RESUMO
Cholecystoenteric fistulas occur as a result of a chronic inflammatory insult involving the gallbladder and the erosion of both its wall and a bowel segment. When the fistula develops, it creates a pathway for gallstones to migrate and cause an intestinal obstruction, known as gallstone ileus. When it obstructs the gastric outlet, a proximal variant of gallstone ileus occurs, known as Bouveret's syndrome. A 65-year-old man presented to the emergency department with a three-day history of epigastric and right upper quadrant pain and persistent vomiting, preceded by unintentional weight loss of 15 kg over three months. Endoscopic and complementary imaging studies identified a concurrent gastric outlet obstruction caused by a lodged gallstone in the duodenal bulb and gallstone ileus. The patient underwent an urgent exploratory laparotomy and was submitted to an enterolithotomy and gastrolithotomy. Due to a sudden deterioration on the fourth postoperative day, he underwent an emergent re-laparotomy that found fecal peritonitis and complete dehiscence of both closures. The patient was then managed with damage control surgery. An atypical gastric resection and enterectomy of the distal ileum were performed and the patient was admitted to the intensive care unit in temporary abdominal closure (laparostomy). The patient failed to improve and died on the same day. Ultimately, the patient's multiple comorbidities, including morbid obesity, malnutrition, and diabetes, contributed to poor tissue healing and the fatal outcome. Gallstone ileus and Bouveret's syndrome are two rare complications of cholecystoduodenal fistulas that have not yet been reported to occur simultaneously. Both intestinal and gastric obstruction makes the surgical approach the first-line treatment.
RESUMO
Morgagni's hernia is a very uncommon congenital diaphragmatic hernia. A few patients may remain asymptomatic until adulthood. Clinical presentation may include bowel obstruction, chest pain or dyspnoea. The authors report the case of a 71-year-old female patient, admitted to the emergency department due to respiratory symptoms, whose thoracic computed tomography revealed a large Morgagni's hernia, containing colon. She underwent an elective laparoscopic repair with mesh. Thoracic computed tomography is the best imaging study for its diagnosis. Laparoscopic repair is safe and allows symptomatic relief and incarceration risk reduction.
RESUMO
BACKGROUND: Pyoderma gangrenosum (PG) is a rare ulcerative condition that is diagnostically and therapeutically challenging, as debridement leads to ulcer deterioration (pathergy phenomenon); immunosuppression is considered the gold standard therapy. CASE REPORT: The authors present the case of a 42-year-old woman with PG and uncontrolled iatrogenic diabetes, secondary to a total pancreatectomy performed in another hospital in 1998 due to nesidioblastosis. In 2008, she was referred to the diabetic foot consultation at Centro Hospitalar Tondela-Viseu (Viseu, Portugal) due to an infected wound on the left leg thought to be related to a trauma from footwear, but the injury worsened despite treatment. Characteristics of the lesion led to the diagnosis of PG and treatment was adjusted. The patient was followed-up weekly at the diabetic foot consultation; at 2-months follow-up, the leg ulcer was closed but additional lesions emerged in multiple areas of her body. Therapy included local antiseptics, antibiotics, pain control, systemic corticosteroids, immunosuppressors, intravenous immunoglobulin, and surgical debridement. Due to her noncompliance, this proved to be a challenging case. CONCLUSION: Although PG is rare, clinicians should suspect it in the presence of purplish wound edges with a necrotic center. Surgical debridement, while necessary in other ulcers, can worsen the condition and should only be applied to self-detachable necrotic plaques.
