Lesión hepática asociado a hemoperitoneo masivo secundario a trauma, reporte de caso / Liver injury associated with massive hemoperitoneum secondary to trauma, case report

Resumen Descripción del caso: Paciente de 23 años con hemorragia abdominal de origen no claro, que posteriormente presenta inestabilidad hemodinámica, requiriendo manejo quirúrgico en tres ocasiones con evolución satisfactoria. Hallazgos clínicos: Presentó sangrado cuantificado de 5500 cc en cavidad abdominal (grado IV - clasificación ATLS) con lesiones hepáticas en los segmentos I, IV y VIII, sin hallazgos sugestivos de trauma al examen físico, ni otros hallazgos traumáticos internos. Tratamiento y resultados: Se llevó a cabo una intervención quirúrgica precoz mediante laparotomía exploratoria con hallazgos ya descritos, además de dos tiempos quirúrgicos adicionales que llevaron al control del sangrado, con evolución satisfactoria. Relevancia clínica: El sangrado abdominal y laceración de víscera sólida secundario a trauma cerrado de abdomen es una etiología común en pacientes jóvenes masculinos, siendo contrario a esta afirmación el sangrado de origen hepático sin trauma es una etiología poco común. El presente caso resulta ser una dificultad diagnóstica en cuanto a la etiología, ya que lo evidenciado en la exploración quirúrgica no concuerda con el examen físico externo, sin una historia clínica clara al ingreso se deja la interrogante de la causa.

Summary: Case description: 23-year-old patient with abdominal hemorrhage of unclear origin, who subsequently presented hemodynamic instability, requiring surgical management on three occasions with satisfactory evolution. Clinical findings: she presented quantified bleeding of 5500 cc in the abdominal cavity (grade IV-ATLS classification) with liver lesions in segments I, IV and VIII, without findings suggestive of trauma on physical examination, or other internal traumatic findings. Treatment and results: An early surgical intervention was carried out through exploratory laparotomy with findings already described, in addition to two additional surgical procedures that led to control of bleeding, with satisfactory evolution. Clinical relevance: Abdominal bleeding and solid viscus laceration secondary to blunt abdominal trauma is a common etiology in young male patients, contrary to this statement, bleeding of hepatic origin without trauma is a rare etiology. The present case turns out to be a diagnostic difficulty in terms of etiology, since what was evidenced in the surgical exploration does not agree with the external physical examination, without a clear clinical history at admission, the question of the cause is left.

Splenic rupture in dairy cattle: Report of 24 cases.

Splenic rupture in cattle is scarcely described in the literature. The aim of this work was to report the occurrence of splenic rupture in cattle in southern Brazil as well as to describe the causes of the condition. Between 2013 and 2022, 24 of the 1769 bovine necropsies performed in southern Brazil were due to splenic rupture, accounting for 1.36% of the diagnoses. Animals died due to hemoperitoneum caused by a rupture in the splenic capsule, typically associated with marked splenomegaly and a large hematoma between the capsule and the parenchyma. Clinical signs were described in a subset of cases (11 of 24 cases, 46%) and included apathy, abdominal pain, mucosal pallor, tachycardia, and respiratory distress. However, the majority (13 of 24 cases, 54%) presented as sudden death. The underlying cause of splenic rupture was established as follows: 16 cases (67%) secondary to babesiosis, 4 cases (17%) due to lymphoma, 1 case (4%) due to a thrombus, 1 case (4%) due to external trauma, 1 case due to a ruptured nodular lymphoid hyperplasia (4%), and 1 case of undetermined cause (4%). Hypovolemic shock caused by splenic rupture is an important cause of death of dairy cattle, and babesiosis and bovine leukemia virus-associated lymphoma are among the most common etiologic diagnoses (84% of cases). The description of the causes of this condition is important to clarify the pathogenesis and occurrence of splenic rupture in dairy cattle.

Hemoperitoneo secundario a tumor maligno de la vaina del nervio periférico en hígado / Hemoperitoneum secondary to a malignant tumor of the sheath of the peripheral nerve in the liver

RESUMEN Los tumores malignos de la vaina del nervio periférico se asocian con frecuencia a neurofibromatosis tipo 1. Se localizan habitualmente en las extremidades o en la zona axial. Su ubicación visceral es muy rara y el origen hepático infrecuente. Suelen ser agresivos con pobre repuesta a la quimioterapia y radioterapia, por lo que el manejo quirúrgico es la mejor opción de tratamiento. Presentamos el caso de un joven con neurofibromatosis tipo 1, quien cursó con hemoperitoneo como complicación de un tumor maligno de la vaina del nervio periférico ubicado en el hígado.

