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1.
Ann Hematol ; 99(5): 1121-1128, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32130472

RESUMO

AIM:  To measure histological villous atrophy and to clarify the diagnostic accuracy of endoscopic villous atrophy in gastrointestinal graft-versus-host disease. METHODS:  Data for patients who underwent upper and/or lower endoscopic examinations after hematopoietic stem cell transplantation were retrospectively collected. In study 1, group A included 56 patients in whom GI-GVHD was histologically confirmed and group B included 60 patients in whom GI-GVHD was not histologically confirmed. Group C included 59 patients before HSCT. The lengths of villi and crypts in the duodenum and terminal ileum were histologically measured. In study 2, the diagnostic accuracies of villous atrophy of the duodenum and of the terminal ileum using magnifying endoscopy were evaluated. RESULTS:  In study 1, the lengths of villi and the villi/crypt (V/C) ratios of the duodenum and terminal ileum in group A were significantly smaller than those in the other groups (p < 0.05). V/C ratio was moderately correlated with clinical severity, histological grades, and endoscopic grades in the terminal ileum. In study 2, the diagnostic accuracies of magnified images for villous atrophy were 83.8% in the duodenum and 94.9% in the terminal ileum. CONCLUSION:  Magnifying endoscopy enables evaluation of villous atrophy and is useful for optical biopsy of GVHD.


Assuntos
Duodenopatias/patologia , Duodeno/patologia , Endoscopia Gastrointestinal , Doença Enxerto-Hospedeiro/patologia , Transplante de Células-Tronco Hematopoéticas , Doenças do Íleo/patologia , Íleo/patologia , Mucosa Intestinal/patologia , Adolescente , Adulto , Idoso , Aloenxertos , Atrofia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
3.
Medicine (Baltimore) ; 98(44): e17691, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31689793

RESUMO

BACKGROUND: Ectopic pancreas in the ileum, including lesions within Meckel diverticulum, can cause severe manifestations and complications; yet, it was seldom reported in English literature. AIM: This study aimed to raise awareness and provide information for better clinical management of this rare yet serious condition. METHODS: A total of 1713 cases of small bowel resection were performed in our hospital between 2009 and 2018, among which 10 cases of ileac ectopic pancreas were identified. A comprehensive retrospective review of the 10 cases was taken. RESULTS: Five lesions were located in the ileum wall and 5 were within Meckel diverticulum. Two lesions within Meckel diverticulum were incidental; the remaining 8 lesions were all associated with abdominal pain, gastrointestinal bleeding, and anemia. Of the 5 patients with lesions in the ileum wall, computed tomography uniformly revealed ileoileal intussusceptions with masses as lead points. Capsule endoscopies were performed in 6 cases, of which 3 showed positive findings. Double-balloon enteroscopy was conducted in one case and revealed an ileal diverticulum. Therapeutically, the offending bowel segments were removed, and intussusceptions were restored except for one case in which diverticulectomy was applied. No relapse or sequela was observed in the follow-up. CONCLUSIONS: Ileac ectopic pancreas can be seen in the ileum wall or Meckel diverticulum. The majority of the lesions found in clinical practice present with abdominal pain, gastrointestinal bleeding, and anemia. Lesions in the ileum wall often cause ileoileal intussusception. Computed tomography, capsule endoscopy, and double-balloon enteroscopy are helpful preoperative examinations. Segmental small bowel resection is the treatment of choice.


Assuntos
Coristoma/patologia , Doenças do Íleo/patologia , Pâncreas , Adolescente , Adulto , Idoso , Coristoma/diagnóstico por imagem , Coristoma/cirurgia , Enteroscopia de Duplo Balão , Feminino , Humanos , Doenças do Íleo/diagnóstico por imagem , Doenças do Íleo/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
4.
Pediatr Emerg Care ; 35(11): e203-e205, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31688804

RESUMO

Familial Mediterranean fever (FMF) is a recurrent disease with autosomal recessive trait and fever that is generally self-limiting. Clinical manifestations are pain in the abdomen, chest, and joints as a result of inflammation in the serous surfaces. No case of multiple intestinal perforations has been reported in children with FMF, whereas cases with a single intestinal perforation have been encountered, although very rarely. In addition, co-occurrence of FMF and inflammatory bowel disease is a situation that is very rarely reported in the literature. Here, we report a case of a 5-year-old girl who was being followed up with the diagnosis of FMF and who also had inflammatory bowel disease, which was complicated with multiple ileal perforations. Our aim is to point out a rarely encountered co-occurrence and also the importance of evaluation of additional diseases with FMF that are unresponsive to treatment so as to prevent complications.


