Normal pressure hydrocephalus: Diagnostic delay. / Hidrocefalia de presión normal: demora en el diagnóstico

INTRODUCTION: Normotensive hydrocephalus is a differential diagnosis in the evaluation of the dementia syndrome. The diagnostic protocols would allow detecting this pathology that has more effective treatment than other dementias. OBJECTIVE: To describe a population with clinical suspicion of normal pressure hydrocephalus evaluated in a Colombian psychiatric hospital and discuss the possible reasons for its diagnostic and therapeutic delay. MATERIALS AND METHODS: We conducted a retrospective study of medical records to identify patients with suspected normal pressure hydrocephalus during a 5-year period. RESULTS: Thirty-five patients with suspected normal pressure hydrocephalus underwent diagnostic lumbar puncture and five of them were considered candidates for a peritonealvenous shunt, but none underwent this surgical procedure. After three to six months of the lumbar puncture, the gait pattern improved in 22.8% of the patients, cognition in 22.8%, and sphincter control in 11.4%. Improvement was not sustained in the long term (1 year) in any of them. CONCLUSION: This study suggests the poor implementation of the protocols for evaluating patients with cognitive deficits and delays in the diagnosis of normal pressure hydrocephalus. A small number of patients were identified as candidates for treatment. Normal pressure hydrocephalus is a potentially reversible clinical entity with the placement of a peritoneal ventricular shunt, but delays in diagnosis and treatment have deleterious consequences for patients and their families.

Introducción. La hidrocefalia normotensiva es un diagnóstico diferencial en la evaluación del síndrome demencial. Los protocolos diagnósticos permitirían detectar esta condición, cuyo tratamiento es más efectivo que el de otras demencias. Objetivo. Describir una población con sospecha clínica de hidrocefalia normotensiva evaluada en un hospital psiquiátrico colombiano y discutir las posibles razones de la demora en el diagnóstico y en la terapia de esta condición clínica. Materiales y métodos. Se hizo un estudio retrospectivo de los registros médicos para detectar pacientes con sospecha de hidrocefalia normotensiva durante un período de cinco años. Resultados. A 35 pacientes con sospecha de hidrocefalia normotensiva se les hizo una punción lumbar diagnóstica. Cinco de ellos se consideraron candidatos para una derivación ventrículo-peritoneal, pero ninguno se sometió a este procedimiento quirúrgico. A los 3-6 meses de la punción lumbar, se observó una mejoría del patrón de la marcha en el 22,8 % de los pacientes, de la cognición en el 22,8 % y del control del esfínter en el 11,4 %. La mejoría no se mantuvo a largo plazo (un año) en ningún paciente. Conclusión. Se encontró una implementación deficiente de los protocolos de evaluación de los pacientes con déficit cognitivos y demoras en el diagnóstico de la hidrocefalia normotensiva, así como un número reducido de pacientes clasificados como candidatos para el tratamiento. La hidrocefalia normotensiva es una condición clínica potencialmente reversible con la colocación de una derivación ventrículo-peritoneal. Los retrasos en el diagnóstico y en el tratamiento tienen consecuencias perjudiciales para los pacientes y sus familias.

Textiloma Intra-abdominal. Reporte de un caso / Textiloma Intraabdominal. Case report

Los cuerpos extraños olvidados en el abdomen después de una operación quirúrgica, también denominados textilomas tienen una incidencia de 1 por cada 1500 laparotomías, aunque resulta muy difícil evaluar la real estadística por los escasos reportes debido a las posibles implicaciones médico-legales que en muchos países traen aparejadas. En el presente trabajo se realiza la presentación de un interesante caso intervenido en el Hospital Universitario "Dr. Mario Muñoz Monroy" del municipio Colón. Se trata de una paciente femenina de 47 años de edad operada inicialmente de Histerectomía Total Abdominal que dos meses después regresa con una Oclusión Intestinal Completa y es llevada al quirófano donde se encuentra un "Plastrón Abscedado". La Evolución clínica post-operatoria fue excelente. El estudio de la pieza anatómica demostró la presencia de una compresa totalmente "enrollada" dentro de la luz del intestino por lo que se deduce que el cuerpo extraño "provocó" una fístula peritoneo-entérica, con el paso total de la compresa hacia la luz del intestino, causando un cuadro oclusivo. Cada uno de los médicos especializados en ramas quirúrgicas está expuesto a la ocurrencia de dicha contingencia que es multicausal y completamente ajena a la voluntad del equipo a cargo del paciente. Por tal motivo resulta vital la exploración cuidadosa de todos los medios usados en cada una de las laparotomías (AU).

