphism of CYP2C19 and the efficacy of Helicobacter pylori eradication therapy in children / 中华儿科杂志

Objective: To investigate the relationship between genetic polymorphisms of cytochrome P450 2C19 (CYP2C19) and the efficacy of Helicobacter pylori (Hp) eradication therapy in children. Methods: The retrospective cohort study was conducted on 125 children with gastroscopy and positive rapid urease test (RUT) from September 2016 to December 2018 who presented to the Children's Hospital of Zhejiang University School of Medicine due to gastrointestinal symptoms including nausea, vomiting, abdominal pain, bloating, acid reflux, heartburn, chest pain, vomiting blood and melena. Hp culture and drug susceptibility test were carried out with gastric antrum mucosa before treatment. All the patients completed 2 weeks of standardized Hp eradication therapy and had 13C urea breath test 1 month after that, which was used to evaluate the curative effect. The DNA of gastric mucosa after RUT was analyzed and CYP2C19 gene polymorphism was detected. Children were grouped according to metabolic type. Combined with the results of Hp culture and drug susceptibility, the relationship between CYP2C19 gene polymorphism and the efficacy of Hp eradicative treatment was analyzed in children. Chi square test was used for row and column variables, and Fisher exact test was used for comparison between groups. Results: One hundred and twenty five children were enrolled in the study, of whom 76 were males and 49 females. The genetic polymorphism of CYP2C19 in these children found poor metabolizer (PM) of 30.4% (38/125), intermediate metabolizer (IM) of 20.8% (26/125), normal metabolizer (NM) of 47.2% (59/125), rapid metabolizer (RM) of 1.6% (2/125), and ultrarapid metabolizer (UM) of 0. There were statistically significant in positive rate of Hp culture among these groups (χ2=124.00, P<0.001). In addition, the successful rates of Hp eradication in PM, IM, NM and RM genotypes were 84.2% (32/38), 53.8% (14/26), 67.8% (40/59), and 0, respectively, with significant differences (χ2=11.35, P=0.010); those in IM genotype was significantly lower than that in PM genotype (P=0.011). With the same standard triple Hp eradicative regimen, the successful rate of Hp eradication for IM type was 8/19, which was lower than that of PM (80.0%, 24/30) and NM type (77.3%, 34/44) (P=0.007 and 0.007, respectively). There was a significant difference in the efficacy of Hp eradication treatment among different genotypes (χ2=9.72, P=0.008). According to the clarithromycin susceptibility result, the successful rate of Hp eradication treatment for IM genotype was 4/15 in the sensitive group and 4/4 in the drug-resistant group (χ2=6.97, P=0.018). Conclusions: The genetic polymorphism of CYP2C19 in children is closely related to the efficacy of Hp eradication treatment. PM has a higher successful rate of eradication treatment than the other genotypes.

Short-term efficacy of empagliflozin in children with glycogen storage disease type Ⅰb / 中华儿科杂志

Objective: To analyze the short-time efficacy of empagliflozin in the treatment of glycogen storage disease type Ⅰb (GSD Ⅰb). Methods: In this prospective open-label single-arm study, the data of 4 patients were collected from the pediatric department in Peking Union Medical College Hospital from December 2020 to December 2022. All of them were diagnosed by gene sequencing and had neutropenia. These patients received empagliflozin treatment. Their clinical symptoms such as height and weight increase, abdominal pain, diarrhea, oral ulcer, infection times, and drug applications were recorded at 2 weeks, 1 month, 2 months, 3 months, 6 months, 9 months, 12 months, and 15 months after treatment to assess the therapeutic effect. The liquid chromatography-tandem mass spectrometry method was used to monitor the changes in 1, 5-anhydroglucitol (1, 5AG) concentration in plasma. At the same time, adverse reactions such as hypoglycemia and urinary tract infection were closely followed up and monitored. Results: The 4 patients with GSD Ⅰb were 15, 14, 4 and 14 years old, respectively at the beginning of empagliflozin treatment, and were followed up for 15, 15, 12 and 6 months, respectively. Maintenance dose range of empagliflozin was 0.24-0.39 mg/(kg·d). The frequency of diarrhea and abdominal pain decreased in cases 2, 3, and 4 at 1, 2 and 3 months of treatment, respectively. Their height and weight increased at different degrees.The absolute count of neutrophils increased from 0.84×109, 0.50×109, 0.48×109, 0.48×109/L to 1.48×109, 3.04×109, 1.10×109, 0.73×109/L, respectively. Granulocyte colony-stimulating factor was gradually reduced in 1 patients and stopped in 3 patient. Plasma 1, 5 AG levels in 2 children were significantly decreased after administration of empagliflozin (from 46.3 mg/L to 9.6 mg/L in case 2, and from 56.1 mg/L to 15.0 mg/L in case 3). All 4 patients had no adverse reactions such as hypoglycemia, abnormal liver or kidney function, or urinary system infection. Conclusion: In short-term observation, empagliflozin can improve the symptoms of GSD Ⅰb oral ulcers, abdominal pain, diarrhea, and recurrent infection, also can alleviate neutropenia and decrease 1, 5AG concentration in plasma, with favorable safety.

