RESUMO
Reportar un caso de evisceración vaginal espontánea en paciente con antecedentes quirúrgicos de histerectomía vaginal y hacer una revisión de la literatura sobre los principales factores de riesgo asociados a la presentación de este evento. Se presenta el caso de una paciente de 74 años multípara de 12 partos vaginales con antecedente ginecológico de histerectomía vaginal en 2012, en el año 2014 una sacroespinocolpopexia con colocación de cinta transobturadora más colporrafia anterior, en 2018 presenta cuadro con asas intestinales protruyendo con signos de isquemia a través de defecto en cúpula vaginal, se realiza resección de intestino delgado y anastomosis termino-terminal, con posterior cierre de defecto por vía abdominal. Se realizó una búsqueda en las bases de datos PubMed, Scielo, Google Scholar y Science Direct para artículos publicados en inglés y español, de los últimos 22 años. Se identificaron 16 títulos que cumplieron con los criterios de selección, los resultados de la revisión muestran factores de riesgo comunes. La evisceración vaginal por dehiscencia de la cúpula vaginal es una patología poco prevalente, el abordaje mínimamente invasivo, que ha aumentado en los últimos años, ha conllevado un aumento de la incidencia, siendo la histerectomía por laparoscopia el de mayor riesgo.
To report a case of spontaneous vaginal evisceration in a patient with a surgical history of vaginal hysterectomy, and to review the literature on the main risk factors associated with the presentation of this event. We present the case of a 74-year-old multiparous patient with 12 vaginal deliveries with a gynecological history of vaginal hysterectomy in 2012, in 2014 a sacrospinocolpopexy with placement of transobturator tape plus anterior colporrhaphy, in 2018 she presented with intestinal loops protruding with signs of ischemia through a defect in the vaginal vault, resection of the small intestine and end-to-end anastomosis were performed, with subsequent closure of the defect through the abdomen. A search was made in the PubMed, Scielo, Google Scholar and Science Direct databases for articles published in English and Spanish, from the last 22 years. 16 titles that met the selection criteria were identified; the results of the review show common risk factors. Vaginal evisceration due to dehiscence of the vaginal vault is a rare pathology, the minimally invasive approach, which has increased in recent years, has led to an increase in incidence, with laparoscopic hysterectomy being of greater risk.
Assuntos
Humanos , Feminino , Idoso , Doenças Vaginais/cirurgia , Doenças Vaginais/etiologia , Histerectomia Vaginal/efeitos adversos , Enteropatias/cirurgia , Enteropatias/etiologia , Prolapso Visceral , Fatores de RiscoRESUMO
Intestinal Failure (IF) includes the loss of functional intestinal mass and the requirement of long term Parenteral Nutrition (PN) to achieve the development and growth in childhood. OBJECTIVE: To evaluate the experience in a specialized unit for pediatric patients with IF, describing the clinical cha racteristics of those admitted from November 2009 to December 2019. PATIENTS AND METHOD: Retros pective and descriptive review from clinical records of 24 cases that matched the inclusion criteria. The following variables were recorded: gender, neonatal history, origin unit, patient age and anthropome tric diagnosis at admission to the unit, cause of IF, hospital stay, anthropometric data and parenteral nutrition dependency at discharge. In those patients with a diagnosis of short bowel syndrome (SBS), the cause of intestinal resection and the characteristics of the intestinal remnant were identified: ana tomical classification, remnant length (defining ultra-short as < 25 cm), presence of ileocecal valve, and characteristics of the colon. RESULTS: The median age at admission was 7.8 months. Seventeen cases were preterm. Regarding IF etiology, 10 patients presented SBS, 6 patients with Intestinal Neuromus cular Disease (INMD), 7 children with SBS associated with INMD, and 1 case of intestinal lymphan giectasia. Within the SBS etiologies found in this group, intestinal atresia (8 cases) and necrotizing enterocolitis (9 patients) were the main causes with a similar proportion. Eight patients had no ileo cecal valve. According to anatomical classification, 1 case was Type I, 8 were Type II, and 8 were Type III. Related to bowel length, 3 were ultrashort, besides being Type II; in those with > 40 cm of bowel length, 7 were Type III. Overall average hospital stay was 456.4 days. Enteral autonomy was achieved in 16 patients and 8 cases required home parenteral nutrition. CONCLUSIONS: IF requires life support, PN and prolonged hospital stay. The principal etiology of IF is SBS caused by congenital intestinal atresia and necrotizing enterocolitis. Nevertheless, the high frequency of INMD could be attributed to the local protocol analysis. Most of our patients had poor prognosis factors, however, the management by a specialized team allowed the achievement of enteral autonomy in 66.7% of cases.