ABSTRACT Malignant peripheral nerve sheath tumors are frequently associated with neurofibromatosis type 1. They are usually located in the extremities or in the axial area. Its visceral location is very rare and its hepatic origin is infrequent. They tend to be aggressive with a poor response to chemotherapy and radiotherapy, so surgical management is the best treatment option. We present the case of a young man with neurofibromatosis type 1, who presented with hemoperitoneum as a complication of a malignant tumor of the peripheral nerve sheath located in the liver.

Unrecognized abdominal pregnancy with six months' evolution revealed by acute intestinal obstruction in women with PCOS.

Abdominal pregnancy is a rare form of ectopic pregnancy where implantation and development of the egg take place in the peritoneal cavity outside the tubo-uterine mucosa, in contact with intestinal loops. Diagnosis is most often difficult. We report the case of a 32-year-old woman (gravida 1, para 1), with a history of PCOS, diagnosed with abdominal pregnancy at 20 weeks of amenorrhea complicated by acute intestinal obstruction. Diagnosis was confirmed by abdomino-pelvic scan. Surgery was performed with the patient under general anesthesia. She presented a macerated fetus with an infiltration of the placenta causing a perforation of the sigmoid colon and uterus. Hartmann's procedure was performed and the perforation of the uterus was sutured. Abdominal pregnancy remains a rare variety of ectopic pregnancy. Preoperative diagnosis is difficult due to the presence of a variety of non-specific symptoms. This type of ectopic pregnancy remains challenging for gynecologists and radiologists.

Hemoperitoneum after a Bothrops snakebite: Case report.

Snakebites are frequent in tropical countries. Brazil has an average of 27,000 cases per year, with a fatality rate of 0.5%, and the Bothrops genus is the most common causative agent, accounting for about 70-90% of the accidents. This report describes a case of human envenomation by a juvenile Bothrops jararaca snake in São Paulo, Brazil, in a 71 years-old man, previously healthy. He presented a life-threatening envenomation, which developed to severe hypotension, acute kidney injury and extensive peritoneal hemorrhage. The hemoperitoneum was diagnosed due to persistent hypotension associated with anemia, pain and gastrointestinal complaints. Abdominal Computed Tomography scans showed a moderate to large amount of presumable hematic material inside the abdominal cavity, predominantly in the perihepatic and perisplenic spaces. The intra-abdominal hemorrhage was not surgically addressed, and the patient was discharged 5 days after hospitalization, with the progressive absorption of the hemoperitoneum. Systemic bleeding is one of the complications and main causes of death in Bothrops envenomations. Acute peritoneal hemorrhage is one of these serious complications that must be carefully addressed since its management must take into account the risk of bleeding caused by toxins that affect hemostasis. The case described highlights the importance of early diagnosis and adequate management of this potentially fatal complication in snakebites.

Hemoperitoneo secundario a lesión esplénica tras colonoscopia diagnóstica. Una complicación infrecuente

Introducción: La colonoscopia es una herramienta básica en el estudio de patologías del área colorrectal, así como uno de los pilares del screening del cáncer de colon y recto. Sin embargo, no es un procedimiento exento de riesgos, algunos de ellos con elevada morbimortalidad. Caso Clínico: Varón de 55 años con enolismo crónico y hepatopatía por Virus Hepatitis C y Enfermedad Pulmonar Obstructiva Crónica. En estudio por diarrea se solicita una ecografía de abdomen donde, como único hallazgo, se muestra una lesión de 7 mm a nivel de páncreas y una colonoscopia con intención diagnóstica que no muestra alteraciones significativas. Con la sospecha de que la lesión pancreática pudiese ser la causa del cuadro diarreico, se realiza un escáner abdominal donde se muestra una colección subcapsular a nivel esplénico de 11 × 3 cm compatible con hematoma sin signos de sangrado activo. Dada la estabilidad hemodinámica, se inicia manejo conservador, con empeoramiento del dolor abdominal e hipotensión en las siguientes 12 h. Se repite prueba de imagen objetivando aumento de hematoma esplénico y líquido libre intraabdominal. Se indica cirugía urgente donde se evidencia hemoperitoneo secundario a lesión esplénica que obliga a realizar esplenectomía. Conclusión: La presencia de una posible lesión esplénica yatrogénica se debe tener en cuenta en el diagnóstico diferencial en un paciente con dolor abdominal de inicio agudo y anemización o alteración del estado hemodinámico dentro de las primeras 24-48 h tras la realización de una colonoscopia.

