[Cystic neoplasm of the pancreas: a ten years experience]. / Tumores quísticos de páncreas. Informe de 10 años.

BACKGROUND: Pancreatic cystic lesions (PCL) are identified in 1 % of patients who undergo abdominal computed tomography scans, because it is difficult to discriminate clinically between benign and malignant PCL. The PCL must be distinguished from inflammatory pseudocysts, which can have a similar radiographic appearance. The aim of this study was to review the incidence of PCL during 10 years. METHODS: Nineteen consecutive patients who underwent surgical resection of a cystic lesion of the pancreas during a 10-year period were reviewed. RESULTS: From 1998, 434 patients underwent to pancreatic surgery, 103 (25.75%) resulted with neoplasm of the pancreas and a PCL was diagnosed in 19 of them (18.44%). They were more common in women (n=15, 79%). The pathologic diagnosis was mucinous cystadenoma (n=6, 31.5%) followed by serous cystadenoma and solid cystic papilar tumor (n=4, 21%). Mucinous cystadenocarcinoma was diagnosed in a 77 year-old man and a serous cystadenocarcinoma was diagnosed in a 53 years-old woman; cystic degeneration of two insulinomas were diagnosed in a 71 year-old woman and a 32 year-old man (5.26%). CONCLUSIONS: PCLs represent a spectrum of associated diseases. The incidence of serous cystadenoma is lower in our experience.

[Pyloric stenosis as a presenting clinical pattern of Crohn's disease]. / Estenosis pilórica como manifestación inicial de enfermedad de Crohn.

BACKGROUND: Gastroduodenal involvement in Crohn's disease (CD) is relatively rare (0.5-13%) and occasionally causes pyloric stenosis, for which medical therapy may be ineffective and surgery may be required. With more frequent use of upper endoscopy, however, upper gastrointestinal involvement has been found to be more common than previously suspected. About one third of the patients with symptomatic gastroduodenal CD undergo surgery, most of them for obstruction. Gastroenterostomy with vagotomy is the surgical treatment of choice. Resection, strictureplasty or balloon dilatation maybe performed in selected patients. CLINICAL CASE: We report a 50-year-old woman patient with recurrent vomiting especially after eating and epigastric discomfort with dyspepsia, abdominal pain, with initially misdiagnosed pyloric CD that three years later developed colonic stenosis. CONCLUSIONS: Clinics should be aware of the possibility that in young and middle aged adults such upper gastrointestinal symptoms as epigastric discomfort, vomiting and weight loss may occur as a initial manifestation of CD or as an extension of the disease.

[Ogilvie syndrome. Report of two cases]. / Pseudoobstrucción colónica aguda (síndrome de Ogilvie). Informe de dos casos.

Acute colonic pseudo-obstruction or "Ogilvie syndrome (OS)," is a gastrointestinal motility disorder characterized by marked dilatation of the colon in the absence of mechanical obstruction. It occurs most commonly in the postoperative state or with severe medical illness; it has been associated with a wide range of comorbidities, including trauma, pelvic surgery (orthopedic, gynecologic, urologic), metabolic disorders, central nervous system disorders, and prostaglandin abnormalities. OS may also be drug induced or idiopathic. Left untreated, it can progress to perforation, peritonitis, and death. Definitive management of OS traditionally has consisted of mechanical decompression. However, neostigmine, an acetyl-cholinesterase inhibitor, has recently emerged as a safe and effective pharmacologic alternative in the adult population. We present two cases of OS attended in the intensive care unit treated with colonoscopy and cecostomy respectively.

[Mucocele of the appendix: an unusual finding in a patient with ulcerative colitis]. / Mucocele apendicular: un hallazgo inusual en colitis ulcerativa.

BACKGROUND: Patients with ulcerative colitis (UC) or Crohn's disease (CD) have an increased risk for the development of colorectal dysplasia and carcinoma. Although appendiceal inflammation occurs histologically in 40-86% of colectomy specimens from patients with inflammatory bowel disease (IBD), appendiceal neoplasms have been reported only infrequently, and the notion of a direct association between IBD and appendiceal neoplasia is speculative. CLINICAL CASE: A 54-year-old male patient developed abdominal pain and bloody diarrhea 3 years prior. Colonoscopy and biopsy established the diagnosis of UC (proctosigmoiditis). Disease activity was moderate at the beginning and the patient initially received medical treatment with mesalazine and prednisone. He was admitted to our clinic for right lower abdominal pain. Physical examination revealed tenderness on palpation at this site. Laboratory tests were normal (including serum carcinoembryonic antigen and CA 19-9). Colonoscopy showed intrinsic compression of the cecum. The patient underwent partial cecum resection and extirpation of the mucocele. He presented postsurgical ileus resolved with medical treatment. Final histological report revealed cystadenoma of the appendix. At the 20-month follow-up, the patient was in satisfactory condition. CONCLUSIONS: We present the eighth patient, to our knowledge, with a primary cystadenoma of the appendix and UC. Special attention should be paid to patients with extraordinary symptoms during follow-up, even in UC patients.