Assuntos
Enterocolite Necrosante , Atresia Intestinal , Enteropatias , Insuficiência Intestinal , Síndrome do Intestino Curto , Criança , Enterocolite Necrosante/complicações , Enterocolite Necrosante/etiologia , Humanos , Recém-Nascido , Atresia Intestinal/complicações , Enteropatias/diagnóstico , Enteropatias/etiologia , Enteropatias/terapia , Nutrição Parenteral/efeitos adversos , Estudos Retrospectivos , Síndrome do Intestino Curto/etiologia , Síndrome do Intestino Curto/cirurgiaRESUMO
OBJECTIVES: Data on multidisciplinary programs dedicated to home parenteral nutrition (HPN) in Latin America are limited. This study describes the results of the first multidisciplinary pediatric intestinal rehabilitation program for HPN at a public tertiary hospital in Brazil. METHODS: We retrospectively reviewed patients aged 0-18 years with intestinal failure (IF) who required parenteral nutrition (PN) for >60 days between January/2014 and December/2020. RESULTS: Fifty-four patients were discharged on HPN (15 achieved enteral autonomy, 34 continued on HPN at the end of the study, 1 underwent intestinal transplantation, and 4 died). The median (IQR) age at the study endpoint of patients who achieved enteral autonomy was 14.1 (9.7-19) versus 34.7 (20.4-53.9) months in those who did not achieve enteral autonomy. Overall prevalence of catheter-related thrombosis was 66.7% and catheter-related bloodstream infection rate was 0.39/1000 catheter-days. Intestinal failure-associated liver disease (IFALD) was present in 24% of all patients; none of the patients who achieved enteral autonomy had IFALD. All patients showed significant improvement in anthropometric parameters during the HPN period. The sociodemographic characteristics of the patients' family members were mothers less than 20 years old (7.5%), schooling time more than 10 years (55.5%), and household income between 1 and 3 times the minimum wage (64.8%). The 5-year survival rate for HPN is 90%, and 27.7% of patients achieve enteral autonomy. CONCLUSION: The treatment of pediatric patients with IF followed by a multidisciplinary pediatric intestinal rehabilitation program with HPN is feasible and safe in the Brazilian public health system.
Assuntos
Enteropatias , Hepatopatias , Nutrição Parenteral no Domicílio , Adulto , Brasil , Criança , Humanos , Enteropatias/etiologia , Enteropatias/terapia , Hepatopatias/etiologia , Nutrição Parenteral no Domicílio/efeitos adversos , Estudos Retrospectivos , Adulto JovemRESUMO
OBJECTIVES: To assess the natural history and outcomes of children with intestinal failure in a large, multicenter, geographically diverse contemporary cohort (2010-2015) from 6 pediatric intestinal failure programs. STUDY DESIGN: Retrospective analysis of a multicenter intestinal failure cohort (n = 443). Competing-risk analysis was used to obtain cumulative incidence rates for the primary outcome (enteral autonomy, transplantation, or death). The χ2 test and Cox proportional hazard regression were used for bivariate and multivariable analyses. RESULTS: The study cohort comprised 443 patients (61.2% male). Primary etiologies included short bowel syndrome (SBS), 84.9%; dysmotility disorder, 7.2%; and mucosal enteropathy, 7.9%. Cumulative incidences for enteral autonomy, transplantation, and death at 6 years of follow-up were 53.0%, 16.7%, and 10.5%, respectively. Enteral autonomy was associated with SBS, ≥50% of small bowel length, presence of an ileocecal valve (ICV), absence of portal hypertension, and follow-up in a non-high-volume transplantation center. The composite outcome of transplantation/death was associated with persistent advanced cholestasis and hypoalbuminemia; age <1 year at diagnosis, ICV, and intact colon were protective. CONCLUSIONS: The rates of death and transplantation in children with intestinal failure have decreased; however, the number of children achieving enteral autonomy has not changed significantly, and a larger proportion of patients remain parenteral nutrition dependent. New strategies to achieve enteral autonomy are needed to improve patient outcomes.
