RESUMO
Gallstone ileus, a mechanical intestinal obstruction caused by the passage of a gallstone into the intestinal lumen through a fistula, although not common, deserves to more carefully studied due to its morbidity and mortality. Its incidence among older-age groups explains its association with chronic and degenerative diseases, which increase the complexity of the treatment choice. The need and appropriateness of a surgical approach to a cholecystenteric fistula to solve the obstructive emergency, in a one or two stage procedure, has been discussed in the literature. It has also been reported that gallstone ileus is an uncommon cause of upper intestinal obstruction. Intestinal obstruction is seen more frequently after a gallstone impacts at the ileocecal valve. The authors report a case of gallstone ileus as a cause of upper intestinal obstruction and discuss its diagnosis and treatment.
Assuntos
Colelitíase/complicações , Obstrução Intestinal/etiologia , Idoso , Idoso de 80 Anos ou mais , Colelitíase/diagnóstico , Colelitíase/cirurgia , Feminino , Humanos , Obstrução Intestinal/diagnóstico , Obstrução Intestinal/cirurgiaRESUMO
Os pacientes com síndrome da imunodefiência adquirida (SIDA) podem apresentar quadro de abdome agudo com manifestaçoes clínicas muito variadas, levando a erros e retardos no diagnóstico pré-operatório e retardos freqüentes na açao cirúrgica. Objetivo. Estudar os dados clínicos, critérios diagnósticos, etiologia, conduta cirúrgica e morbimortalidade dos pacientes com SIDA submetidos à laparotomia exploradora. Métodos. Foram estudados, retrospectivamente, os dados de 31 pacientes com SIDA atendidos no Serviço de Cirurgia de Emergência do Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, no período de 1986 a 1993, com diagnóstico clínico de abdome agudo e submetidos à laparotomia exploradora. Resultados. A principal manifestaçao clínica foi a dor abdominal, e o diagnóstico de abdome agudo foi a baseado em exame físico, exames laboratoriais e métodos de imagem. A causa mais freqüente de abdome agudo foi a perfuraçao do trato gastrointestinal, sendo a infecçao por citomegalovírus a etiologia mais freqüente da perfuraçao. Todos os doentes apresentaram algum tipo de complicaçao pós-operatória, prevalecendo a infecçao da ferida cirúrgica. A mortalidade foi de 42 por cento, em decorrência de sepse e falência de múltiplos órgaos e sistemas. Conclusoes. Basedos nestes dados, concluímos que os sinais clínicos de abdome agudo nos doentes com SIDA sao menos evidentes; as estomias devem ser a conduta de eleiçao. A morbimortalidade é extremamente elevada devido ao estado imuno-comprometido, ao retardo diagnóstico e a laparotomias nao terapêuticas.
Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Abdome Agudo/cirurgia , Síndrome da Imunodeficiência Adquirida/complicações , Estudos Retrospectivos , Emergências , Abdome Agudo/diagnóstico , Abdome Agudo/etiologia , Abdome Agudo/mortalidade , Laparotomia/efeitos adversos , Laparotomia/mortalidade , Complicações Pós-Operatórias , Infecções Oportunistas Relacionadas com a AIDSRESUMO
UNLABELLED: Patients with Acquired Immunodeficiency Syndrome (AIDS) may present acute abdomen with modified clinical manifestations which may lead to errors and delays in preoperative diagnosis, with frequent delays in treatment. PURPOSE: To study clinical signs, diagnostic criteria, etiology, surgical management and mortality in patients with AIDS submitted to exploratory laparotomy. METHODS: We reviewed the records of thirty-one AIDS patients admitted in the period 1986-1993 at the Emergency Surgical Service--Hospital das Clínicas, University of São Paulo submitted to exploratory celiotomy due to acute abdome. RESULTS: Abdominal pain was the most frequent symptom and the diagnosis of acute abdome was made based upon physical examination, laboratory tests and imaging techniques. Gastrointestinal tract perforation was the most frequent cause of acute abdome, mainly due to Cytomegalovírus infection. All patients presented postoperative complication, specially wound infection. Mortality rate was 42% due to sepsis and multiple organ failure. CONCLUSION: Based upon these data we conclude that: AIDS patients usually present masked clinical signs of acute abdomen; stomas should be formally indicated. Mortality is extremely high due to immunocompromised state, delayed diagnosis and treatment and non therapeutic celiotomies.
