Pie diabético / Diabetic foot

The prevalence of diabetes has increased considerably, constituting a global epidemic today. Many of these patients will develop chronic complications of diabetes, including diabetic foot, which aggravates the patient’s clinical condition, decreases the quality of life and has a great socioeconomic impact. The most important action to reduce the morbidity and mortality associated with this pathology is the prevention of this complication, performing a propermetabolic management and serial control of the patient, educating about self-care of the feet. Once diabetic foot ulcer is present, the cornerstones of treatment are debridement of the wound, management of any infection, revascularization procedures when indicated, and discharge of the ulcer, all of the above in order to avoid amputation. This article intends tomake a review about the epidemiology, pathophysiology, classification, diagnosis, prevention and management of diabetic foot oriented to the primary care doctor.

Síndrome ligamento arcuato medio / Median arcuate ligament syndrome

Background: Median arcuate ligament syndrome (SLAM) is caused by extrinsic compression of the celiac artery by fibrous bands of this ligament and periaortic lymph node tissue. Case report: We report a 59 years old man with a history of weight loss, epigastric pain and a postprandial murmur. The syndrome was diagnosed by CT angiography. The patient was operated, performing a midline laparotomy and releasing the extrinsic compression. An early and sustained remission of symptoms was achieved.

Introducción: El síndrome del ligamento arcuato medio (SLAM), es causado por la compresión extrínseca del tronco celíaco por bandas fibrosas de este ligamento y tejido ganglionar periaórtico. Caso clínico: Reportamos el caso de un hombre de 59 años con historia de baja de peso, dolor postprandial y soplo epigástrico, al cual se le diagnostica SLAM por medio de angioTC. Se realiza abordaje quirúrgico, con laparotomía media y liberación de la compresión extrínseca, logrando remisión de los síntomas de forma inmediata y sostenida. El SLAM es una causa infrecuente de dolor abdominal, requiere estudio por imágenes para su diagnóstico, la resolución quirúrgica constituye su tratamiento.

Disección espontánea de arteria mesentérica superior / Spontaneous dissection of superior mesenteric artery

Introduction: Spontaneous dissection of the superior mesenteric artery (AMS) is a infrecuent pathology, representing the main frequency of isolated peripheral artery dissection, it is more common in males and occurs in the fifth decade of life. Materials and Methods: Retrospective cases analysis of patients with spontaneous dissection of AMS that were handled in our hospital, in last two years. Results: Two patients were diagnosed in this period, both active smoking and hypertensive pathology, appearing with severe abdominal and back pain. The diagnosis was made by CT angiogram of the abdomen and pelvis; establishing medical management of hypertension and standard heparin anticoagulation. Both patients had dissections at new imaging controls and one patient required exploratory laparotomy with bowel resection and intestinal anastomosis. Patients recovered satisfactorily and are in control. Conclusions: Spontaneous dissection of the SMA is a rare disease with uncertain evolution, it may occur in middle age of life, associated with smoking and hypertension. The suspected diagnosis is clinical and can be confirmed by CT angiography. Initial management remains conservative and occasionally is surgical.

Introducción: La Disección espontánea de la arteria mesentérica superior (AMS) es una patología infrecuente, representando la primera frecuencia de disección de arteria periférica aislada, ocurre más en varones en la quinta década de la vida. Material y Método: Casos en los últimos 2 años revisados en forma retrospectiva. Resultados: Dos pacientes fueron diagnosticados en este período, presentándose ambos por dolor abdominal y lumbar de gran intensidad al Servicio de Urgencia del hospital; ambos tabáquicos activos y con hipertensión arterial (HTA). El diagnóstico fue realizado por angioTC de abdomen y pelvis, instaurándose manejo médico de HTA y anticoagulación con heparina estándar. Los 2 pacientes presentaron nuevas disecciones en los controles imagenológicos y un paciente requirió laparotomía exploradora con resección intestinal y anastomosis por isquemia intestinal. Los pacientes evolucionaron satisfactoriamente y se encuentran en control. Conclusiones: La disección espontánea de la AMS es una enfermedad poco frecuente de evolución incierta, que ocurre en la edad media de la vida, asociada a tabaquismo e HTA, la sospecha es clínica y el diagnóstico por imágenes. El manejo inicial sigue siendo médico y ocasionalmente es quirúrgico.

Aneurisma esplénico / Splenic aneurysm

Introduction: The splenic aneurysm (AAE) is a rare disease that occurs mainly in women, being mostly asymptomatic until rupture. Clinical case: We report a case of a woman aged 65, previously healthy, who complains of pain in the left upper quadrant, two-month history, performing a CT of the abdomen showing a 4.7 cm AAE without signs of rupture. Aneurysm resection was performed with splenic preservation with no signs of complication...

Introducción: El aneurisma esplénico (AAE) es una enfermedad poco frecuente, que ocurre principalmente en mujeres, siendo en su mayoría asintomático, hasta su ruptura. Caso clínico: Presentamos el caso de una mujer de 65 años, previamente sana, que consulta por dolor en hipocondrio izquierdo, de dos meses de evolución, realizándose una tomografía de abdomen, que muestra un AAE de 4,7 cm sin signos de ruptura. Se realiza resección de aneurisma con preservación esplénica, sin signos de complicación en el postoperatorio. Aunque presenta infartos esplénicos en el control se mantiene asintomática...