Assuntos
Enteropatias/epidemiologia , Enteropatias/terapia , Adolescente , Criança , Pré-Escolar , Progressão da Doença , Feminino , Seguimentos , Humanos , Incidência , Lactente , Recém-Nascido , Enteropatias/etiologia , Intestinos/transplante , Masculino , Nova Zelândia/epidemiologia , América do Norte/epidemiologia , Nutrição Parenteral , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Resultado do Tratamento , Reino Unido/epidemiologiaRESUMO
La falla intestinal (FI) se define como la disminución de la función del intestino por debajo de lo mínimo necesario para la absorción de los macronutrientes y / o agua y electrolitos, de tal manera que se requiere de la suplementación intravenosa (SIV) para mantener la salud y el crecimiento. Desde el punto de vista funcional se clasifica en tres tipos. FI tipo I: condición aguda, de corto duración y generalmente auto limitada, FI tipo II: estado agudo prolongado, a menudo en pacientes metabólicamente inestables, que requieren cuidado multidisciplinario y SIV durante períodos de una semana o meses, acompañada de complicaciones sépticas, metabólicas y nutricionales y FI tipo III: condición crónica, en pacientes metabólicamente estables, que requieren SIV durante meses o años. Su manejo requiere de terapia nutricional y en casos seleccionados cirugía autóloga de reconstrucción(AU)
Intestinal failure (FI) is defined as the decrease in intestinal function below the minimum necessary for the absorption of macronutrients and / or water and electrolytes, in such a way that intravenous supplementation (IVS) is required to maintain health and growth. From a functional point of view, it is classified into three types. FI type I: acute condition, of short duration and generally self-limited, FI type II: prolonged acute state, often in metabolically unstable patients, requiring multidisciplinary care and SIV for periods of a week or months, accompanied by septic, metabolic and nutrition and FI type III: chronic condition, in metabolically stable patients, who require SIV for months or years. Its management requires nutritional therapy and in selected cases autologous reconstruction surgery(AU)
Assuntos
Síndrome do Intestino Curto/terapia , Enteropatias/complicações , Enteropatias/diagnóstico , Enteropatias/etiologia , Qualidade de Vida , Doença Crônica , Suplementos Nutricionais , Insuficiência Intestinal , Isquemia/complicaçõesRESUMO
A síndrome de Ehlers-Danlos é estabelecida por distúrbios hereditários do tecido conjuntivo que tem como manifestações principais a hipermobilidade articular, a hiperextensibilidade da pele e a fragilidade de tecidos, como articulações, ligamentos, pele, vasos sanguíneos e órgãos internos. São reconhecidos 13 subtipos, de acordo com Classificação Internacional de 2017. Dentre estes, abordamos o hipermóvel, cujo diagnóstico é eminentemente clínico, com manifestações sistêmicas distintas. Esse artigo refere-se ao caso de uma paciente diagnosticada com síndrome de Ehlers-Danlos hipermóvel, tendo como intuito a atualização acerca dos novos critérios diagnósticos, assim como o diagnóstico precoce de tal raropatia.
Ehlers-Danlos syndrome is established through hereditary disorders of connective tissue, and has as its manifestations: joint hypermobility, skin hyperextensibility, and fragility of tissues such as joints, ligaments, skin, blood vessels, and internal organs. Thirteen subtypes have been recognized according to the 2017 International Classification. Among these, the hypermobile type, the diagnosis of which is eminently clinical, with distinct systemic manifestations, will be addressed. This article refers to the case of a patient diagnosed with hypermobile Ehlers-Danlos syndrome, with the objective of updating the new diagnostic criteria, as well as the early diagnosis of such a rare disease.