Assuntos
Abdome Agudo/cirurgia , Síndrome da Imunodeficiência Adquirida/complicações , Infecções Oportunistas Relacionadas com a AIDS , Abdome Agudo/diagnóstico , Abdome Agudo/etiologia , Abdome Agudo/mortalidade , Adolescente , Adulto , Emergências , Feminino , Humanos , Laparotomia/efeitos adversos , Laparotomia/mortalidade , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos RetrospectivosRESUMO
Mechanic intestinal obstruction, caused by the passage of biliary calculus from vesicle to intestine, through fistulization, although not frequent, deserve study due to the morbi-mortality rates. Incidence in elder people explains the association with chronic degenerative diseases, increasing complexity in terms of therapy decision. Literature discusses the need and opportunity for the one or two-phase surgical attack of the cholecyst-enteric fistule, in front of the resolution on the obstructive urgency and makes reference to Gallstone Ileus as an exception for strong intestinal obstruction. The more frequent intestinal obstruction observed is when it occurs a Gallstone Ileus impacting in terms of ileocecal valve. The authors submit a Gallstone Ileus manifestation as causing strong intestinal obstruction, discussing aspects regarding diagnostic and treatment.
Assuntos
Colelitíase/complicações , Obstrução Intestinal/etiologia , Idoso , Idoso de 80 Anos ou mais , Fístula Biliar/diagnóstico , Fístula Biliar/cirurgia , Colelitíase/diagnóstico , Colelitíase/cirurgia , Feminino , Humanos , Fístula Intestinal/diagnóstico , Fístula Intestinal/cirurgia , Obstrução Intestinal/diagnóstico , Obstrução Intestinal/cirurgia , Masculino , Complicações Pós-Operatórias , Cuidados Pré-OperatóriosRESUMO
Gastrointestinal hemorrhage continues to be a major medical problem. Even with improvements in both diagnostic and therapeutic, a significant number of patients still require surgical intervention for control of hemorrhage. When the source of persistent lower gastrointestinal hemorrhage is unknown, subtotal colectomy is a conceptually rational management choice. The authors present a case of massive lower gastrointestinal hemorrhage with unusual fatal outcome. A review of literature of this condition and a discussion about the diagnosis, treatment and etiopathogenesis are presented.
Assuntos
Hemorragia Gastrointestinal/diagnóstico , Angiografia , Colonoscopia , Evolução Fatal , Hemorragia Gastrointestinal/terapia , Humanos , Masculino , Pessoa de Meia-Idade , CintilografiaRESUMO
Gastric perforation following splenectomy is a rare complication occurring in less than 1% of patients and it is mainly associated with iatrogenic injury to the greater curvature of the stomach. The authors report a case of gastric fistula in a patient who underwent splenectomy for blunt abdominal trauma and discuss the main etiopathogenic and diagnostic aspects.
Assuntos
Traumatismos Abdominais/cirurgia , Fístula Gástrica/etiologia , Esplenectomia/efeitos adversos , Traumatismos Abdominais/complicações , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
A retrospective review of 35 patients with diaphragmatic injury attended at the Emergency Service of the Hospital das Clínicas, University São Paulo is analysed. Diagnosis was made through chest roentgenogram (48.5%), peritoneal lavage (37%) and contrast studies (14.5%). The most common extra-abdominal lesion were due to head, pelvic and thoracic trauma. Thirty-one patients sustained injuries to the left-side and four to the right. Associated intra-abdominal injury occurred in 89% of them. Retroperitoneal haematoma, spleen and liver injury were the most frequent lesions. All cases were treated by laparotomy, pleural space irrigation through the diaphragmatic lesion, thoracic drainage and suture of the injury. The morbidity rate was 40% and deaths occurred in 22.8%. Based upon these data, we concluded: the mechanism of trauma, chest RX findings and pelvic fracture are important clues for early recognition; irrigation of pleural space seems to be important in order to prevent empyema. Despite of this, the mortality remains high.