[Tuberculosis of the pancreas: an unsuspected cause of abdominal pain and fever]. / Tuberculosis pancreática: una causa insospechada de dolor abdominal y fiebre.

BACKGROUND: Tuberculosis is frequently the form of presentation of human immunodeficiency virus (HIV) infection even in patients who have not developed acquired immune deficiency syndrome (AIDS). Nevertheless, pancreatic affection is uncommon. Tuberculosis of the pancreas (TBP) is a clinical rarity and mimics pancreatic carcinoma both clinically and radiologically. CLINICAL CASE: We present the case of a 42-year-old man with a 5-day evolution of moderate abdominal pain in the right lower quadrant and fever and vomiting without diarrhea. The patient had no history of abdominal surgery. CT scan revealed a heterogeneously enhancing, multicystic structure in the pancreatic head. Due to suspicion of malignancy, a pancreatoduodenectomy was performed with pathological result of pancreatic tuberculosis. The patient was discharged on the 10th postoperative day without surgical complications. He died 10 months later of Pneumocystis jirovecii pneumonia. By that time he had a positive serum HIV antibodies test. CONCLUSIONS: TBP diagnosis can be missed or significantly delayed because it is often not suspected prior to laparotomy unless there is evidence of pulmonary tuberculosis. TBP should be considered in the differential diagnosis of a mass in the head of the pancreas. The response to early antituberculosis treatment is very effective.

Multiple intestinal lipomatosis. Case report.

BACKGROUND: Intestinal lipomatosis is a rare disease with an incidence at autopsy ranging from 0.04 to 4.5%. Few cases have been reported in the medical literature. The condition is usually asymptomatic. Symptomatic cases usually present as obstruction or, less frequently, as bleeding. Intestinal barium studies, ultrasonography and computed tomography (CT) are useful diagnostic techniques. CLINICAL CASE: A 51-year-old male was evaluated for progressive abdominal pain, tachycardia, headache and nausea. One year before this examination, he was evaluated for gastrointestinal bleeding. Abdominal CT with contrast enhancement demonstrated multiple submucosal masses in stomach and small bowel. CT and barium examination features were typical of lipomas. No specific treatment, invasive procedures or surgery were performed for the asymptomatic intestinal lipomas. The patient has remained symptom-free for 1 year. CONCLUSIONS: Benign tumors of the small bowel are relatively rare, with lipoma being the most common type. The case reported here is considered to be unusual because stomach, duodenum, jejunum and ileum were affected. Lipomas are usually seen as smooth, nonulcerated filling defects. With these typical radiographic findings, preoperative diagnosis is possible keeping in mind this rare disease.

[Congenital diaphragmatic adult hernia. Case report]. / Hernia diafragmática congénita en el adulto. Informe de un caso.

BACKGROUND: Bochdalek's hernia is a congenital defect of the posterolateral region of the diaphragm, usually on the left side. It appears frequently in infants and is rare in adults. Diagnosis is incidental or when it becomes symptomatic. Our objective was to offer the general surgeon a differential diagnosis for presence of noncardiac thoracic pain in the adult. CLINICAL CASE: We present the case of a 78-year-old female with cardiorespiratory and digestive symptoms of slight intensity and managed for many years as hypertensive cardiopathy and dyspeptic syndrome until she was admitted to our service with severe epigastric pain. Postero-anterior x-ray of the thorax demonstrated the presence of the stomach in the thoracic cavity. This was confirmed by barium esophagogram, upper gastrointestinal endoscopy and abdominal CT scan where porcelain gallbladder was also detected. The patient underwent abdominal surgery where a large diaphragmatic hernia was found with the complete stomach and small bowel inside. Primary repair of the diaphragm and cholecystectomy were performed, confirming gallbladder cancer. DISCUSSION: It is frequent that thoracic pain in patients of advanced age is interpreted as cardiac and/or digestive pathology and that more diagnostic investigation is not pursued due to patient age and invasive nature of the studies. Therefore, patients are treated according to their symptoms. It is important that the surgeon establishes an etiological diagnosis in order to offer appropriate treatment. CONCLUSIONS: Congenital diaphragmatic hernia in the adult is rarely suspected in the differential diagnosis of noncardiac thoracic pain. The surgeon must keep this in mind, especially in patients of advanced age, even when cardiac and/or gastrointestinal diagnosis is confirmed.