Assuntos
Febre Familiar do Mediterrâneo/complicações , Doenças do Íleo/etiologia , Doenças Inflamatórias Intestinais/complicações , Perfuração Intestinal/etiologia , Pré-Escolar , Colchicina/efeitos adversos , Febre Familiar do Mediterrâneo/tratamento farmacológico , Feminino , Humanos , Doenças do Íleo/patologia , Doenças do Íleo/cirurgia , Perfuração Intestinal/cirurgia
5.
World J Gastroenterol ; 25(27): 3619-3633, 2019 Jul 21.
Artigo em Inglês | MEDLINE | ID: mdl-31367161

RESUMO

BACKGROUND: Magnetic resonance enterography (MRE) is increasingly attractive as a noninvasive and radiation-free tool for assessing Crohn's disease (CD). Diffusion-weighted imaging (DWI) is recommended as an optional MRE sequence for CD by the European Society of Gastrointestinal and Abdominal Radiology, and has shown a superb potential as a quantitative modality for bowel inflammation evaluation. However, the measurement reproducibility of quantitative DWI analysis in MRE has not been ascertained so far. To facilitate the application of quantitative diffusion-weighted MRE in the clinical routine, systematic investigations of the intra and interobserver reproducibility of DWI quantitative parameters should be performed. AIM: To evaluate the intra and interobserver reproducibility of quantitative analysis for diffusion-weighted MRE (DW-MRE) in ileal CD. METHODS: Forty-four subjects (21 with CD and 23 control subjects) who underwent ileocolonoscopy and DW-MRE (b = 800 s/mm2) within one week were included. Two radiologists independently measured apparent diffusion coefficients (ADC) of the terminal ileum and signal intensity ratio (SR) of the terminal ileum to ipsilateral psoas muscle on DWI images (b = 800 s/mm2). Between- and within-reader agreements were assessed using intraclass correlation coefficients (ICC), coefficients of variation (CoV), and 95% limits of agreement of Bland-Altman plots (BA-LA LoA). Diagnostic performances of ADC and SR for identifying inflamed terminal ileum from the normal were evaluated by receiver operating characteristic (ROC) curve analysis. RESULTS: There were no significant differences in ADC or SR values between the two sessions or between the two radiologists either in the CD or control group (paired t-test, P > 0.05). The intra and interobserver reproducibility of ADC (ICC: 0.952-0.984; CoV: 3.73-6.28%; BA-LA LoA: ±11.27% to ±15.88%) and SR (ICC: 0.969-0.989; CoV: 3.51%-4.64%; BA-LA LoA: ±10.62% to ±15.45%) was excellent for CD. Agreement of ADC measurements was slightly less in control subjects (ICC: 0.641-0.736; CoV: 10.47%-11.43%; BA-LA LoA: ± 26.59% to ± 30.83%). SR of normal terminal ileum demonstrated high intra and interobserver reproducibility (ICC: 0.944-0.974; CoV: 3.73%-6.28%; BA-LA LoA: ± 18.58% to ± 24.43%). ADC and SR of two readers had outstanding diagnostic efficiencies (area under the ROC curve: 0.923-0.988). CONCLUSION: Quantitative parameters derived from DW-MRE have good to excellent intra and interobserver agreements with high diagnostic accuracy, and can serve as robust and efficient quantitative biomarkers for CD evaluation.