Foreign bodies left in the abdomen after surgery, also called gossypibomas have an incidence ranging between 1 in 1500 laparotomy, although it is very difficult to assess the actual statistics for scarce reports due to possible medico-legal implications in They rigged bring many countries. In this paper presenting an interesting case involved the University Hospital "Dr. is done Mario Muñoz Monroy "Columbus Township. This is a female patient of 47 years initially operated total abdominal hysterectomy two months later he returns with a complete intestinal occlusion and is taken to the operating room where there is a "Plastron abscessed". The postoperative clinical evolution was excellent. The study of the anatomical specimen showed a pad completely "wrapped" into the lumen of the intestine so it follows that the foreign body "caused" a fistula peritoneal-enteral, with the full bore of the pad into the light bowel, causing occlusive condition. Each specialized doctors in surgical branches exposed to the occurrence of such a contingency that has multiple causes and completely beyond the control of the team in charge of the patient. Therefore it is vital careful examination of all the media used in each of the laparotomy (AU).

Textiloma Intra-abdominal. Reporte de un caso / Textiloma Intraabdominal. Case report

Los cuerpos extraños olvidados en el abdomen después de una operación quirúrgica, también denominados textilomas tienen una incidencia de 1 por cada 1500 laparotomías, aunque resulta muy difícil evaluar la real estadística por los escasos reportes debido a las posibles implicaciones médico-legales que en muchos países traen aparejadas. En el presente trabajo se realiza la presentación de un interesante caso intervenido en el Hospital Universitario "Dr. Mario Muñoz Monroy" del municipio Colón. Se trata de una paciente femenina de 47 años de edad operada inicialmente de Histerectomía Total Abdominal que dos meses después regresa con una Oclusión Intestinal Completa y es llevada al quirófano donde se encuentra un "Plastrón Abscedado". La Evolución clínica post-operatoria fue excelente. El estudio de la pieza anatómica demostró la presencia de una compresa totalmente "enrollada" dentro de la luz del intestino por lo que se deduce que el cuerpo extraño "provocó" una fístula peritoneo-entérica, con el paso total de la compresa hacia la luz del intestino, causando un cuadro oclusivo. Cada uno de los médicos especializados en ramas quirúrgicas está expuesto a la ocurrencia de dicha contingencia que es multicausal y completamente ajena a la voluntad del equipo a cargo del paciente. Por tal motivo resulta vital la exploración cuidadosa de todos los medios usados en cada una de las laparotomías (AU).

Foreign bodies left in the abdomen after surgery, also called gossypibomas have an incidence ranging between 1 in 1500 laparotomy, although it is very difficult to assess the actual statistics for scarce reports due to possible medico-legal implications in They rigged bring many countries. In this paper presenting an interesting case involved the University Hospital "Dr. is done Mario Muñoz Monroy "Columbus Township. This is a female patient of 47 years initially operated total abdominal hysterectomy two months later he returns with a complete intestinal occlusion and is taken to the operating room where there is a "Plastron abscessed". The postoperative clinical evolution was excellent. The study of the anatomical specimen showed a pad completely "wrapped" into the lumen of the intestine so it follows that the foreign body "caused" a fistula peritoneal-enteral, with the full bore of the pad into the light bowel, causing occlusive condition. Each specialized doctors in surgical branches exposed to the occurrence of such a contingency that has multiple causes and completely beyond the control of the team in charge of the patient. Therefore it is vital careful examination of all the media used in each of the laparotomy (AU).

