Prevalencia de dolor en pacientes hospitalizados en Unidad de Cuidados Intensivos Metabólicos con intubación orotraqueal y bajo sedación, medido con escala COMFORT / Prevalence of pain in patients hospitalized at the Metabolic Intensive Care Unit with endotracheal intubation and sedation, measured with COMFORT scale

Introducción: El dolor es un padecimiento frecuente en pacientes hospitalizados en unidades de cuidados intensivos, sin embargo es subdiagnosticado en aquellos pacientes que no tienen la capacidad para expresarlo. Diversas escalas se han validado a nivel mundial para determinar el nivel de dolor en dichos pacientes, pero existe poco personal entrenado para aplicarlas y escasos estudios sobre prevalencia de dolor en UCI. Objetivos: Se determina la prevalencia de dolor en pacientes hospitalizados en la Unidad de Cuidados Intensivos Metabólicos (UCIM) orointubados y bajo sedación. Material y métodos: Estudio de cohorte, descriptivo, observacional y prospectivo. Fueron incluidos todos los pacientes hospitalizados en UCIM que cumplen con los criterios de inclusión (pacientes orointubados bajo sedación). Resultados: Se incluyeron 36 pacientes, siendo el 77,7 % del sexo masculino. La edad osciló entre 18 y 71 años con media de 51 y desviación estándar de 14,05. El 86 % de los pacientes ingresó por patología quirúrgica y el 75 % se encontraba con politerapia analgésica. La prevalencia de dolor medido con escala COMFORT fue del 69,4 %. Conclusión: La prevalencia de dolor en pacientes intubados y bajo sedación endovenosa en la UCIM es similar a la reportada en la literatura, siendo el nivel de sedación el factor que más se correlaciona de manera significativa con una mayor intensidad de dolor (AU)

Introduction: Pain is common in hospitalized patients in intensive care condition; however, it is underdiagnosed in patients who are unable to express it. Multiple scales have been validated worldwide to determine the level of pain in these patients; however there are a few trained personnel to apply them as well as lack of medical information about prevalence of pain in ICU. Objectives: To determine prevalence of pain in hospitalized patients at the Metabolic Intensive Care Unit, with oral intubation and under sedation. Methods: Cohort study, descriptive, observational and prospective. Including all patients hospitalized in UCIM with oral intubation plus sedation, fulfilling inclusion criteria. Results: A total of 36 patients were included, 77.7 % were male. Age ranged between 18 and 71 years old with 51 in average and standard deviation of 14.05. 86 % of patients were admitted for surgical pathology and 75 % were treated with analgesic combination therapy. Prevalence of pain measured with COMFORT scale was 69.4 %. Conclusion: Prevalence of pain in our intubated patients under intravenous sedation is same to that reported in the literature, with level of sedation as a main factor associated to increase the presence of pain (AU)

[Bouveret's syndrome; a case report]. / Síndrome de Bouveret: reporte de un caso.

OBJECTIVE: To present a rare case of duodenal obstruction caused by an impacted gallstone(Bouveret s syndrome) and discusses the best therapeutic option for its resolution. BACKGROUND: Bouveret's syndrome is the less common presentation of a gallstone ileus. This syndrome is rare and predominates in elderly women; the main symptoms are nausea, vomiting, and epigastric pain, and sometimes hematoemesis, mimicking a pyloric stenosis. Diagnosis is made by endoscopy. Endoscopic lithotripsy must be the first-line treatment however surgery is indicated in case of failure or complication during the procedure. Morbidity and mortality rates are high. CASE REPORT: We present a 75 years old, female patient, with history of diabetes mellitus and hypertension. With 15 days of nausea, vomiting,loss of appetite and abdominal pain, with secondary dehydration and bad general conditions. She was subjected to an endoscopy and a duodenal obstruction by a large gallstone was founded,the endoscopic attempts to extract the gallstone were unsuccessful and surgery was performed with a dudenotomy and two layer closure with good outcome. The patient was discharged on the 8th postoperative day. CONCLUSIONS: Bouveret's syndrome is a rare variety of a gallstone ileus and must be considered like differential diagnosis in cases of gastric outlet obstruction.