Effect of pancreatic extracorporeal shock wave lithotripsy on chronic pancreatitis stones / 中华外科杂志

Objective: To analyze the therapeutic effect and safety of pancreatic extracorporeal shock wave lithotripsy(P-ESWL) for patients with chronic pancreatitis complicated by stones of the pancreatic duct and to investigate the influencing factors. Methods: A retrospective analysis was performed on clinical data from 81 patients with chronic pancreatitis complicated by pancreatic duct calculus treated with P-ESWL in the Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi 'an Jiaotong University from July 2019 to May 2022. There were 55 males(67.9%) and 26 females(32.1%). The age was (47±15)years (range: 17 to 77 years). The maximum diameter(M(IQR)) of the stone was 11.64(7.60) mm, and the CT value of the stone was 869 (571) HU. There were 32 patients (39.5%) with a single pancreatic duct stone and 49 patients(60.5%) with multiple pancreatic duct stones. The effectiveness, remission rate of abdominal pain, and complications of P-ESWL were evaluated. Student's t test, Mann Whitney U test, χ2 test, or Fisher's exact test was used to compare the characteristics between the effective and ineffective groups of lithotripsy. The factors influencing the effect of lithotripsy were analyzed by univariate and multivariate logistic regression analysis. Results: Eighty-one patients with chronic pancreatitis were treated with P-ESWL 144 times, with an average of 1.78 (95%CI:1.60 to 1.96) times per person. Among them, 38 patients(46.9%) were treated with endoscopy. There were 64 cases(79.0%) with effective removal of pancreatic duct calculi and 17 cases(21.0%) with ineffective removal. Of the 61 patients with chronic pancreatitis accompanied by abdominal pain, 52 cases(85.2%) had pain relief after lithotripsy. After lithotripsy treatment, 45 patients(55.6%) developed skin ecchymosis, 23 patients(28.4%) had sinus bradycardia, 3 patients(3.7%) had acute pancreatitis, 1 patient(1.2%) had a stone lesion, and 1 patient(1.2%) had a hepatic hematoma. Univariate and multivariate logistic regression analysis showed that the factors affecting the efficacy of lithotripsy included the age of patient(OR=0.92, 95%CI: 0.86 to 0.97), the maximum diameter of the stone(OR=1.12,95%CI:1.02 to 1.24) and the CT value of the stone(OR=1.44, 95%CI: 1.17 to 1.86). Conclusions: P-ESWL is effective in the treatment of patients with chronic pancreatitis complicated by calculi of the main pancreatic duct.Factors affecting the efficacy of lithotripsy include patient's age, maximum stone diameter, and CT value of calculi.

Melanoma metastásico en intestino delgado: causa infrecuente de perforación: reporte de caso / Metastatic melanoma in the small intestine: infrequent cause of perforation: case report / Melanoma metastático em intestino delgado: causa rara de perfuração: relato de caso

El intestino delgado es el sitio de asiento más frecuente del melanoma metastásico. Su diagnóstico es un desafío por cursar asintomático o con síntomas inespecíficos. Son pocos los casos que presentan complicaciones, siendo infrecuente la peritonitis por perforación. El objetivo del trabajo es comunicar el caso clínico de una peritonitis por perforación de una metástasis de melanoma en intestino delgado. Caso clínico: Paciente de sexo masculino de 66 años con diagnóstico de melanoma de cuello y secundario óseo, encefálico y pulmonar, fue intervenido de urgencia por peritonitis aguda por perforación de metástasis en intestino delgado. El estudio histológico confirmó secundarismo de melanoma cutáneo. Conclusión: Sabiendo que el yeyuno íleon es el sitio de asiento más frecuente de las metástasis de melanoma, ante la presencia de síntomas digestivos inespecíficos o anemia se debe sospechar su compromiso y evaluar posibles alternativas terapéuticas.