Introduction: Colonoscopy is a basic tool in the study of pathology of the colorectal area, as well as one of the pillars of colon and rectal cancer screening. However, it is not a risk-free procedure, some of them with high morbimortality. Case Report: 55-year-old male with chronic alcoholism and hepatopathy due to HCV, COPD. During a study for diarrhea, an ultrasound of the abdomen revealed a 7 mm pancreas tumor, and a diagnostic colonoscopy showed no significant alterations. With the suspicion that the pancreatic lesion could be the cause of the diarrhea, an abdominal scan was performed showing a subcapsular collection at the splenic level of 11 × 3 cm compatible with hematoma without signs of active bleeding. Due to the hemodynamic stability, conservative management was decided, with worsening abdominal pain and hypotension in the following 12 hours. A new imaging test showed an enlarged splenic hematoma and free abdominal fluid suggestive of hemoperitoneum. Urgent surgery found hemoperitoneum secondary to splenic lesion and splenectomy was required. Conclusion: The presence of a possible iatrogenic splenic lesion should be considered in the differential diagnosis in a patient with acute onset abdominal pain and anemia or hemodynamic status alteration within the first 24-48 hours after colonoscopy.

Hemoperitoneo espontáneo asociado con endometriosis en gestante de segundo trimestre / Spontaneus hemoperitoneum associated with endometriosis in a second trimester pregnant woman

Resumen ANTECEDENTES: El hemoperitoneo espontáneo es una complicación infrecuente durante la gestación (1 de cada 100,000 embarazos) con importante repercusión en la morbilidad y mortalidad materno-fetal. CASO CLÍNICO: Paciente de 44 años, con 21+6 semanas de embarazo, con diagnóstico previo al embarazo de endometriosis, que acudió a Urgencias debido a un dolor abdominal. Después de comprobar la viabilidad fetal, se solicitó una ecografía abdominal-pélvica urgente en la que se visualizó líquido libre en la fosa de Morrison, periesplénico y perihepático. Durante su estancia en Urgencias sufrió una anemización aguda acompañada de inestabilidad hemodinámica; se decidió una laparotomía exploradora urgente. Entre los hallazgos operatorios destacó el hemoperitoneo de 1.5 litros y de sangrado en torno del anejo derecho y el parametrio. En el control ecográfico a las 12 horas de la intervención se comprobó la ausencia del latido fetal; a las 72 horas se registró la expulsión espontánea del feto. La evolución de la paciente fue favorable por lo que se dio de alta a los 10 días de la intervención. CONCLUSIONES: Si bien durante el embarazo no hay forma de anticipar las complicaciones de la endometriosis preexistente, es importante, en caso de dolor abdominal intenso, sospechar otros eventos raros que potencialmente puedan ser mortales.

Abstract BACKGROUND: Spontaneous hemoperitoneum is a rare complication in pregnancy (1 in 100.000 pregnancies) with a great impact on maternal and fetal morbidity and mortality. CLINICAL CASE: A 44-year-old woman, 21+6 weeks pregnant, with a diagnosis of endometriosis, who went to the Emergency Department due to abdominal pain. After verifying fetal viability, an urgent abdominal ultrasound was requested in which free fluid was visualized at the level of Morrison's fossa, perisplenic and perihepatic. During her stay in the Emergency Department, she developed acute anemia accompanied by hemodynamic instability, for which an urgent exploratory laparotomy was performed. Among the operative findings, the presence of hemoperitoneum of 1,5 liters and bleeding at the level of the right adnexa and parametrium stood out. In ultrasound control 12 hours after the intervention, the absence of a fetal heartbeat was verified producing the spontaneuous expulsion of the fetus at 72 hours. Subsequently, the patient's evolution was favorable, and she was discharged 10 days after the intervention. CONCLUSION: Although during pregnancy there is no way to anticipate the occurrence of complications from pre-existing endometriosis. It is important the severe abdominal pain occurs, to suspect rare but life-threatening events.

Rotura aneurismática de la arteria hepática común / Ruptured common hepatic artery aneurysm

RESUMEN Los aneurismas de la arteria hepática son una patología poco frecuente. Cuando son sintomáticos, se debe sospechar un sufrimiento aneurismático y su tratamiento está indicado. Presentamos el caso clínico de un paciente con mal terreno cardiovascular, que consultó por un cuadro clínico de dolor epigástrico, repercusión hemodinámica e ictericia. La imagenología evidenció la presencia de un aneurisma de la arteria hepática común complicado con compromiso del origen de la arteria hepática propia y la arteria gastroduodenal. La presencia de una vascularización arterial hepática "no convencional" con una arteria hepática derecha proveniente de la arteria mesentérica superior, en la angiotomografía, permitió cambiar la táctica quirúrgica haciéndose prescindible la realización de un bypass. Este caso resalta la importancia de determinar en el preoperatorio no solo la extensión del aneurisma, sino también la anatomía vascular hepática a fin de planificar mejor la cirugía, disminuyendo así la morbimortalidad de esta enfermedad.