Assuntos
Doença de Crohn/diagnóstico por imagem , Imagem de Difusão por Ressonância Magnética/métodos , Doenças do Íleo/diagnóstico por imagem , Adulto , Doença de Crohn/patologia , Feminino , Humanos , Doenças do Íleo/patologia , Íleo/diagnóstico por imagem , Íleo/patologia , Processamento de Imagem Assistida por Computador , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Curva ROC , Reprodutibilidade dos Testes , Estudos Retrospectivos
6.
Am J Emerg Med ; 37(9): 1746-1750, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31257125

RESUMO

BACKGROUND: Identification of intussusception is feasible with emergency department (ED) point-of-care ultrasound (PoCUS) due to its ease-of-use and high accuracy. Little is known about the clinical characteristics and outcomes of small bowel-small bowel intussusception (SB-SBI) relative to ileocolic intussusception (ICI) identified by PoCUS. METHODS: We conducted a retrospective cohort study at a single, tertiary care, urban pediatric ED of intussusception identified by PoCUS. Demographic information, clinical data, and outcomes, including clinical course, intussusception characteristics, recurrence rates, and interobserver agreement (Cohen's kappa), were evaluated. RESULTS: ED PoCUS identified thirty-seven patients with intussusception over a 4-year period. Twenty-one patients (57%) identified were SB-SBI. The median age was 54 months (IQR 35-76 months) for SB-SBI and 8 months (IQR 5.8-13.5 months) for ICI. The mean diameter was 1.68 cm (SD 0.52 cm) for SB-SBI and 2.74 cm (SD 0.43 cm) for ICI (p < 0.05). Two of 21 (9.5%) SB-SBI subjects required surgical intervention, while the rest spontaneously reduced. Fourteen of 16 (88%) ICI subjects required intervention. There were two (9.5%) recurrences of SB-SBI and 1 (6.3%) recurrence of ICI confirmed on PoCUS. Cohen's kappa was 0.85 (95% CI 0.68-1.0). CONCLUSIONS: SB-SBI may be identified more frequently than previously thought when screened with ED PoCUS. Older children with SB-SBI may have underlying lead-points and may require surgical intervention. PoCUS can help differentiate between variants of intussusception that range from a surgical emergency to a transient source of abdominal pain that may be recurrent and otherwise unexplained, allowing clinicians to better manage these patients accordingly.


Assuntos
Doenças do Íleo/diagnóstico , Intestino Delgado/diagnóstico por imagem , Intussuscepção/diagnóstico , Sistemas Automatizados de Assistência Junto ao Leito/estatística & dados numéricos , Ultrassonografia/métodos , Adolescente , Criança , Pré-Escolar , Serviço Hospitalar de Emergência , Feminino , Humanos , Doenças do Íleo/patologia , Lactente , Intestino Delgado/patologia , Intussuscepção/classificação , Intussuscepção/patologia , Masculino , Estudos Retrospectivos
7.
J Int Med Res ; 47(6): 2709-2715, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31014143

RESUMO

During the past century, the incidence of myocardial infarction has markedly increased worldwide. Percutaneous coronary intervention with stent implantation is often considered as the first-choice treatment, especially in emergency cases. Current guidelines recommend delayed elective noncardiac surgery for such vulnerable patients. However, few suggestions are available regarding the exact treatment strategy for patients who have already undergone percutaneous coronary intervention but suddenly need emergent noncardiac surgery for an unrelated reason. We herein present a case involving a patient with acute myocardial infarction who had undergone implantation of a drug-eluting stent and developed an ileal perforation due to fish bone ingestion 3 days postoperatively. After carefully balancing the risks of stent thrombosis and uncontrollable bleeding, dual antiplatelet therapy and low-molecular-weight heparin were given with close monitoring. Emergency laparotomy and partial small bowel resection surgery were then performed, after which the patient eventually recovered. This case indicates a possible management strategy for patients with acute myocardial infarction complicated by emergency noncardiac surgery.