The small intestine is the most frequent site of metastatic melanoma. However, its diagnosis continues to be a challenge since it is usually asymptomatic or with non-specific symptoms. Few cases result in complications, peritonitis due to perforation being infrequent. The objective of the work is to report a clinical case of peritonitis due to perforation of a melanoma metastasis in the small intestine. Clinical case: A 66-year-old male patient diagnosed with melanoma of the neck and secondary bone, brain and lung melanoma, underwent emergency surgery for acute peritonitis due to perforation of metastasis in the small intestine, which was resected and anastomosed. The histology confirmed the secondary nature of the cutaneous melanoma. Conclusion: Knowing that the jejunum-ileum is the most frequent site of melanoma metastases, in the presence of non-specific digestive symptoms or anemia, its involvement should be suspected and possible therapeutic alternatives should be evaluated.

O intestino delgado é o local mais frequente de melanoma metastático. O diagnóstico é um desafio por ser assintomático ou apresentar sintomas inespecíficos. Há poucos casos que apresentam complicações, sendo pouco frequente a peritonite por perfuração. O objetivo deste trabalho é relatar um caso clínico de peritonite por perfuração de metástase de melanoma no intestino delgado. Caso clínico: Paciente do sexo masculino, 66 anos, diagnosticado com melanoma no pescoço com metástase óssea, cefálica e pulmonar. Foi submetido a cirurgia de emergência por peritonite aguda por perfuração de metástases do intestino delgado. O estudo histológico confirmou melanoma cutâneo. Conclusão: Sabendo que o jejuno e o íleo é o local mais frequente de metástase de melanoma, na presença de sintomas digestivos inespecíficos ou anemia deve-se suspeitar de seu acometimento e avaliar possíveis alternativas terapêuticas.

Apendicetomía electiva: caso clínico y revisión de la bibliografía / Elective appendectomy: clinical case and literature review / Apendectomia eletiva: caso clínico e revisão da literatura

Las masas inflamatorias de origen apendicular son cuadros de presentación poco frecuente, el 3 % de las apendicitis agudas. Su manejo terapéutico puede ser sistematizado en cirugía de inicio o tratamiento conservador. Este último consiste en antibioticoterapia exclusiva, o asociada al drenaje percutáneo. Es una alternativa frente a emprender una apendicectomía demandante, con riesgo de no identificar el apéndice cecal, lesión visceral y necesidad de conversión o resecciones extendidas. Sin embargo, en estos pacientes, la ausencia de la confirmación diagnóstica anatomo-patológica obliga a un seguimiento protocolizado a fin de descartar diagnósticos diferenciales de mayor relevancia pronóstica. Objetivo: Presentar el caso de un paciente en el que se realizó manejo conservador y apendicetomía electiva. Se realizó una revisión bibliográfica de las pautas de seguimiento e indicación de la apendicectomía electiva. Discusión y conclusiones: Las masas inflamatorias de origen apendicular representan un desafío diagnóstico y terapéutico, requiriendo un manejo y seguimiento específico. La indicación de apendicectomía electiva es controversial, es planteable frente a la persistencia de imágenes patológicas y dudas diagnósticas, o en pacientes con apendicitis recurrentes.

Inflammatory masses of appendiceal origin are infrequent; represent 3 % of acute appendicitis. Its therapeutic management can be systematized in initial surgery or conservative treatment. The latter consists of exclusive antibiotic therapy, or associated with percutaneous drainage. it is an alternative to undertaking a demanding appendectomy, with the risk of not identifying the cecal appendix, visceral injury, and the need for conversion or extended resections. However, the absence of pathological diagnostic confirmation requires protocolized follow-up in order to rule out differential diagnoses of greater prognostic relevance. Objective: present the case of a patient who underwent conservative management and elective appendectomy. a bibliographic review was carried out in the databases: pubmed, cochrane library, scielo and lilacs. Discussion and conclusions: inflammatory masses of appendiceal origin represent a diagnostic and therapeutic challenge, requiring specific management and follow-up. The indication for elective appendectomy is controversial, it is considered in the presence of persistent pathological images and diagnostic doubts, or in patients with recurrent appendicitis.