ABSTRACT Hepatic artery aneurysms are rare. Expanding aneurysms should be suspected in case of symptoms and treatment is indicated. We report the case of a patient with a history of cardiovascular disease who sought medical care due to epigastric pain, hemodynamic instability and jaundice. The imaging tests showed the presence of an aneurysm of the common hepatic artery complicated with involvement of the origin of the proper hepatic artery and the gastroduodenal artery. The surgical approach could be changed due to presence of a "non-conventional" hepatic arterial variant with a right hepatic artery originating from the superior mesenteric artery in the computed tomography angiography as bypass surgery was not necessary. This case highlights the importance of determining the extent of the aneurysm in the preoperative period and the anatomy of the hepatic vessels to better plan the surgery, thus reducing morbidity and mortality of this disease.

Hemoperitoneum in a cow with lumbar muscle hemangiosarcoma

Background: Hemangiosarcoma is a malignant neoplasm of endothelial cells with an infiltrative growth pattern. Hemangiosarcomas are frequently reported in canines and rare in felines, sheep, goats, swine, horses and cattle. Few cases of hemangiosarcoma were reported in cattle. In the present report, we describe the clinicopathological findings of a bovine muscle hemangiosarcoma. Case: A 6-year-old, Girolando cow from the Dairy Cattle Sector of the Federal Rural University of Rio de Janeiro (UFRRJ), Seropédica, presented sternal decubitus. Clinical signs were markedly pale mucous membranes, moderate dehydration, respiratory distress, and increased heart rate. The hematological examination revealed intense regenerative anemia. Due to the worsening of the clinical condition, the cow was submitted to euthanasia. The necropsy and collection of various fragments of organs were performed, which were sent to the "Setor de Anatomia Patológica" (SAP-UFRRJ). Tissues were fixed in 10 % buffered formalin, routinely processed for histology and stained with Hematoxylin and Eosin (HE). The external mucous membranes were markedly pale. Multifocal areas of 1.5 x 1.0 cm, irregular and dark red were observed dissecting the quadratus lumborum muscle (hemangiosarcoma) fibers. These neoplasms were associated with an extensive cruoric clot adhered to the muscle fibers. The extensive, red, friable mass measured approximately 76 x 55 x 20 cm on the serous surfaces of the organs of the peritoneal cavity (hemoperitoneum). The spleen was moderately reduced. The bone marrow was markedly pale. Histologically, it was observed that there was an extensive proliferation of endothelial cells in the quadratus lumbar muscle mass dissecting the epimysium and perimysium. Endothelial cells had moderate pleomorphism, organized in vascular channels and forming multifocally solid areas with a significant amount of eosinophilic fibrillar material (fibrin). Sections of muscle neoplasm were subjected to immunohistochemistry with anti-von Willebrand factor primary antibody, which showed a multifocal moderate cytoplasmic immunolabeling of neoplastic endothelial cells. Discussion: There are few reports of striated muscle hemangiosarcoma in cattle. Muscular hemangiosarcomas were reported in a 4-month-old calf in the left cervical trapezius muscle and a 6-year-old Holstein cow with left pelvic limb mass lateral and distal to the knee. Some reports presented hemangiosarcoma in the iliopsoas muscle, left cervical trapezius muscle, pelvic limb muscles and right cervical muscle of the bovine. In the presented report, hemoperitoneum occurred as a result of hemorrhages from muscle hemangiosarcoma. Other studies have demonstrated cavity hemorrhages in joint, pelvic, pleural and cranial cavities associated with hemangiosarcoma. Hemangiosarcoma with regenerative anemia must be distinguished from other diseases that cause anemia. The main differential diagnoses of bovine with anemia are vena cava syndrome, coumarin derivatives poisoning, acute poisoning by Pteridium spp., tick fever, anaplasmosis, babesiosis and trypanosomiasis. Hemangiosarcoma should be differentiated from other lesions as hemangioma, vascular tumor of lymphatic endothelium and perivascular wall tumors. Cases with poorly differentiated morphology should be submitted for immunohistochemistry. In the present hemangiosarcoma case, we have used the von Willebrand factor for immunohistochemistry diagnosis. Expression of angiogenic growth factors such as CD31, vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF) and angiopoietin-1 (Ang-1) have also been used in the diagnosis of vascular proliferation lesions. Hemangiosarcoma in cattle should be included mainly in the differential diagnosis of diseases that cause acute anemia in cattle.