Assuntos
Stents Farmacológicos , Corpos Estranhos/complicações , Hemorragia Gastrointestinal/etiologia , Doenças do Íleo/etiologia , Perfuração Intestinal/etiologia , Infarto do Miocárdio/terapia , Alimentos Marinhos/efeitos adversos , Idoso , Animais , Feminino , Peixes , Corpos Estranhos/cirurgia , Hemorragia Gastrointestinal/patologia , Hemorragia Gastrointestinal/cirurgia , Humanos , Doenças do Íleo/patologia , Doenças do Íleo/cirurgia , Perfuração Intestinal/patologia , Perfuração Intestinal/cirurgia , Infarto do Miocárdio/complicações , Intervenção Coronária Percutânea , Prognóstico
8.
Pediatrics ; 143(4)2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30898843

RESUMO

Heterotopic gastric mucosa (HGM) is defined as the presence of gastric mucosa outside of the stomach, which is documented by histologic finding. HGM is typically a solitary lesion; however, in our Case Report, the patient presented with multilocus HGM, an uncommon form in which the small bowel is extensively involved. We report a unique case of multilocus HGM mimicking very early-onset inflammatory bowel disease with recurrent gastrointestinal bleeding, chronic inflammation, and stricturing in a newborn patient. Histologic findings from the ileocecal specimen revealed multiple ulcers surrounded by chronic inflammation. Subsequently, a Technetium-99m pertechnetate scan demonstrated an increased tracer uptake in the remaining ileum. This radiologic finding, in combination with the discovery of gastric mucosa within the remainder of resected ileal specimen, led to the diagnosis of HGM. Omeprazole was initiated, and the patient is now asymptomatic without further gastrointestinal bleeding. Increased awareness of this rare disease and performing a Technetium-99m pertechnetate early can correctly diagnose HGM and prevent disease complication.


Assuntos
Coristoma/patologia , Mucosa Gástrica , Doenças do Íleo/patologia , Recém-Nascido Prematuro , Doenças Inflamatórias Intestinais/diagnóstico , Biópsia por Agulha , Diagnóstico Diferencial , Idade Gestacional , Humanos , Doenças do Íleo/diagnóstico , Imuno-Histoquímica , Recém-Nascido , Doenças Inflamatórias Intestinais/congênito , Doenças Inflamatórias Intestinais/tratamento farmacológico , Masculino , Omeprazol/uso terapêutico , Resultado do Tratamento
9.
Am J Gastroenterol ; 114(8): 1238-1247, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30865014

RESUMO

Involvement of the gastrointestinal (GI) tract is an infrequent extrathoracic presentation of sarcoidosis. We reviewed 305 cases of GI involvement reported in 238 patients, in whom GI sarcoidosis was the first sign of the disease in half the cases. The disease does not affect the GI tract uniformly, with a clear oral-anal gradient (80% of reported cases involved the esophagus, stomach, and duodenum). Clinicopathological mechanisms of damage may include diffuse mucosal infiltration, endoluminal exophytic lesions, involvement of the myenteric plexus, and extrinsic compressions. Ten percent of patients presented with asymptomatic or subclinical disease found on endoscopy. The diagnosis is relevant clinically because 22% of cases reviewed presented as life threatening. In addition, initial clinical/endoscopic findings may be highly suggestive of GI cancer. The therapeutic approach is heterogeneous and included wait-and-see or symptomatic approaches, glucocorticoid/immunosuppressive therapy, and surgery. Sarcoidosis of the gut is a heterogeneous, potentially life-threatening condition that requires a multidisciplinary approach and early clinical suspicion to institute personalized therapeutic management and follow-up.


Assuntos
Gastroenteropatias/diagnóstico , Sarcoidose/diagnóstico , Transtornos de Deglutição/etiologia , Duodenopatias/diagnóstico , Duodenopatias/patologia , Duodenopatias/terapia , Endoscopia Gastrointestinal , Acalasia Esofágica/diagnóstico , Acalasia Esofágica/etiologia , Acalasia Esofágica/patologia , Acalasia Esofágica/terapia , Doenças do Esôfago/complicações , Doenças do Esôfago/diagnóstico , Doenças do Esôfago/patologia , Doenças do Esôfago/terapia , Mucosa Esofágica/patologia , Gastroenteropatias/complicações , Gastroenteropatias/patologia , Gastroenteropatias/terapia , Glucocorticoides/uso terapêutico , Humanos , Doenças do Íleo/diagnóstico , Doenças do Íleo/patologia , Doenças do Íleo/terapia , Imunossupressores/uso terapêutico , Doenças do Jejuno/diagnóstico , Doenças do Jejuno/patologia , Doenças do Jejuno/terapia , Linfadenopatia/complicações , Mediastino , Plexo Mientérico , Miotomia , Pólipos/diagnóstico , Pólipos/patologia , Pólipos/terapia , Inibidores da Bomba de Prótons/uso terapêutico , Sarcoidose/complicações , Sarcoidose/patologia , Sarcoidose/terapia , Gastropatias/diagnóstico , Gastropatias/patologia , Gastropatias/terapia
10.
Med J Malaysia ; 74(1): 90-91, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30846671