Massas inflamatórias de origem apendicular são quadros de apresentação pouco frequentes, 3 % de as apendicites agudas. seu manejo terapêutico pode ser sistematizado em cirurgia inicial ou tratamento conservador. esta última consiste na antibioticoterapia exclusiva, ou associada à drenagem percutânea. é uma alternativa à realização de uma apendicectomia exigente, com risco de não identificação do apêndice cecal, lesão visceral e necessidade de conversão ou ressecções extensas. no entanto, nesses pacientes, a ausência de confirmação diagnóstica patológica requer acompanhamento protocolarizado para afastar diagnósticos diferenciais de maior relevância prognóstica. Objetivo: apresentar o caso de um paciente submetido a tratamento conservador e apendicectomia eletiva. foi realizada revisão bibliográfica nas bases de dados: pubmed, biblioteca cochrane, scielo e lilacs. Discussão e conclusões: as massas inflamatórias de origem apendicular representam um desafio diagnóstico e terapêutico, exigindo manejo e seguimento específicos. a indicação de apendicectomia eletiva é controversa, sendo considerada na presença de imagens patológicas persistentes e dúvidas diagnósticas, ou em pacientes com apendicite recorrente.

Les péritonites biliaires: aspects diagnostiques et thérapeutiques / Biliary peritonitis: diagnostic and therapeutic aspects

Buts : Le but était de décrire les aspects diagnostiques et thérapeutiques des péritonites biliaires. Patients et méthodes : Il s'est agi d'une étude transversale descriptive à collecte rétrospective sur une période de 10 ans incluant les patients opérés pour péritonite biliaire. Résultats : Nous avons colligé 10 cas de péritonite biliaire d'un 'âge moyen de 38 ans avec un sex-ratio de 2,3. Deux patients présentaient une contusion abdominale par suite d'un accident de la circulation routière. Une douleur abdominale maximale à l'hypochondre droit était présente chez trois patients, des signes d'irritation péritonéale chez tous les patients, un sérodiagnostic de Widal et Félix positif chez huit patients. À la laparotomie médiane la vésicule biliaire était perforée chez trois patients, gangrénée chez cinq, phlegmoneuse chez un, scléro-atrophique chez un. La cholécystectomie a été réalisée chez tous les patients. La péritonite biliaire était d'origine traumatique chez deux patients, et typhique chez huit. En post opératoire on notait quatre cas de sepsis, et trois cas de suppuration pariétale. Trois patients sont décédés. Conclusion : les péritonites biliaires découvertes lors de laparotomies pour péritonite, étaient secondaires à des cholécystites typhiques, et avaient une forte morbi-mortalité.

Aims: The aim was to describe the diagnostic and therapeutic aspects of biliary peritonitis. PATIENTS AND METHODS: This was a descriptive cross-sectional study with retrospective collection over a period of 10 years including patients operated on for biliary peritonitis. Results: We collected 10 cases of biliary peritonitis with an average age of 38 years with a sex ratio of 2.3. Two patients presented with an abdominal contusion following a road traffic accident. Maximum abdominal pain in the right hypochondrium was present in three patients, signs of peritoneal irritation in all patients, positive Widal and Felix serodiagnosis in eight patients. At midline laparotomy, the gallbladder was perforated in three patients, gangrenous in five, phlegmonous in one, sclero-atrophic in one. Cholecystectomy was performed in all patients. Biliary peritonitis was of traumatic origin in two patients, and typhoid in eight. Postoperatively, there were four cases of sepsis and three cases of parietal suppuration. Three patients died. Conclusion: Biliary peritonitis discovered during laparotomies for peritonitis, was secondary to typhoid cholecystitis, and had a high morbidity and mortality.

Clinicopathological characteristics and prognosis of patients with small bowel tumors: A single center analysis of 220 cases / 中华胃肠外科杂志