[Anal malignant melanoma. Case report and literature review]. / Melanoma maligno anal. Reporte de casos y revisión de la literatura.

OBJECTIVE: To present two cases of anorectal malignant melanoma as due to its non specific presentation and rarity they are often misdiagnosed like hemorrhoids. BACKGROUND: Anal melanomas are rare tumors that constitute less than 1% of the malignant colorectal tumors and represent both a diagnostic and therapeutic challenge to physicians. They are generally pigmented but could be amelanotic in 29% of the cases and they are associated with poor prognosis, regardless of the surgical procedure used. Melanomas are often misdiagnosed by a lot of anorectal conditions and diagnosis must be suspected in patients with an anal mass. CASE REPORT: We present two anorectal cases of malignant melanoma treated by wide local excision, the principal complain in both patients was the presence of an anal mass and bleeding. Both patients were treated by local excision since survival rates are comparable to those of patients treated by abdomino perineal resections (with a high morbility and mortality rates) and a better quality of life is achieved with control of the symptoms. CONCLUSIONS: Anal melanoma is a rare entity with a poor prognosis. The overall treatment goal should be to optimize the quality of life.

[Colonic duplication. A case report and literature review]. / Duplicación colónica. Informe de un caso y revisión de la literatura.

INTRODUCTION: Colonic duplication is an uncommon congenital anomaly. Bowel obstruction, presence of an abdominal mass, and sometimes bleeding and perforation may be the clinical manifestations. OBJECTIVE: To report a patient with colonic duplication who underwent to surgical treatment due to acute abdominal pain. REPORT OF THE CASE: 17 year-old, female patient admitted to the emergency room due to acute abdominal pain and signs of intestinal obstruction, at her initial evaluation she was tachycardic, hyperthermic with 38 degrees C, dehydration, abdominal distention, acute abdominal pain, absent peristalsis and peritoneal signs. Laboratories with Hb 14.2 g/dL, leucocytosis of 16,000 mm3, plain abdominal films showed dilation of intestinal loops and air-fluid levels. A laparotomy for intestinal obstruction was performed; operative findings were a tubular colonic duplication that demands a complete resection of the duplicated segment. CONCLUSION: Colonic duplication is a rare congenital anomaly, the onset of the symptoms can occur during infancy or early childhood. It must be consider as differential diagnoses in patients with intestinal obstruction and palpable abdominal mass in this rank of ages.

Colonic perforation as a complication of ventriculoperitoneal shunt: a case report.

Late perforation after ventriculoperitoneal (VP) shunting is extremely rare. Colonic perforation is uncommon and represents 0.1%-0.7% of abdominal complications. Colonic perforation can challenge diagnostic and therapeutic decisions, and there are no clear guidelines on the management of this problem. We present a 34-year-old woman who was admitted for a 1-week history of sensation of a foreign body through the anus at the time of bowel movements. She had previously undergone a VP derivation for hydrocephalus secondary to neurocysticercosis. Plain abdominal radiographs demonstrated the shunt within the colonic lumen and through the descendening and sigmoid colon. The shunt was exteriorized in the cervical area and a laparotomy was performed with a primary two-layer colonic close. The patient received antibiotic therapy for 2 weeks with good outcome. Percutaneous and endoscopic approaches have been reported in patients with no abdominal signs. Prompt recognition of this complication is critical to avoid high mortality rates.

Endoanal sonography in assessment of fecal incontinence following obstetric trauma.