Ascite cirrótica: aspectos clínicos / Cirrhotic ascites: clinical aspects

A ascite é a mais comum das três complicações da cirrose. A sua presença é indicativo de mau prognóstico, e está associada a complicações que aumentam a morbidade e a mortalidade. O gradiente de albumina sérico-ascítico é o método utilizado para se fazer o diagnóstico diferencial da ascite associada à hipertensão portal daquela de outra etiologia. A patogênese da ascite cirrótica revela primordialmente dois fatores: alterações na hemodinâmica portal e retenção de sódio e água. A teoria que explica a formação da ascite e as alterações hemodinâmicas na cirrose é a da vasodilatação. Esta vasodilatação é associada às altas concentrações de substâncias como o óxido nítrico dentre outras. O tratamento da ascite consiste na restrição de sódio, diuréticos orais, paracentese abdominal, derivação peritoneovenosa, TIPS e transplante de fígado.

Ascites is the most common of the three major complications of cirrhosis (the others complications are hepatic encephalopathy and visceral haemorrhage). Its presence is an indicative sign of poor prognosis, predisposing the patient to many complications which increase morbidity and death rate. The serum-ascites albumin gradient is the method which you can differentiate ascites caused by portal hypertension from others etiologies. In ascites pathogenesis there are two factors to be considered: The portal hemodynamic and the sodium and water retainers. The theory which explains the ascites formation and the hemodynamics alterations in cirrhosis is the vasodilatation one. The vasodilatation would be secondary to high serum concentrations of vasodilators, including nitric oxide and others. The treatment of ascites in cirrhotic patients includes clinical and surgical procedures like saline restriction, oral diuretics, abdominal paracentesis, peritoneovenousderivation, TIPS, and liver transplantation.

Evaluation of the management of arachnoid cyst of the posterior fossa in pediatric population: experience over 27 years.

INTRODUCTION: The necessity of surgical treatment of the arachnoid cyst in general and posterior fossa arachnoid cyst (PFAC) in particular is sometimes controversial. Surgery is warranted in symptomatic patients. In this study, we evaluated our experience throughout 27 years in the management of patients with PFAC. MATERIALS AND METHODS: The study was designed with special emphasis on clinical features, surgery, and outcome. We investigated a total of 112 arachnoid cysts. Of them, 23 patients were symptomatic for PFAC. We assessed clinical characteristic and outcome for all patients. We obtained information from medical records and outpatient charts on age, sex, presenting symptoms, associated abnormalities, psychomotor status, modality of treatment, complications and follow-up in 23 patients (9 boys, 14 girls, ages 1 day-6 years) who had been admitted for evaluation and treatment of PFAC at Kobe Children's Hospital between 1978 and 2004. RESULTS: The mean follow-up period was 93 months (range 5-313 months). More than half of the patients had a history of increased head size and signs of intracranial pressure as presenting symptoms. One-third of the patients had associated abnormalities and six patients (26%) presented hydrocephalus. Computed tomography cisternography displayed delayed filling of the cyst in 11 patients (48%). All patients were treated surgically; the total number of surgical procedures was 55 with a surgical rate of 2.4 per patients. The marsupialization and marsupialization with cyst-peritoneal (C-P) shunt were the most common open surgical procedure in 14 and 5 patients, respectively. Endoscopic cysternostomy was performed in three patients. In our series, 25 (45%) of 55 surgical procedures included shunt malfunction and removal. The marsupialization of the cyst wall was successful in 9 of 14 operated patients (64%); the other five patients needed additional C-P or ventriculoperitoneal (V-P) shunt. Marsupialization with cyst-peritoneal shunt was successful in only one of five patients (20%), and for the other four patients, additional C-P or V-P shunt was necessary. No mortality is reported. Eight patients presented minor surgical morbidities that were resolved conservatively. DISCUSSION: The relatively good results using marsupialization or endoscopic cisternostomy as surgical procedure and the high incidence of shunt malfunction buttresses our use of both operations as a first-line surgery at present. Surgical procedure that does not include shunting decreases the ratio of recurrent operation because this kind of complication develops over time and should be consider as a second-line procedure.

