Abdominal and pelvic actinomycosis due to longstanding intrauterine device: a slow and devastating infection

Actinomycosis is a chronic or subacute bacterial infection characterized by large abscess formation, caused mainly by the gram-positive non-acid-fast, anaerobic, or microaerophilic/capnophilic, obligate parasites bacteria from the genus. Although pelvic inflammatory disease is an entity associated with the longstanding use of intrauterine devices (IUDs), actinomycosis is not one of the most frequent infections associated with IUDs. We present the case of a 43-year-old female patient who was referred to the emergency facility because of a 20-day history of abdominal pain with signs of peritoneal irritation. Imaging exams revealed collections confined to the pelvis, plus the presence of an IUD and evidence of sepsis, which was consistent with diffuse peritonitis. An exploratory laparotomy was undertaken, and a ruptured left tubal abscess was found along with peritonitis, and a huge amount of purulent secretion in the pelvis and abdominal cavity. Extensive lavage of the cavities with saline, a left salpingo-oophorectomy, and drainage of the cavities were performed. The histopathological examination of the surgical specimen revealed an acute salpingitis with abscesses containing sulfur granules. Therefore, the diagnosis of abdominal and pelvic actinomycosis was made. The postoperative outcome was troublesome and complicated with a colocutaneous fistula, which drained through the surgical wound. A second surgical approach was needed, requiring another extensive lavage and drainage of the recto-uterine pouch, plus the performance of a colostomy. Broad-spectrum antibiotics added to ampicillin were the first antimicrobial regimen followed by 4 weeks of amoxicillin during the outpatient follow-up. The patient satisfactorily recovered and is already scheduled for the intestinal transit reconstitution.

Neoplasias duodenais primárias: análise de casuística e conduta cirúrgica / Primary duodenal tumors: clinicopathologic experience and surgical treatment

São apresentados 18 casos de neoplasias primárias do duodeno, salientando-se sua raridade e as dificuldades diagnósticas, a despeito dos modernos recursos endoscópicos e de identificação por imagem. A literatura revela que de 1% a 10% de todos os tumores do aparelho digestório se situam no intestino delgado. A localização duodenal é, por isso, muito pouco freqüente, possui sintomatologia indefinida e implica conduta terapêutica mais complexa do que quando o tumor se situa em outros segmentos do intestino delgado. Os sintomas mais comuns são dor, náusea, vômito e hemorragia. A presente casuística consiste de 11 neoplasias malignase sete benignas. Entre as primeiras o adenocarcinoma é o mais freqüente, sendo os lipomas os mais comuns dosneoplasmas benignos. Enquanto nestes a exérese local representa a conduta mais adequada, a duodenopancreatectomiacefálica foi a cirurgia de escolha nos tumores malignos da segunda porção duodenal, exibindo bons resultados. As lesões malignas da terceira porção e principalmente da quarta porção do duodeno foram tratadas pela ressecção duodenojejunal, também com resultados satisfatórios.

Eighteen primary duodenal tumors, including 11 malignant and 8 benign, are presented, stressing their poorly defined natural history and rare frequency. The most common histological diagnosis was adenocarcinoma. There were 6 adenocarcinomas, 2 carcinoids, 1 linfoma, 1 anaplastic and 1 neuroectodermic carcinoma. Benign lesions were occasionally found during a gastroduodenal or a biliary surgery (n = 4) and during the autopsies (n = 3). They consisted of lipomas (n = 4), adenomatous polyps (n = 2) and leiomyoma (n = 1). Concerning the malignant lesions, 6 pancreaticoduodenectomies, 3 duodenojejunal segmentary resection and one paliation consisting of gastrojejunostomy and biopsy were performed. One carcinoid lesion was found at the duodenal bulb during a gastroduodenectomy for a gastric ulcer. Pancreaticoduodenectomy can be done with acceptable risk and it seems that patients with duodenal adenocarcinoma are more likely to survive longer after radical surgery than those with cancer of the head of pancreas. Every patient of this series treated by pancreaticoduodenectomy or duodenojejunal segmentary resection had an uneventful recovery and the follow-up ranged from 16 months to 7 years. As for the duodenal carcinoids, local resection is usually followed by recurrence, so an agressive surgical management is the best approach. Benign tumors must be treated by local excision when disclosed.

Coledocofibroscopia percutânea no tratamento da litiase residual dos ductos biliares / Percutaneous choledochofiberoscopy as treatment of retained common bile duct stones

Os autores relatam quatro casos de pacientes portadores de litiase residual do hepatocoledoco, nos quais foi utilizada com sucesso a coledocofibroscopia percutanea atraves do trajeto do dreno de Kehr, como alternativa terapeutica