Tubal heterotopic pregnancy. case report

ABSTRACT Introduction: Heterotopic pregnancy (HP) is an uncommon yet interesting condition with a high mortality rate despite its low incidence. It can be difficult to diagnose due to its diverse clinical manifestations. Case presentation. A 32-year-old, mestizo, pregnant woman from Pasto (Colombia) attended the emergency department of a tertiary care institution due to diffuse abdominal pain associated with vaginal bleeding. Taking into account the imaging findings (ultrasound) and the gonadotropin levels found, the patient was diagnosed with heterotopic pregnancy in right fallopian tube that required surgical treatment by laparotomy. Eight days after the procedure, the patient attended a follow-up appointment during which an ultrasound showed continuity of intrauterine pregnancy. Conclusions. The mainstay for the diagnosis of heterotopic pregnancy is clinical suspicion, but it is necessary to confirm it through diagnostic aids such as ultrasound and the measurement of human chorionic gonadotropin levels. A heterotopic pregnancy should be suspected in patients with abdominal pain, even if they do not have risk factors for this type of pregnancy. Choosing medical or surgical treatment will depend on the clinical and hemodynamic condition of the patient and the location and size of the ectopic pregnancy.

RESUMEN Introducción. El embarazo heterotópico se considera una patología de interés debido a que, aunque su incidencia es baja, su tasa de mortalidad es elevada; además, esta es una entidad que representa un reto diagnostico por sus diversas presentaciones clínicas. Presentación del caso. Mujer de 32 años, mestiza, procedente de Pasto (Colombia) y en estado de embarazo, quien asistió al servicio de urgencias de una institución de tercer nivel de atención por un dolor abdominal difuso asociado a sangrado vaginal. Teniendo en cuenta los hallazgos imagenológicos (ecografía) y los niveles de gonadotropina encontrados, la paciente fue diagnosticada con embarazo heterotópico de ubicación tubárica derecha que requirió tratamiento quirúrgico por laparotomía. A los 8 días del procedimiento la paciente asistió a control y mediante ecografía se evidenció continuidad de embarazo intrauterino. Conclusiones. El pilar fundamental para el diagnóstico del embarazo heterotópico es la sospecha clínica, pero es necesario confirmarlo mediante ayudas diagnosticas como la ecografía y a través de la medición de los niveles de gonadotropina coriónica humana. Este evento se debe sospechar en pacientes con cuadro de dolor abdominal a pesar de que no tengan factores de riesgo para presentarlo. La elección de tratamiento (médico o quirúrgico) depende de la condición clínica y hemodinámica de cada paciente y de la ubicación y el tamaño del embarazo ectópico.

Acute abdomen secondary to massive bleeding due to rupture of liver metastases of a gastrointestinal stroma tumor.

Hemoperitoneum secondary to non-traumatic liver rupture is a rare cause of an acute abdomen. We present the case of a patient with a hepatic rupture secondary to metastasis of a gastrointestinal stromal tumor (GIST) who required an emergent laparotomy due to hemodynamic instability. Intraoperatively, a lesion of more than 20cm dependent on the posterior gastric wall and a hemoperitoneum secondary to rupture of liver metastases and decapsulation of the Glisson capsule was evidenced. A frequent complication of GIST tumors is its rupture causing gastrointestinal bleeding or hemoperitoneum, as occurred in our case.

El hemoperitoneo secundario a estallido hepático no traumático es una causa poco frecuente de abdomen agudo. Se presenta el caso de una paciente con estallido hepático secundario a metástasis de un tumor del estroma gastrointestinal (GIST) que requirió una laparotomía emergente por inestabilidad hemodinámica. Se evidenció intraoperatoriamente una lesión de más de 20 cm dependiente de la pared posterior gástrica y un hemoperitoneo secundario a estallido de metástasis hepáticas y descapsulación de la cápsula de Glisson. Una complicación frecuente de los GIST es la rotura que ocasiona hemorragia digestiva o hemoperitoneo, como ocurrió en nuestro caso.

Hemoperitoneo secundario a rotura de carcinoma hepatocelular / Hemoperitoneum secondary to rupture of hepatocellular carcinoma

Introducción: El carcinoma hepatocelular es un tumor hipervascular compuesto por vasos sanguíneos anormales, constituye la forma más frecuente de cáncer primario del hígado. Alrededor del 90 por ciento de estos tumores se desarrollan sobre una enfermedad hepática previa. Un aumento en la carga vascular debido a la hipertensión portal conlleva a sangrado. Objetivo: Presentar un paciente a quien se le practicó laparotomía exploradora de urgencia por hemoperitoneo de gran cuantía secundario a una rotura intratumoral sobre un hígado cirrótico. Caso clínico: Paciente de 66 años de edad, con antecedentes patológicos de diabetes mellitus tipo 2, hiperplasia benigna de próstata, alcoholismo crónico y cirrosis hepática. Acudió al cuerpo de guardia por dolor abdominal difuso y signos de hipovolemia aguda. Se realizó laparotomía de urgencia y se constata hemoperitoneo de gran cuantía, secundario a una rotura intratumoral. Se le realizó aspiración de contenido hemático, electrocoagulación y compresión por empaquetamiento. Se controló el sangrado. El paciente tuvo una evolución tórpida y falleció 24 horas posteriores a la laparotomía. Conclusiones: El hemoperitoneo secundario a rotura de un carcinoma hepatocelular, es una complicación poco frecuente, pero fatal; por lo que se hace necesario su estudio para lograr un diagnóstico y tratamiento oportuno(AU)