RESUMO

Burkitt lymphoma is a rare entity especially in this part of the world. We had an 11-year-old patient presented with swelling of the mandible for a short one-month duration. He was planned for excision biopsy. However developed severe abdominal pain while in the hospital and was diagnosed as intussusception after ultrasound was done. We proceeded with right hemicolectomy and excision of buccal mass. Early recognition and close monitoring of insidious jaw lesions is recommended even in young adults not within the modal age category of endemic Burkitt.


Assuntos
Linfoma de Burkitt/diagnóstico , Doenças do Íleo/etiologia , Intussuscepção/etiologia , Doenças Mandibulares/etiologia , Linfoma de Burkitt/complicações , Linfoma de Burkitt/patologia , Criança , Humanos , Doenças do Íleo/diagnóstico por imagem , Doenças do Íleo/patologia , Intussuscepção/diagnóstico por imagem , Intussuscepção/patologia , Masculino , Doenças Mandibulares/patologia , Ultrassonografia
11.
Gastrointest Endosc ; 89(2): 357-363.e2, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30670179

RESUMO

BACKGROUND AND AIMS: Although erosions and ulcerations are the most common small-bowel abnormalities found on wireless capsule endoscopy (WCE), a computer-aided detection method has not been established. We aimed to develop an artificial intelligence system with deep learning to automatically detect erosions and ulcerations in WCE images. METHODS: We trained a deep convolutional neural network (CNN) system based on a Single Shot Multibox Detector, using 5360 WCE images of erosions and ulcerations. We assessed its performance by calculating the area under the receiver operating characteristic curve and its sensitivity, specificity, and accuracy using an independent test set of 10,440 small-bowel images including 440 images of erosions and ulcerations. RESULTS: The trained CNN required 233 seconds to evaluate 10,440 test images. The area under the curve for the detection of erosions and ulcerations was 0.958 (95% confidence interval [CI], 0.947-0.968). The sensitivity, specificity, and accuracy of the CNN were 88.2% (95% CI, 84.8%-91.0%), 90.9% (95% CI, 90.3%-91.4%), and 90.8% (95% CI, 90.2%-91.3%), respectively, at a cut-off value of 0.481 for the probability score. CONCLUSIONS: We developed and validated a new system based on CNN to automatically detect erosions and ulcerations in WCE images. This may be a crucial step in the development of daily-use diagnostic software for WCE images to help reduce oversights and the burden on physicians.


Assuntos
Endoscopia por Cápsula , Doenças do Íleo/diagnóstico , Doenças Inflamatórias Intestinais/diagnóstico , Intestino Delgado/patologia , Doenças do Jejuno/diagnóstico , Redes Neurais de Computação , Reconhecimento Automatizado de Padrão , Úlcera/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Anti-Inflamatórios não Esteroides/efeitos adversos , Área Sob a Curva , Aprendizado Profundo , Úlcera Duodenal/diagnóstico , Úlcera Duodenal/etiologia , Úlcera Duodenal/patologia , Feminino , Humanos , Doenças do Íleo/etiologia , Doenças do Íleo/patologia , Doenças Inflamatórias Intestinais/complicações , Doenças Inflamatórias Intestinais/patologia , Doenças do Jejuno/etiologia , Doenças do Jejuno/patologia , Masculino , Pessoa de Meia-Idade , Úlcera Péptica/induzido quimicamente , Úlcera Péptica/diagnóstico , Úlcera Péptica/patologia , Curva ROC , Sensibilidade e Especificidade , Software , Úlcera/etiologia , Úlcera/patologia
17.
Pediatr Dev Pathol ; 22(1): 75-79, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-29890901