Lipomatosis intestinal múltiple: informe de un caso / Multiple intestinal lipomatosis: case report

Introducción: La lipomatosis intestinal es una rara enfermedad con una incidencia en autopsias de 0.04 a 4.5 %. Pocos casos se han informado en la literatura médica. La condición es por lo general asintomática. Los casos sintomáticos se presentan con obstrucción o, con menor frecuencia, hemorragia. Los estudios con bario, ultrasonografía y tomografía computarizada son los procedimientos diagnósticos más comunes. Caso clínico: Hombre de 51 años de edad evaluado por dolor abdominal progresivo, taquicardia, cefalea y náusea. Fue estudiado un año antes por hemorragia gastrointestinal sin diagnóstico definitivo. La tomografía computarizada de abdomen con contraste demostró múltiples masas submucosas en estómago e intestino delgado. Las características del estudio con bario y tomografía computarizada fueron típicas de lipomatosis, por lo que no se realizaron procedimientos invasivos o quirúrgicos. El paciente se ha mantenido asintomático por un año. Conclusiones: Los tumores benignos del intestino delgado son relativamente raros, siendo el lipoma el tipo más común. El caso informado es inusual debido a la afección de estómago, duodeno, yeyuno e íleon. Los lipomas por lo general se presentan con superficie lisa y defectos de llenado no ulcerados. Con los hallazgos radiológicos típicos es posible hacer el diagnóstico preoperatorio si se considera esta rara enfermedad.

BACKGROUND: Intestinal lipomatosis is a rare disease with an incidence at autopsy ranging from 0.04 to 4.5%. Few cases have been reported in the medical literature. The condition is usually asymptomatic. Symptomatic cases usually present as obstruction or, less frequently, as bleeding. Intestinal barium studies, ultrasonography and computed tomography (CT) are useful diagnostic techniques. CLINICAL CASE: A 51-year-old male was evaluated for progressive abdominal pain, tachycardia, headache and nausea. One year before this examination, he was evaluated for gastrointestinal bleeding. Abdominal CT with contrast enhancement demonstrated multiple submucosal masses in stomach and small bowel. CT and barium examination features were typical of lipomas. No specific treatment, invasive procedures or surgery were performed for the asymptomatic intestinal lipomas. The patient has remained symptom-free for 1 year. CONCLUSIONS: Benign tumors of the small bowel are relatively rare, with lipoma being the most common type. The case reported here is considered to be unusual because stomach, duodenum, jejunum and ileum were affected. Lipomas are usually seen as smooth, nonulcerated filling defects. With these typical radiographic findings, preoperative diagnosis is possible keeping in mind this rare disease.

Hernia diafragmática congénita en el adulto: informe de un caso / Congenital diaphragmatic adult hernia: case report

BACKGROUND: Bochdalek's hernia is a congenital defect of the posterolateral region of the diaphragm, usually on the left side. It appears frequently in infants and is rare in adults. Diagnosis is incidental or when it becomes symptomatic. Our objective was to offer the general surgeon a differential diagnosis for presence of noncardiac thoracic pain in the adult. CLINICAL CASE: We present the case of a 78-year-old female with cardiorespiratory and digestive symptoms of slight intensity and managed for many years as hypertensive cardiopathy and dyspeptic syndrome until she was admitted to our service with severe epigastric pain. Postero-anterior x-ray of the thorax demonstrated the presence of the stomach in the thoracic cavity. This was confirmed by barium esophagogram, upper gastrointestinal endoscopy and abdominal CT scan where porcelain gallbladder was also detected. The patient underwent abdominal surgery where a large diaphragmatic hernia was found with the complete stomach and small bowel inside. Primary repair of the diaphragm and cholecystectomy were performed, confirming gallbladder cancer. DISCUSSION: It is frequent that thoracic pain in patients of advanced age is interpreted as cardiac and/or digestive pathology and that more diagnostic investigation is not pursued due to patient age and invasive nature of the studies. Therefore, patients are treated according to their symptoms. It is important that the surgeon establishes an etiological diagnosis in order to offer appropriate treatment. CONCLUSIONS: Congenital diaphragmatic hernia in the adult is rarely suspected in the differential diagnosis of noncardiac thoracic pain. The surgeon must keep this in mind, especially in patients of advanced age, even when cardiac and/or gastrointestinal diagnosis is confirmed.