Assuntos
Humanos , Feminino , Adulto , Doenças Raras/diagnóstico , Síndrome de Ehlers-Danlos/diagnóstico , Instabilidade Articular/diagnóstico , Educação Física e Treinamento , Serviço Hospitalar de Fisioterapia , Ecocardiografia Doppler , Tomografia Computadorizada por Raios X , Terapia Cognitivo-Comportamental , Síndrome de Fadiga Crônica/etiologia , Serviço Hospitalar de Cardiologia , Tolerância ao Exercício/genética , Debilidade Muscular/etiologia , Dilatação Patológica/diagnóstico por imagem , Luxações Articulares/etiologia , Síndrome de Ehlers-Danlos/complicações , Síndrome de Ehlers-Danlos/genética , Síndrome de Ehlers-Danlos/terapia , Osteoartrite da Coluna Vertebral/diagnóstico por imagem , Estrias de Distensão/etiologia , Dor Musculoesquelética/etiologia , Dor Crônica/etiologia , Enteropatias/etiologia , Instabilidade Articular/complicações , Instabilidade Articular/genética , Instabilidade Articular/terapia , Serviço Hospitalar de Anestesia , Insuficiência da Valva Mitral/diagnóstico por imagem , Serviço Hospitalar de Terapia OcupacionalRESUMO
We report the case of a 33 year-old woman who complained of severe dysmenorrhea since menarche. From 2003 to 2009, she underwent 4 laparoscopies for the treatment of pain associated with endometriosis. After all four interventions, the pain recurred despite the use of gonadotropin-releasing hormone (GnRH) analogues and the insertion of a levonorgestrel intrauterine system (LNG-IUS). Finally, a colonoscopy performed in 2010 revealed rectosigmoid stenosis probably due to extrinsic compression. The patient was advised to get pregnant before treating the intestinal lesion. Spontaneous pregnancy occurred soon after LNG-IUS removal in 2011. In the 33rd week of pregnancy, the patient started to feel severe abdominal pain. No fever or sings of pelviperitonitis were present, but as the pain worsened, a cesarean section was performed, with the delivery of a premature healthy male, and an intestinal rupture was identified. Severe peritoneal infection and sepsis ensued. A colostomy was performed, and the patient recovered after eight days in intensive care. Three months later, the colostomy was closed, and a new LNG-IUS was inserted. The patient then came to be treated by our multidisciplinary endometriosis team. The diagnostic evaluation revealed the presence of intestinal lesions with extrinsic compression of the rectum. She then underwent a laparoscopic excision of the endometriotic lesions, including an ovarian endometrioma, adhesiolysis and segmental colectomy in 2014. She is now fully recovered and planning a new pregnancy. A transvaginal ultrasound (TVUS) performed six months after surgery showed signs of pelvic adhesions, but no endometriotic lesions.
Relatamos o caso de uma mulher de 33 anos que apresentava de dismenorreia grave desde a menarca. Entre 2003 e 2009, a paciente foi submetida a quatro laparoscopias para o tratamento de dor associada à endometriose. A dor persistiu apos as 4 cirurgias apesar do uso de análogos do hormônio de liberação de gonadotropina (GnRH) e da inserção de um sistema intrauterino de levonorgestrel (SIU-LNG). Finalmente, uma colonoscopia realizada em 2010 revelou estenose rectosigmoide, provavelmente devido à compressão extrínseca. A paciente foi aconselhada a engravidar antes de tratar a lesão intestinal. A gravidez espontânea ocorreu logo após a remoção de LNG-IUS em 2011. Na 33ª semana de gestação, a paciente começou a sentir dor abdominal intensa, sem febre ou sinais de peritonite. Como a dor piorou consideravelmente, a paciente foi submetida à cesariana com nascimento prematuro de um menino saudável. Durante a cesárea foi identificado rotura intestinal com peritonite grave e sepse. Uma colostomia foi realizada, e a paciente admitida no centro de terapia intensiva por 8 dais. A colostomia foi fechada e um novo SIU-LNG inserido. A paciente passou a ser tratada pela nossa equipe multidisciplinar de endometriose. A avaliação diagnóstica revelou a presença de lesões intestinais com compressão extrínseca do reto. Foi então submetida a uma excisão laparoscópica das lesões endometrióticas, incluindo um endometrioma ovariano, adesiólise e colectomia segmentar em 2014. Ela está agora totalmente recuperada e planeja nova gravidez. Uma ultrassonografia transvaginal (TVUS) realizada seis meses após a cirurgia revelou sinais de aderências pélvicas sem lesões de endometriose.