Introduction: Hepatocellular carcinoma is a hypervascular tumor made up of abnormal blood vessels. It is the most frequent form of primary liver cancer. About 90 percent of these tumors develop over a previous liver disease. An increase in vascular load due to portal hypertension leads to bleeding. Objective: To present a patient who underwent emergency exploratory laparotomy due to large hemoperitoneum secondary to an intratumoral rupture of a cirrhotic liver. Clinical case: A 66-year-old male patient with a pathological history of type 2 diabetes mellitus, benign prostatic hyperplasia, chronic alcoholism and liver cirrhosis. He came to emergency due to diffuse abdominal pain, as well as signs of acute hypovolemia. An emergency laparotomy was performed, confirming a large hemoperitoneum secondary to an intratumoral rupture. Blood content aspiration, electrocoagulation and compression by packing were performed, managing to control bleeding. He had a torpid evolution, dying 24 hours after the laparotomy. Conclusions: Hemoperitoneum secondary to rupture of a hepatocellular carcinoma is a rare, but fatal complication; therefore, its study is necessary to achieve a timely diagnosis and treatment(AU)

Peritonitis esclerosante encapsulante: una causa rara de obstrucción intestinal / Sclerosing encapsulating peritonitis: a rare cause of intestinal obstruction

RESUMEN La peritonitis esclerosante encapsulante es una rara entidad de baja incidencia. Su fisiopatología no está clara, reconociéndose dos tipos: idiopática y secundaria, esta última generalmente como complicación de la diálisis peritoneal. Su diagnóstico suele ser tardío manifestándose con clínica de obstrucción intestinal. Es importante conocer los signos radiológicos. Asocia una alta mortalidad, por lo que es fundamental sospecharla precozmente e incluirla en el diagnóstico diferencial de los cuadros de obstrucción intestinal. Presentamos el caso de una obstrucción intestinal como forma de presentación de una peritonitis esclerosante encapsulante.

ABSTRACT Sclerosing encapsulating peritonitis is a rare condition with a low incidence rate. The pathophysiology of this disease is not clear, though two types are distinguished: idiopathic and secondary; the latter usually occurs as a peritoneal dialysis complication. The diagnosis of the condition is usually delayed and it presents with intestinal obstruction. It is important to know the X-ray findings. This disease is associated with a high mortality rate; therefore, early detection and a differential diagnosis in cases of intestinal obstruction are important. We report a case of intestinal obstruction as a clinical manifestation of sclerosing encapsulating peritonitis.

Rotura esplénica espontánea secundaria a mononucleosis infecciosa / Spontaneous splenic rupture secondary to infectious mononucleosis

Resumen La rotura esplénica es una complicación rara pero potencialmente fatal de la mononucleosis infecciosa. Presentamos el caso de una mujer de 18 años que consultó por dolor abdominal de siete días de evolución, asociado a fiebre y pérdida de conciencia brusca y transitoria. En el hemograma presentaba una anemia y linfocitosis. Se realizó una tomografía computada de abdomen y pelvis que mostró un extenso hemoperitoneo, con el bazo rodeado por un hematoma, y numerosas adenopatías cervicales, mesentéricas e inguinales. Se efectuó una laparoscopía que demostró abundante hemoperitoneo con coágulos a lo largo de la gotera parietocólica izquierda. El bazo estaba completamente decapsulado y rodeado por una colección hemática con sangrado en napa. Se realizó una esplenectomía total sin complicaciones. El estudio histopatológico esplénico mostró una atenuación de la pulpa blanca y expansión de la pulpa roja con áreas de hemorragia y necrosis. La IgM anti-cápside para virus de Epstein Barr fue positiva. La paciente evolucionó de manera favorable.