RESUMO

Gastrointestinal diaphragm disease is a rare entity characterized by the formation of thin membranous circumferential mucosal septa, resulting in marked narrowing of the intestinal lumen. The most frequent etiology is the chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs). Idiopathic cases and other possible etiologies have been reported. We present a rare association of diaphragm disease with Crohn's disease in a boy without a history of significant NSAID usage.


Assuntos
Cápsulas Endoscópicas , Doença de Crohn/patologia , Corpos Estranhos , Doenças do Íleo/etiologia , Íleo/patologia , Mucosa Intestinal/patologia , Obstrução Intestinal/etiologia , Adolescente , Doença de Crohn/complicações , Doença de Crohn/diagnóstico por imagem , Humanos , Doenças do Íleo/diagnóstico por imagem , Doenças do Íleo/patologia , Íleo/diagnóstico por imagem , Mucosa Intestinal/diagnóstico por imagem , Obstrução Intestinal/diagnóstico por imagem , Obstrução Intestinal/patologia , Masculino
18.
Forensic Sci Med Pathol ; 15(2): 284-287, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30397871

RESUMO

Intussusception is one of the most common causes of intestinal obstructions in younger children, especially infants. Though rare, fatalities due to intussusception are known to be caused by intestinal obstruction associated with peritonitis, generalized sepsis and shock from intestinal infarction due to disruption in blood supply or electrolyte and fluid imbalance. An eight-month-old female infant, who initially presented with a single episode of vomiting and fever (37.8 °C), was examined as an outpatient at the department of pediatrics of a general hospital. Clinical examination revealed no characteristic features of acute abdomen, so the child was sent home. Nine to ten hours later her condition deteriorated: she became hyperpyretic and stuporous. On her way to the University Children's Hospital, the infant died; the death was confirmed upon admission, i.e. some 15 h after the onset of symptoms. The autopsy revealed an 8 cm long intussusception of the distal part of the ileum to the cecum. There was no gross or microscopic evidence of peritonitis at autopsy. The shock caused by intestinal obstruction with consequent intestinal necrosis was considered to be the cause of death.


Assuntos
Doenças do Íleo/patologia , Valva Ileocecal/patologia , Obstrução Intestinal/patologia , Intussuscepção/patologia , Evolução Fatal , Feminino , Humanos , Lactente , Necrose , Choque/etiologia
20.
Folia Med Cracov ; 58(3): 83-87, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30521513

RESUMO

Meckel's diverticulum represents a remnant of the proximal end of the omphalomesenteric duct, which constitutes a connection between the middle intestine and the vitelline vesicle. It is the most common congenital anomaly of the gastrointestinal tract and is found in approximately 0.3-2% of the general population. Complications such as hemorrhage, bowel obstruction, inflammation, perforation, intussusception, volvulus and malignant transformation develop in only 4-4.8% of all patients, with most cases presenting in childhood, while relative risk decreases during life. The aim of the present study is to present our experience in managing a 15-year old male patient with Meckel's diverticulum covered perforation. It was a case of disguised perforation of the Meckel's diverticulum, with development of adhesions to the anterior surface of the right third of the transverse colon, which was successfully treated on the basis of emergency. Diagnosis was made intraoperatively and was documented by histological examination of the excised diverticulum.


Assuntos
Colo Transverso/patologia , Diverticulite/patologia , Doenças do Íleo/patologia , Perfuração Intestinal/patologia , Divertículo Ileal/patologia , Aderências Teciduais/patologia , Úlcera/patologia , Adolescente , Diverticulite/cirurgia , Humanos , Doenças do Íleo/cirurgia , Perfuração Intestinal/cirurgia , Masculino , Divertículo Ileal/cirurgia , Aderências Teciduais/cirurgia , Úlcera/cirurgia
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