OBJECTIVES: Fecal incontinence is a common, incapacitating and largely unrecognized medical problem and can be caused by various factors. Obstetric trauma is the most common cause of fecal incontinence secondary to trauma. We aimed to analyze the role of endoanal ultrasound in assessment of this type of fecal incontinence, and report the functional results of surgical treatment. METHODS: We reviewed the records of all 22 patients with fecal incontinence secondary to obstetric trauma who were evaluated by endoanal ultrasound and underwent surgical management in our department from April to 1997 to April 2002. Pre- and postoperative evaluation of the degree of incontinence was done using the incontinence score of Jorge and Wexner. RESULTS: The patients had a median age of 43 (range, 29-68) years. All had vaginal deliveries, five of which (22.7%) were instrumental. Most of the patients had total fecal incontinence (solids) with preoperative incontinence score values of 15-20 (median, 18). Endoanal ultrasound confirmed structural defects in the anterior external anal sphincter alone in 16 (72.7%) patients, and both anterior external and internal sphincter defects in six (27.3%) patients. A thinned perineal body was present in all patients. All patients received surgical treatment with overlapping sphincteroplasty and there was improvement of continence in 19 (86.4%) patients with postoperative incontinence score values between 4 and 0 (median, 2). CONCLUSIONS: Endoanal sonography is an accurate method for assessing sphincter anatomy, delineating both internal and external anal sphincters. Surgical treatment of sphincter defects is associated with good outcome.

Experience in management of Fournier's gangrene.

We report our experience and results in the management of Fournier's gangrene. Fournier's gangrene is a synergistic infective necrotizing fasciitis, which involves perianal, perineal and genital regions, originated mostly from colorectal and genitourinary sources. Charts and records from 28 patients with Fournier's gangrene diagnosed between 1993 and 1997 were reviewed. The mean patients age was 57.8 years (range, 22-82 years); mean hospital stay was 19 days. Eighteen patients (64.3%) were diabetic. The most common source of gangrene was ischiorectal abscess in 22 patients (78.6%). Colostomy was performed on 14 patients (50%) and cystostomy on 7 patients (25%). Ten patients (35.7%) died because of sepsis. In conclusion, medical and surgical treatment should be aggressive. Colostomy should only be performed if sphincter complex is damaged. Multidisciplinary management is mandatory, because of high morbidity and mortality.

[Transmesenteric intestinal plication for intestinal occlusion secondary to disseminated adhesions. A 12-year experience]. / Plicatura intestinal transmesentérica para la oclusión intestinal secundaria a adherencias diseminadas. Experiencia de 12 años.

OBJECTIVE: To report the experience with intestinal plication in patients with adhesive intestinal obstruction that was followed up to 12 years. BACKGROUND: To diminish the high recurrence rate of adhesive intestinal obstruction, there are surgical techniques of intestinal plication. In 1977 Blanco modified a pre-existing transmesenteric technique that is the used in our institution. METHOD: We studied the medical records of 32 patients who underwent intestinal plication using the transmesenteric technique. The postoperative evaluation was based in recurrence and mortality. RESULTS: There were 32 patients, 56% women and 44% men, with a mean age of 50 years. All patients had a history of intraabdominal surgical procedures. The postoperative evaluation was satisfactory. The success rate was over 90%. The recurrence rate was 9.3% and we had no mortality. The mean follow-up was 3.5 years (median 3 [range 1-12] years). There were no significant differences between this technique and the Noble and Childs-Phillips plication techniques. CONCLUSIONS: This technique of intestinal plication is useful in the surgical management of patients with adhesive intestinal obstruction.

[Toxic megacolon secondary to pseudomembranous colitis]. / Megacolon tóxico secundario a colitis pseudomembranosa.

BACKGROUND: Toxic megacolon is a rare complication of pseudomembranous colitis. OBJECTIVE: The aim of this paper is to present a rare case of toxic megacolon secondary to pseudomembranous colitis. METHODS: The chart of a 75-year-old male, who developed a toxic megacolon secondary to pseudomembranous colitis no was reviewed. RESULTS: The clinical features and outcome of a 75-year-old male with pseudomembranous colitis are depicted. The main symptoms were no ever, abdominal distention, bloody and diarrhea; the man suddenly developed a toxic megacolon and taken was to surgery. Total colectomy with proximal rectal closure was performed. The patient died within 24 hours of the abdominal procedure. CONCLUSIONS: Toxic megacolon is a rare complication of pseudomembranous colitis. Its presence should be suspected when these patients develop no colonic dilatation with associated systemic toxicity. Aggressive surgical intervention is indicated.