Assuntos
Diafragma/lesões , Ferimentos não Penetrantes/diagnóstico , Acidentes de Trânsito , Adulto , Diafragma/diagnóstico por imagem , Diafragma/cirurgia , Feminino , Humanos , Masculino , Traumatismo Múltiplo/epidemiologia , Radiografia , Estudos Retrospectivos , Ruptura , Taxa de Sobrevida , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/cirurgiaRESUMO
Foram analisados, retrospectivamente, os prontuários de 48 pacientes com síndrome de Forunier atendidos no Serviço de Cirurgia de Emergência do Hospital das Clínicas da Faculdade de Medicina da Universidade de Säo Paulo, no período de 1982 a 1991. Foram analisados os dados clínicos e laboratoriais à admissäo. Os seguintes fatores, associados a um mau prognóstico, foram considerados estatísticamente significativos: elevaçäo da creatinina sérica, hipoxemia, alcalose ou acidose metabólica, diabete e idade maior que 50 anos. Baseados nestes critérios, os pacientes foram divididos em dois grupos: grupo I, forma leve (32 casos) e grupo II, forma grave (16 casos). Acreditamos que esta classficaçäo permita um melhor planejamento da terapêutica. Nos casos classificados como graves, o tratamento deve incluir debridamento amplo, com ressecçäo de todos os tecidos necróticos, reoperaçöes programadas, transversocolostomia, antibioticoterapia de amplo espectro e nutriçäo parenteral total. Nas formas leves, os pacients podem ser tratados com debridamento e antibioticoterapia
Assuntos
Humanos , Masculino , Adolescente , Adulto , Pessoa de Meia-Idade , Escroto , Gangrena/terapia , Estudos Retrospectivos , Gangrena/etiologia , Gangrena/patologia , Doenças dos Genitais Masculinos/patologia , Doenças dos Genitais Masculinos/terapia , SíndromeRESUMO
The records of 48 patients with Fournier's syndrome (FS) treated at the Emergency Surgical Service of the Hospital das Clínicas of the University of São Paulo Medical School in the period 1982-1991 were reviewed. Clinical and laboratory data at admission were analysed. The following factors were statistically significant when associated with bad prognosis: elevated serum creatinine, hypoxemia, metabolic alkalosis or acidosis, diabetes and age over 50 years. Based on these five criteria, the patients were divided into two groups: Group I, mild FS (32 cases) and Group II, severe FS (16 patients). This classification permits a better planning of therapy. In cases classified as severe, treatment should include wide débridement, with resection of all necrotic tissues, scheduled reoperations for further débridements, transverse colostomy, wide spectrum antibiotic therapy and total parenteral nutrition. In the mild cases, the patients may be treated with débridement and antibiotics only.
Assuntos
Escroto/patologia , Adolescente , Adulto , Idoso , Gangrena/etiologia , Gangrena/patologia , Gangrena/terapia , Doenças dos Genitais Masculinos/patologia , Doenças dos Genitais Masculinos/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , SíndromeRESUMO
The authors review the cases of traumatic rectal injuries admitted to the Emergency Service of the "Hospital das Clínicas", University of São Paulo Medical School, during the period of July 1981 to July 1988. Forty-five patients (62.5%) had their injuries due to gunshot, 14 (19.4%) due to foreign bodies on the rectum, 10 (13.8%) due to blunt trauma and 3 (4.1%) due to stab wounds. The intraperitoneal rectum was injured in 32 patients (44.4%) and extraperitoneal portion of the rectum in 40 patients (55.5%). On the intraperitoneal injuries the management adopted were simple suture (14 patients), associated with a colostomy (17 patients) and in one patient the Hartmann procedure was adopted. On the extraperitoneal wounds the management adopted were rectal repair (when feasible), colostomy, distal washout and drainage. The complications rate was 27.8%, and from them, the majority (70%) were related to infectious nature. Seven patients died (9.7%), four of them as a consequence of sepsis. The morbidity and mortality of the rectal injuries were closed related to infectious complications as a consequence of late diagnosis. For this reason, the authors consider that all efforts should be employed to establish the prompt diagnosis.