Catéter de derivación peritoneo-venosa para el tratamiento de la ascitis refractaria: presentación de un caso / Peritoneal-venous catheter in the treatment of refractory ascitis: one case presentation

En casos de ascitis refractaria que no cede con el manejo médico habitual, el drenaje peritoneo-venoso con el equipo de Denver es una buena solución en pacientes selec¬cionados adecuadamente. Presentamos un caso de una ascitis refractaria exitosamente manejada con esta técnica en un paciente con una leucemia promielocítica aguda.

Efeito da derivação pleuroperitoneal no tratamento de hidrotórax recorrente induzido. Pleurodese em coelhos / Effect of the pleuroperitoneal derivation in the treatment of induced recurrent hydrothorax: pleurodesis in rabbits

OBJETIVO: Verificar a pleurodese, através da histologia hematoxilina - eosina e microscopia eletrônica, obtida após injeção de tetraciclina, em coelhos com uso de derivação pleuroperitoneal no tratamento de hidrotórax recorrente induzido. MÉTODOS: Foram utilizados 30 coelhos New - Zealand, machos e adultos. Empregou-se anestesia dissociativa quetamina e xilazina em injeção intramuscular 0,1 cm3 para cada 100g de peso do animal. Para induzir hidrotórax utilizou-se tetraciclina 7 mg/kg, diluída em 10 cm3 de água destilada (pH 4) injetada via percutânea no 4o espaço intercostal anterior esquerdo. O ato operatório constituiu de laparotomia subcostal à esquerda com 4 cm de extensão e incisão do hemidiafragma na porção muscular de 0,5 cm de diâmetro. No grupo A (controle) realizou-se fechamento da abertura do diafragma com pontos simples e fio monofilamentar 5.0. No grupo B (derivação) após abertura do diafragma introduziu-se prótese cilíndrica com 2 cm de comprimento. No grupo C (drenagem) foi feita uma laparotomia subcostal esquerda com 2 cm de extensão e introdução de cateter no 6. Toracotomia lateral esquerda com 2 cm de extensão e descolamento hipodérmico para aplicação do cateter pleurointercostodermoperitoneal. No pós-operatório realizou-se indução de hidrotórax repetida no 1o, 5o, 8o e 12o dia de pós-operatório nos três grupos de estudo através de injeção intrapleural de tetraciclina 7 mg/kg (pH 4) no 4§ espaço intercostal anterior esquerdo. Foi feita eutanasia no 15§ dia e necropsia para retirada de líquido pleural e histologia pleural, pulmonar e peritônio parietal. RESULTADOS: O acúmulo de líquido pleural resultante foi mais significante nos animais do grupo A. A irritação química resultou no espessamento pleural moderado nos grupos B e C. O índice de pleurodese foi 100 por cento do grupo derivação pleuroperitoneal e 80 por cento do grupo drenagem. CONCLUSÃO: A derivação pleuroperitoneal facilita a formação de pleurodese comprovada histologicamente, mesmo com a utilização de dose baixa de tetraciclina em coelhos.

Pathophysiology, diagnosis and treatment of ascites in cirrhosis.