Objective: To analyze the clinicopathological characteristics and prognosis of patients with small bowel tumors. Methods: This was a retrospective, observational study. We collected clinicopathological data of patients with primary jejunal or ileal tumors who had undergone small bowel resection in the Department of Gastrointestinal Surgery, West China Hospital, Sichuan University between January 2012 and September 2017. The inclusion criteria included: (1) older than 18 years; (2) had undergone small bowel resection; (3) primary location at jejunum or ileum; (4) postoperative pathological examination confirmed malignancy or malignant potential; and (5) complete clinicopathological and follow-up data. Patients with a history of previous or other concomitant malignancies and those who had undergone exploratory laparotomy with biopsy but no resection were excluded. The clinicopathological characteristics and prognoses of included patients were analyzed. Results: The study cohort comprised 220 patients with small bowel tumors, 136 of which were classified as gastrointestinal stromal tumors (GISTs), 47 as adenocarcinomas, and 35 as lymphomas. The median follow-up for all patient was 81.0 months (75.9-86.1). GISTs frequently manifested as gastrointestinal bleeding (61.0%, 83/136) and abdominal pain (38.2%, 52/136). In the patients with GISTs, the rates of lymph node and distant metastasis were 0.7% (1/136) and 11.8% (16/136), respectively. The median follow-up time was 81.0 (75.9-86.1) months. The 3-year overall survival (OS) rate was 96.3%. Multivariate Cox regression-analysis results showed that distant metastasis was the only factor associated with OS of patients with GISTs (HR=23.639, 95% CI: 4.564-122.430, P<0.001). The main clinical manifestations of small bowel adenocarcinoma were abdominal pain (85.1%, 40/47), constipation/diarrhea (61.7%, 29/47), and weight loss (61.7%, 29/47). Rates of lymph node and distant metastasis in patients with small bowel adenocarcinoma were 53.2% (25/47) and 23.4% (11/47), respectively. The 3-year OS rate of patients with small bowel adenocarcinoma was 44.7%. Multivariate Cox regression-analysis results showed that distant metastasis (HR=4.018, 95%CI: 2.108-10.331, P<0.001) and adjuvant chemotherapy (HR=0.291, 95% CI: 0.140-0.609, P=0.001) were independently associated with OS of patients with small bowel adenocarcinoma. Small bowel lymphoma frequently manifested as abdominal pain (68.6%, 24/35) and constipation/diarrhea (31.4%, 11/35); 77.1% (27/35) of small bowel lymphomas were of B-cell origin. The 3-year OS rate of patients with small bowel lymphomas was 60.0%. T/NK cell lymphomas (HR= 6.598, 95% CI: 2.172-20.041, P<0.001) and adjuvant chemotherapy (HR=0.119, 95% CI: 0.015-0.925, P=0.042) were independently associated with OS of patients with small bowel lymphoma. Small bowel GISTs have a better prognosis than small intestinal adenocarcinomas (P<0.001) or lymphomas (P<0.001), and small bowel lymphomas have a better prognosis than small bowel adenocarcinomas (P=0.035). Conclusions: The clinical manifestations of small intestinal tumor are non-specific. Small bowel GISTs are relatively indolent and have a good prognosis, whereas adenocarcinomas and lymphomas (especially T/NK-cell lymphomas) are highly malignant and have a poor prognosis. Adjuvant chemotherapy would likely improve the prognosis of patients with small bowel adenocarcinomas or lymphomas.

Systematic review and Meta-analysis of Biling Weitong Granules in treatment of stomach ache disorder / 中国中药杂志

This study aimed to evaluate the efficacy and safety of Biling Weitong Granules in the treatment of stomach ache disorder. Randomized controlled trial(RCT) of Biling Weitong Granules in the treatment of digestive diseases with stomach ache disorder as the primary symptom was retrieved from Chinese and English electronic databases and trial registration platforms from database inception to June 10, 2022. Two investigators conducted literature screening and data extraction according to the screening criteria. The Cochrane risk-of-bias tool(v 2.0) was used to assess the risk of bias in the included studies. Analyses were performed using RevMan 5.4 and R 4.2.2, with summary estimates measured using fixed or random effects models. The primary outcome indicators were the visual analogue scale(VAS) scores and stomach ache disorder symptom scores. The secondary outcome indicators were clinical recovery rate, Helicobacter pylori(Hp) eradication rate, and adverse reaction/events. Twenty-seven RCTs were included with a sample size of 2 902 cases. Meta-analysis showed that compared with conventional western medicine treatments or placebo, Biling Weitong Granules could improve VAS scores(SMD=-1.90, 95%CI[-2.18,-1.61], P<0.000 01), stomach ache disorder symptom scores(SMD=-1.26, 95%CI[-1.71,-0.82], P<0.000 01), the clinical recovery rate(RR=1.85, 95%CI[1.66, 2.08], P<0.000 01), and Hp eradication rate(RR=1.28, 95%CI[1.20, 1.37], P<0.000 01). Safety evaluation revealed that the main adverse events in the Biling Weitong Granules included nausea and vomiting, rash, diarrhea, loss of appetite, and bitter mouth, and no serious adverse events were reported. Egger's test showed no statistical significance, indicating no publication bias. The results showed that Biling Weitong Granules in the treatment of digestive system diseases with stomach ache disorder as the primary symptom could improve the VAS scores and stomach ache disorder symptom scores of patients, relieve stomach ache disorder, and improve the clinical recovery rate and Hp eradication rate, with good safety and no serious adverse reactions. However, the quality of the original studies was low with certain limitations. Future studies should use unified and standardized detection methods and evaluation criteria of outcome indicators, pay attention to the rigor of study design and implementation, and highlight the clinical safety of the medicine to provide more reliable clinical evidence support for clinical application.