Abstract Splenic rupture is a rare but potentially fatal complication of infectious mononucleosis. We report the case of an 18-year-old woman, who presented a 7-day history of abdominal pain, sudden temporary loss of consciousness and fever. Admission blood tests showed anemia, and lymphocytosis. Computed tomography of the abdomen and pelvis demonstrated extensive hemoperitoneum and numerous cervical, mesenteric and inguinal enlarged lymph nodes. Laparoscopy was performed and abundant hemoperitoneum with blood clots along the left parietocolic gutter were observed. The spleen was completely decapsulated and surrounded by a hematoma and the subcapsular tissue was bleeding. Total splenectomy was performed without complications. Splenic histology demonstrated white pulp attenuation and expansion of the red pulp with focal hemorrhage and necrosis. IgM anti-viral capsid antigen of Epstein Barr virus was positive. The patient had a satisfactory recovery.

Hematocele y hemoperitoneo como manifestación inicial de carcinoma hepatocelular: caso clínico / Hematocele and hemoperitoneum as initial manifestation of hepatocellular carcinoma: report of one case

Hepatocellular carcinoma (HCC) rupture is a rare complication, with a higher prevalence in countries of Asia and Europe. Its clinical manifestations can be nonspecific, from abdominal pain and bloating to hemodynamic involvement. We report a 70-year-old male patient with a history of chronic liver disease, presenting with an enlargement and ecchymosis of the scrotum, associated with abdominal bloating. The initial abdominal ultrasound study showed increased liquid content in the scrotal sac and regional edema. A CT of the abdomen and pelvis showed a liver mass with characteristics of hepatocellular carcinoma, associated with extensive hemoperitoneum that drained into the scrotal sac. The patient was treated with embolization of the right hepatic artery and later with surgical resection of the tumor mass, with a good clinical evolution.

Use of point-of-care ultrasound to diagnose spontaneous rupture of fibroid in pregnancy.

Background: Complications of fibroids in pregnancy are well known, including postpartum hemorrhage, labor dystocia, and cesarean delivery. Outside of pregnancy and labor, the rare occurrence of spontaneous fibroid rupture has been documented. Case: The current case report involves a woman who presented with acute abdominal pain in the third trimester of pregnancy and was found to have spontaneous rupture of a fibroid before the onset of labor. Her initial presentation, diagnosis through use of point-of-care ultrasound, acute surgical management, and postoperative course are described. Conclusion: When assessing acute abdominal pain in a pregnant patient, fibroid rupture should be considered despite the absence of prior uterine surgery. Bedside point-of-care ultrasonography is a useful tool for assessment of abdominal pain in the third trimester of pregnancy.

Reporte de un caso: Muerte súbita de Origen Ginecoobstétrico / Sudden death of gyneco-obstetric origin: Case report

Resumen La muerte súbita de origen ginecoobstétrico es poco frecuente tanto en paises americanos como del viejo continente, sin embargo, este tipo de defunciones es por concepto relevante para la legislación de Costa Rica al ser criterio de autopsias médico legales, donde se responde no solo la causa de muerte, sino también otros objetivos propias de la necropsia, como la manera de muerte, donde debe descartarse una diferente a la natural. Los embarazos ectópicos rotos tienen significancia en los registros actuales según la razón de mortalidad materna, con repercusión en la salud reproductiva de las pacientes que lo padecen, convirtiéndose en una patología relevante para el registro médico clínico como forense.

Abstract Sudden death of gyneco-obstetric origin is rare in both American countries and the old continent, however, this type of death is conceptually relevant to Costa Rican legislation as it is the criterion of medical-legal autopsies, where not only the cause is answered of death, but also other objectives typical of the autopsy, such as the way of death, where one other than the natural one must be ruled out. Broken ectopic pregnancies are significant in current records according to the reason of maternal mortality, with repercussions on the reproductive health of patients who suffer from it, becoming a relevant pathology for clinical medical and forensic records.

Fracturas atípicas de fémur asociadas al uso de bifosfonatos / Bisphosphonate associated atypical femur fractures

Resumen Los bifosfonatos son medicamentos ampliamente conocidos por su efecto antagonista de la resorción ósea y la consecuente reducción del riesgo de fracturas en los pacientes con osteoporosis. La literatura actual provee evidencia en términos de datos clínicos y experimentales que asocian el uso prolongado de estos medicamentos con un aumento en el riesgo de fracturas atípicas de fémur. Para establecer si esta asociación es clínicamente relevante, se requiere realizar estudios posteriores que incluyan la relación entre otros factores que podrían influir en la aparición de este tipo de fracturas como lo es la propia enfermedad osteoporótica, el tipo de bifosfonato utilizado, el mecanismo lesional que originó la fractura, medicamentos concomitantes y patologías asociadas.

Abstract Bisphosphonates are medications that are widely known for their antagonizing effect on bone resorption and their consequent reduction in the risk of fractures in patients with osteoporosis. Current literature provides evidence in terms of experimental and clinical data associating prolonged use of these drugs with an increase in the risk of atypical femur fractures. To establish if this association is clinically relevant, there lies a need for further studies that take into account other factors that might influence the occurrence of these type of fractures, like the osteoporotic disease itself, age, intake of other drugs and associated systemic illnesses.