Flegmasia cerulea dolens: reporte de un caso y revisión de la literatura / Flegmasia cerulea dolens: case report and literature review

Phlegmasia Caerulea Dolens is a rare complication of deep vein thrombosis. It presents with a sudden onset of pain, swelling, discoloration and arterial compromise of the affected limb. There’s usually history of prothrombotic events such as malignancy, femoral vein catheterism, antiphospholipid syndrome, recent surgery, pregnancy, etc. Left without treatment, it can evolvein to gangrene, septic shock and death. Diagnosis usually only requires clinical appreciation.Confirmation can be done with ultrasonographic studies with doppler. Treatment can be both medical and surgically based. Medical therapy can be done with heparin and elevation of the affected limb or the use of thrombolytic, whilst surgical therapy can be either venous thrombectomy or amputation. We present the case of a 57-year old smoker, diabetic, and with systemic lupus erythematosus history female patient, that goes to the emergency room with sudden left leg pain, with cyanosis and absence of distal pulses. Besides she presented with lower respiratory symptoms. Diagnosis was confirmed with ultrasound and CT pulmonary angiography was performed showing pulmonary embolism. Medical treatment was initiated with good response.

Fascitis necrosante grave por Serratia marcescens: Reporte de un caso clínico / Fatal necrotizing fasciitis due to Serratia marcescens

Una paciente de 81 años con insuficiencia cardíaca crónica, fibrilación auricular y tratamiento anticoagulante, ingresó por un cuadro fulminante de dolor y celulitis en la extremidad inferior derecha de 24 horas de evolución. Sobre la zona existía una úlcera crónica de cinco meses de evolución, manejada con curaciones locales. Al ingreso, había una placa necrótica pero sin hipotensión o confusión mental. La paciente estaba febril y con taquicardia (126 por min). La evaluación reveló ausencia de leucocitosis, trombosis venosa profunda en la misma pierna e infiltrados radiológicos pulmonares en el lóbulo inferior izquierdo. En las horas siguientes aumentó el dolor, apareció secreción purulenta por la úlcera y la paciente presentó confusión, hipotensión, falla respiratoria y luego shock. La paciente recibió ciprofloxacino endovenoso y clindamicina y fue intervenida a las 15 horas de ingreso, efectuándose una amputación supracondílea. El sondeo cardíaco demostró un gasto bajo (2,3 L/min) y una resistencia vascular sistémica (2888 din.s.cm"5) y presión capilar pulmonar elevada (17 cm H(2)0), cifras compatibles con un shock cardiogénico. Evolucionó en malas condiciones y falleció de falla orgánica múltiple a las 36 horas de ingreso. Los hemocultivos demostraron crecimiento de Serratia marcescens en dos frascos. No se efectuó una necropsia y los cultivos de la secreción de la úlcera fueron negativos.

An 81 year old female patient with chronic heart failure and atrial fibrillation receiving anticoagulant therapy, was admitted with progressive pain on her right leg for the past 24 hours, associated to local erythema, edema and warmth. The lesion evolved at the same site where she presented a chronic ulcer for the previous 5 months managed only with local care. At admission a necrotic plaque on the affected site was perceived; there was no hypotension or mental confusion but signs of a deep venous thrombosis on the involved leg were found. She was febrile (37.8°C) and with tachychardia (126 per minute). Laboratory evaluation revealed normal white blood cell count and a subtherapheutic anticoagulant INR value. A chest x-ray showed infiltrates on the left lower lung lobe. On the following hours the lesion evolved with increasing pain, haemorrhagic bullae and a purulent discharge through the ulcer, with the patient developing mental deterioration, hypotension, respiratory failure and shock. The patient received intravenous ciprofloxacin and clindamycin and was operated 15 hours after admission performing an over-the knee amputation. A cardiac catheterization demonstrated a low cardiac output (2.3 L/min), and both a high systemic vascular resistance (2888 din.s.cm"5) and pulmonary capillary wedge pressure (17 cm H(2)0), results compatible with cardiogenic shock. Evolution was progressively worse and she died of multiple organic failure 36 hours after admission. Two blood culture samples grew Serratia marcescens. No necropsy was performed and cultures taken from the leg remained negative.

Prevalencia de síntomas digestivos en mujeres adultas normales y su asociación a la litiasis biliar / Prevalence ofdigestive symptoms in normal adult women and it association with biliary lithiasis

The aim of this work was to study the prevalence of biliary diseases and digestive symptoms in normal adult women. Four hundred nineteen women were chosen; of these 145 were discarded due to previous gastrointestinal disease (20), previous gastrointestinal complaints (38) and previous cholecystectomy (85). Two hundred seventy six women were subjected to abdominal ultrasound examination; of these, 53 had cholelithiasis and in three a gallbladder cancer was suspected (and confirmed by surgery). Considering women with previous cholecystectomy, cholelithiasis and gallbladder cancer, a 33.6 per cent prevalence of biliary diseases can be inferred. An interrogation about gastrointestinal symptoms was performed to women subjected to ultrasound examinations by 2 professionals unware of ultrasound results. A high frequency of pyrosis, food intolerance and constipation was found, not observing differences between women with or without cholelithiasis. However, these last women had a higher frequency of upper abdominal pain. Both groups had also a high rate of previous surgical procedures