ABSTRACT
INTRODUCTION: Post-traumatic diaphragmatic hernias are not commonly diagnosed immediately after the initial trauma. There is a greater prevalence of left hernias due to the fragility or injury in diaphragm muscle and the lack of solid and fixed structures on the left side. PRESENTATION OF CASE: A male patient, 30 years old, he was admitted to the emergency department presenting diffuse abdominal pain, vomiting, dyspnea, pain in the left hemithorax with worsening during forced inspiration. After performing X-ray and computed tomography (CT), the presence of organs in the abdominal cavity outside the usual position was evidenced and with discrete deviation. Immediate surgery was performed with posterolateral thoracic access through the sixth left intercostal space combined with left subcostal access. Initially, it was found jejunum, ileum and left colonic flexure and accessory spleen filling the hernial sac. DISCUSSION: This report is the first case to report two accessory spleens in manual reduction of herniation between thoracic and abdominal cavities after trauma and percutaneous perforation. The splenectomy performed in both organs occurred due to their advanced ischemia that was due to reduced vascularity. CONCLUSION: The presence of the reported accessory spleen inside the thoracic cavity is only a possible variation within the possibilities in cases of diaphragmatic hernias, which does not modify the surgical procedure in a relevant way.
ABSTRACT
INTRODUCTION: The presence of a foreign body obstructing the bile duct may appear through a typical picture of cholangitis, usually caused by the presence of gallstones. PRESENTATION OF CASE: Male patient, 31 years old, involved an in accident with gunshot in 2006, injured in the abdominal region. Evolved to a picture of intense pain in the right hypochondrium, mainly after fat meals, without irradiation 12 years after being injured. Presented jaundice episode associated to fecal acholia, choluria, pruritus and sporadic fever. It was diagnosed cholangitis due to the foreign body like a bullet, located in the hepatic duct after tomography performed for investigation. The conduction of the case is described next. DISCUSSION: Cholestatic syndrome caused by gun bullet in a prior event to the symptoms is a rare event in the literature. Total, there are 8 case reports of bullets found in bile ducts with distinct evolution time among themselves. The first exam will not necessarily identify the bullet, but it simplifies the visualization of the bile ducts dilation, characterizing obstruction. CONCLUSION: The presence of a foreign body in the bile ducts is well reported in literature, and it is directly dependent on previous history. We should always avoid using cholangioresonance in dubious cases. To keep the ERCP as initial treatment is recommended due to the advances on the procedure quality, but in more severe cases or lack of resources, the surgical exploration is still indicated.