The mechanism by which ascites develops in cirrhosis is multifactorial Severe sinusoidal portal hypertension and hepatic insufficiency are the initial factors. They lead to a circulatory dysfunction characterized by arterial vasodilation, arterial hypotension, high cardiac output and hypervolemia and to renal sodium and water retention. There are evidences that arterial vasodilation in cirrhosis occurs in the splanchnic circulation and is related to an increased synthesis of local vasodilators. Vascular resistance is normal or increased in the remaining major vascular territories (kidney, muscle and skin and brain). Splanchnic arterial vasodilation not only impairs systemic hemodynamics and renal function but also alters hemodynamics in the splanchnic microcirculation. The rapid and high inflow of arterial blood into the splanchnic microcirculation is the main factor increasing hydrostatic pressure in the splanchnic capillaries leading to an excessive production of splanchnic lymph over lymphatic return. Lymph leakage from the liver and other splanchnic organs is the mechanism of fluid accumulation in the abdominal cavity. Continuous renal sodium and water retention perpetuates ascites formation. Large volume paracentesis associated with albumin infusion is the treatment of choice of tense ascites because it is very effective and rapid and is associated with fewer complications that the traditional treatment (sodium restriction and diuretics). However, diuretic should be given after paracentesis to prevent reaccumulation of ascites. In patients with moderate ascites diuretics should be preferred as initial therapy. Patients with refractory ascites could be treated by paracentesis or percutaneous transjugular portacaval shunt (TIPS). TIPS is more effective in the long term control of ascites but may impair hepatic function and induce chronic hepatic encephalopathy.

Complicaciones peritoneales infrecuentes de las derivativas ventrículo peritoneales / Infrequency peritoneal complications of the peritoneal ventricle derivatives

Se presenta una serie de 7 pacientes portadores de pseudoquistes peritoneales o compromiso inflamatorio extenso peritoneal. Se utilizó manejo agresivo de las lesiones peritoneales en los casos en que predominó la obstrucción intestinal. Nosotros proponemos retirar de la cavidad peritoneal el sistema derivativo, idealmente por medio de una neuroendoscopía o derivación ventriculo atrial. Se discuten las diferentes variables en el manejo de estos enfermos

Shunt peritoneo venoso en el tratamiento de ascitis maligna: reporte preliminar / Peritoneal venous shunt in the treatment of malignant ascitis: preliminary report

El presente reporte, menciona el uso de una válvula de drenaje de líquido ascítico, conocida como Shunt Peritoneo Venoso como tratamiento de paliación en los pacientes oncológicos terminales. Lo realizamos en cuatro pacientes portadores de carcinomatosis diseminadas, de distintas neoplasias primarias, con una calidad de vida poco favorable, ya que al momento de admitirlos en nuestro servicio presentaban un cuadro de dificultad respiratoria, saciedad precoz, aletargamiento e imposibilidad para desenvolverse adecuadamente en sus labores habituales. Es un reporte de casos, aunque poco extenso muy alentador, la evolución de los pacientes es adecuada, la calidad de vida, nuestro objetivo principal, es mejorada.

Un cuidado singular / A singular care

La experiencia de una enfermera es utilizada para sugerir un procedimiento paliativo novedoso en el medio, aplicado a un cuadro de ascitis maligna. El objetivo de este procedimiento es mejorar la calidad de vida de la paciente. En relación al caso, se hace referencia a la técnica de colocación de la válvula de derivación peritoneo-venosa, a su funcionamiento en los casos de ascitis por metástasis peritoneal

Un cuidado singular / A singular care

La experiencia de una enfermera es utilizada para sugerir un procedimiento paliativo novedoso en el medio, aplicado a un cuadro de ascitis maligna. El objetivo de este procedimiento es mejorar la calidad de vida de la paciente. En relación al caso, se hace referencia a la técnica de colocación de la válvula de derivación peritoneo-venosa, a su funcionamiento en los casos de ascitis por metástasis peritoneal (AU)

Acquired nevus flammeus.

This is the case of a 55-year-old male with cirrhosis who required a LeVeen shunt for relief of refractory ascites. After eight months he developed recurrence of the ascites and a erythematous patch around the surgical scar. Skin biopsy revealed a proliferation of small and medium-sized vessels throughout the dermis. The acquired form of nevus flammeus is rare an is usually preceded by trauma. This is the report of a patient with an acquired nevus flammeus associated to an obstructed peritoneovenous shunt.