Abdomen agudo por coriocarcinoma accidentado. Reporte de un caso clínico / Acute abdomen by accidented coriocarcinoma. Report of a clinical case

Introducción: El coriocarcinoma es una neoplasia gestacional trofoblástica maligna que puede ocurrir después de una mola hidatiforme, embarazo ectópico, aborto e incluso de un embarazo normal. Se trata de una patología poco frecuente que en ocasiones puede pasar desapercibida. Entre las complicaciones clínicas se destaca la metástasis, pero es excepcional la ruptura uterina, siendo esta la que se presenta en el presente caso denotando la importancia del seguimiento. Presentación de caso: Paciente femenina de 49 años que presenta dolor en hipogastrio y vómito, tiene antecedente de mola hidatiforme no controlada. Examen complementario muestra beta-gonadotropina coriónica humana (B-HCG) cualitativa positiva y culdoscentesis positiva. Se realiza tratamiento quirúrgico por laparotomía exploratoria evidenciándose hemoperitoneo más tumor que perfora útero. Se realiza histerectomía abdominal total. Se confirma diagnóstico presuntivo a través de estudio histopatológico que determina coriocarcinoma. Paciente no continua con tratamiento conociéndose posteriormente su deceso. Conclusiones: Se presenta este caso por ser una patología infrecuente con una complicación poco habitual como es la ruptura uterina por coriocarcinoma, al ser considerada una rareza su importancia radica en el diagnóstico oportuno y adecuado seguimiento del caso.

Hemorragia obstétrica y rotura uterina por un embarazo intersticial. Reporte de un caso / Obstetric hemorrhage and uterine rupture due to an interstitial pregnancy. Report of a case

Resumen: ANTECEDENTES: El embarazo ectópico intersticial ocurre en 2.4% de los casos, quizá debido a la rotura uterina, con lo que se incrementa la morbilidad y mortalidad por hemorragia obstétrica. Los factores de riesgo son los mismos que para el embarazo ectópico tubárico. El tratamiento se establece en función del escenario clínico y deseo genésico de la paciente. CASO CLÍNICO: Paciente de 31 años, que ingresó al servicio de Urgencias por dolor abdominal severo e incapacitante en el hipogastrio, con índice de choque de 1.3 y signos de irritación peritoneal. La ecografía reportó líquido libre en el hueco pélvico y el espacio de Morrison; el saco gestacional extrauterino se encontraba en el anexo izquierdo, el feto sin latido cardiaco, con longitud craneocaudal de 11 semanas de gestación. La laparotomía exploradora evidenció: hemoperitoneo de 2800 cc, rotura uterina en el cuerno derecho, de aproximadamente 8 x 6 cm, visualización del feto e integridad de la bolsa amniótica. Puesto que la paciente manifestó no desear más embarazos se decidió efectuar la histerectomía total abdominal. CONCLUSIONES: El embarazo ectópico intersticial comparte los mismos factores de riesgo que el embarazo tubárico. Hoy día se dispone de diversos métodos de diagnóstico; sin embargo, la detección oportuna permite implementar el tratamiento conservador a seguir y, así, disminuir la morbilidad y mortalidad materna.

Abstract: BACKGROUND: Interstitial ectopic pregnancy occurs in approximately 2.4% of all cases, this tubal portion is located in the proximal segment and shares the muscular portion of the uterus, due to its great myometrial compliance, it facilitates late diagnosis and its clinical presentation is By means of uterine rupture and with it an increase in morbidity and mortality due to obstetric hemorrhage, the risk factors are the same as for tubal ectopic pregnancy, treatment is assessed based on preserving fertility and according to the patient's clinical setting. CLINICAL CASE: A 31-year-old patient who went to the emergency department for severe and disabling abdominal pain in the hypogastrium, shock index 1.3, with signs of peritoneal irritation, ultrasound was performed, which reported free fluid in the pelvic cavity and Morrison space, extrauterine gestational sac at the level of the left annex, embryo without heartbeat, craniocaudal length of 11 weeks of gestation, exploratory laparotomy was performed, in which hemoperitoneum of 2800 cc was observed, uterine rupture in the right cornual region of approximately 8x6cm, with fetus e integrity of the amniotic sac adjacent to the uterine rupture, the patient reported satisfied parity, and therefore a total abdominal hysterectomy was decided. CONCLUSIONS: Interstitial ectopic pregnancy shares the same risk factors as tubal pregnancy. Today, we have various diagnostic aids, so the cornerstone is timely detection, which will allow conservative treatments to decrease maternal morbidity and mortality.