Acquired nevus flammeus

This is the case of a 55-year-old male with cirrhosis who required a LeVeen shunt for relief of refractory ascites. After eight months he developed recurrence of the ascites and a erythematous patch around the surgical scar. Skin biopsy revealed a proliferation of small and medium-sized vessels throughout the dermis. The acquired form of nevus flammeus is rare an is usually preceded by trauma. This is the report of a patient with an acquired nevus flammeus associated to an obstructed peritoneovenous shunt

Glomerulonefritis secundaria en pacientes con derivación ventrículoauricular y ventrículoperitoneal / Shung nephritis patients with ventriculoatrial and ventriculoperitoneal shunts

La glomerulonefritis por derivación se presenta con escasa frecuencia en niños con derivaciones ventrículoauriculares y ventrículoperitoneales, las cuales se aplican como recurso terapéutico en la hidrocefalia. La glomerulonefritis se asocia a la colonización bacteriana de las derivaciones, con el desarrollo de bacteriemias subsecuentes. La etiopatogenia involucra factores inmunológicos, en presencia del antígeno bacteriano y formación de complejos inmunes circulantes y depósito de los mismos, así como de inmunoglobulinas y componentes del complemento en el endotelio glomerular. El resultado es una glomerulonefritis endocapilar difusa, que puede progresar a uremia terminal si no se corrigen los mecanismo etiopatogénicos. En este trabajo se presentan dos casos de nefritis por derivación y se lleva a cabo una revisión de la literatura

Cirugía video-laparoscópica en niños: una nueva alternativa

De marzo a noviembre de 1992 se practicó Cirugía Videolaproscópica como una alternativa qurúrgica a 5 pacientes cuyas edades oscilaban en los 7 y 18 años y con pesos comprendidos entre 43 y 160 libras. De ellos 3 pertenecían al sexo femenino y 2 al masculino. A 3 pacientes se les efectuó colecistectomía por colelitiasis, uno de ellos con enfermedad de células falciformes. A 2 pacientes se les efectuó laparoscopía diagnóstica y liberación de adherencias postoperatorias. No hubo complicaciones. La mayoría de pacientes egresaron al día siguiente. De esta experiencia podemos concluir que la cirugía Videolapparoscópica es una alternativa para pacientes pediátricos que ofrece un menor tiempo de hospitalización, inicio temprano de dieta y actividad física con mínimo dolor. Con resultados estéticos superiores a la cirugía convencional. Se considera una técnica segura al alcance del cirujano pediátrico

Ascitis. Fisiopatología y tratamiento

Cirrhosis of the liver is the main cause of ascitis. Recent studies have shown in compensated cirrhotics a 40 percent chance to develop ascitis after five years of follow up. The presence of ascitis is usually associated with advanced liver disease, and higher mortality than patients with compensated cirrhosis. Many theories have been proposed to explain ascitis formation being the most important the presence of portal hypertension and sodium retention. Extravascular fluid accumulation depends directly of a balance between hydrostatic and colloid-osmotic pressure (Starling law). Hepatic sinusoids differ from splanchnic ones in regard to the presence of fenestrae, that allows albumin and other substances to flow freely from the sinusoid to the extravascular space. For these reasons the sinusoids lacks colloid-osmotic pressure, and the hydrostatic pressure regulates the flow of fluids passing through them. In cirrhosis, diffuse fibrosis and nodule formation cause functional obstruction to the hepatic blood flow, and a secondary increase in the sinusoidal pressure, that leads to exit of fluids from the sinusoids to the hepatic lymphatics and the thoracic duct. When the amount of fluid that leaves the sinusoids exceeds the capacity of the thoracic duct, fluids accumulate in the abdominal cvity (ascitis). A new theory about ascitis formation states that the first event is a diffuse peripheral arterial vasodilation that cause ineffective plasma volume that triggers the production of humoral factors directed to retain sodium in the kidney...

Fistulización de catéter de DVP, a través de colon sigmoide y recto: una complicación de DVP / Distal migration peritoneal shunt to sigmoides fistulitation: DVP complication

Presentamos un caso de fistulización de la porción distal del catéter peritoneal de un sistema de DVP, a través del Colon Sigmoide y Recto, de una paciente manejada en el Servicio de Neurocirugía del Hospital Vargas. Se hace revisión bibliográfica del tema