Descripción de un caso de sepsis abdominal por Desulfovibrio desulfuricans / Description of a case of abdominal sepsis due to Desulfovibrio desulfuricans

Resumen Desulfovibrio spp. son bacterias anaerobias estrictas, ubicuas en la naturaleza, quepueden formar parte del tracto gastrointestinal humano o animal, pero también son bacteriasambientales presentes en el suelo y en el agua. Pueden persistir de manera asintomática enel intestino o comportarse como patógenos oportunistas, asociados con bacteriemia primariae infecciones intraabdominales. El número de infecciones por Desulfovibrio spp. puede estarsubestimado debido a su lenta velocidad de crecimiento y a que muchos laboratorios no realizancultivos en anaerobiosis de manera rutinaria. Pruebas sencillas, como el examen de la movilidaden fresco y de la morfología celular en la coloración de Gram, sumadas a la presencia de SH2en agar SIM y a la observación de una fluorescencia roja a pH alcalino bajo luz UV, seríanindicativas de Desulfovibrio spp. Se describe el caso de una bacteriemia por Desulfovibriodesulfuricans en una mujer con cuadro clínico de sepsis abdominal por apendicitis gangrenosacon fallo multiorgánico.

Abstract Desulfovibrio spp. are strict anaerobes that are ubiquitous in nature. They can reside in the human or animal gastrointestinal tract and, as they are also environmental bacteria, may be present in soil and water. They can persist asymptomatically in the intestine or behave as opportunistic pathogens associated with primary bacteremia and intraabdominal infections. Several Desulfovibrio spp. infections may be underestimated due to their slow growth rate and because many laboratories do not routinely perform anaerobic cultures. Simple tests such as motility detection on a fresh subculture, Gram stain to confirm cell morphology, presence of H2S in SIM agar and production of a red fluorescence in alkaline pH under UV light would be indicative of Desulfovibrio spp.

Complication rates in managing hepatic trauma: a cross-sectional study stratifying their outcomes

Background: Liver trauma is the most commonly observed injured organ in abdominal trauma. The objectives of this study was to determine and evaluate the rates of complication in the management of liver traumaMethods: This cross-sectional observational study using non-probability convenient sampling technique was done at surgical unit of Liaquat University of Medical and Health Sciences, Jamshoro, for 06 months. After ethical approval from Institute’s Institutional Review Board (IRB), patients presenting to surgical emergency of the hospital between ages 16 to 60 years having blunt or penetrating liver trauma within 04 hours of incident, either road traffic accident, sustaining a fall, sporting injury, knife or stab wound were include while patients of liver trauma conservatively managed or had severe co-morbid, not fit for anesthesia, with multiple organs lesions (polytrauma) and all hepatic injury patients that were hemo-dynamically stable were excluded. SPSS version 23 was used for data analysis keeping p-value <0.05 as significant.Results: Among 136 patients with mean age 32.33±11.23 years, 120(88.2%) were males. 122(89.7%) of the patients were admitted due to liver trauma of blunt variety while 14(10%) with penetrating liver injury. Overall mean duration of hospital stay was 13.1±4.58 days. 41(30%) patients reported intra-abdominal sepsis, followed by recurrent hemorrhage in 33(24%) of patients while in 22(16%) of patients, biliary leakage was observed. An insignificant difference persisted in either surgical intervention in terms of the complication rates.Conclusions: Higher complication rates were observed in patients with peri-hepatic packing, however outcome of both surgical techniques in terms of complication rates were found to be insignificant. Further studies are needed to shed light upon the findings or this study.

Outcomes of surgical management of liver trauma at LUMHS Jamshoro

Background: Mortality from liver trauma remains high despite surgical advancements. The objective of this study was to determine the outcomes of surgical management of liver trauma at LUMHS Jamshoro.Methods: A cross-sectional observational study using non-probability convenient sampling technique was done at department of surgery LUMHS Jamshoro for 18 months. Patients between 14 to 50 years with blunt hepatic trauma presenting to the E.R. within 04 hours of incident were included and hepatic trauma patients managed conservatively, having multiple trauma and hemo-dynamically stable were excluded. SPSS version 20 was used for data analysis with mean and SD reported for qualitative and frequency and percentages for quantitative variables. Chi-square test was applied keeping p-value of < 0.05 as statistically significant.Results: From 136 patients with mean age of 32.33±1.23 years, 120 (88%) were male. 122 (89.7%) were admitted due to blunt trauma and 14 (10.3%) due to penetrating trauma. Peri-hepatic packing was performed in 116 (85.2%) and suture hepatorrhaphy in 20 (14.8%). Intra-abdominal sepsis was seen in 41 (30%) of patients followed by recurrent hemorrhage in 33 (24%) while 30 (22%) of patients died. Substantial differences (p < 0.001) were observed in terms of surgical technique and each of the complication i.e. sepsis, bile leak and recurrent hemorrhage among alive patientsConclusions: The most common post-operative complication was intra-abdominal sepsis followed by recurrent haemorrhage and bile leak. Significant mortality was observed in between type of complication as well as surgical technique.

Continuous peritoneal lavage with vacuum peritoneostomy: an experimental study

OBJECTIVE: Despite advances in diffuse peritonitis treatment protocols, some cases develop unfavorably. With the advent of vacuum therapy, the use of laparostomy to treat peritonitis has gained traction. Another treatment modality is continuous peritoneal lavage. However, maintaining this technique is difficult and has been associated with controversial results. We propose a new model of continuous peritoneal lavage that takes advantage of the features and benefits of vacuum laparostomy. METHOD: Pigs (Landrace and Large White) under general anesthesia were submitted to laparostomy through which a multiperforated tube was placed along each flank and exteriorized in the left and lower right quadrants. A vacuum dressing was applied, and intermittent negative pressure was maintained. Peritoneal dialysis solution (PDS) was then infused through the tubes for 36 hours. The stability of peritoneostomy with intermittent infusion of fluids, the system resistance to obstruction and leakage, water balance, hemodynamic and biochemical parameters were evaluated. Fluid disposition in the abdominal cavity was analyzed through CT. RESULTS: Even when negative pressure was not applied, the dressing maintained the integrity of the system, and there were no leaks or blockage of the catheters during the procedure. The aspirated volume by vacuum laparostomy was similar to the infused volume (9073.5±1496.35 mL versus 10165±235.73 mL, p=0.25), and there were no major changes in hemodynamic or biochemical analysis. According to CT images, 60 ml/kg PDS was sufficient to occupy all intra-abdominal spaces. CONCLUSION: Continuous peritoneal lavage with negative pressure proved to be technically possible and may be an option in the treatment of diffuse peritonitis.

Estudio de pacientes ingresados por peritonitis en el Centro Nacional de Cirugía de Mínimo Acceso / Study of patients with peritonitis admitted to the National Center for Minimal Access Surgery

Introducción: La peritonitis postoperatoria es una de las complicaciones más frecuentes que se presenta tras procederes laparoscópicos. Objetivo: Caracterizar la evolución de los pacientes complicados con peritonitis después de un proceder laparoscópico. Material y método: Se realizó un estudio observacional descriptivo de los pacientes con peritonitis ingresados en la terapia intensiva, del Centro Nacional de Cirugía de Mínimo Acceso, desde septiembre de 2010 hasta diciembre de 2015. Se analizaron algunas variables demográficas, procederes laparoscópicos que se complicaron con este diagnóstico, complicaciones clínicas, antibioticoterapia utilizada, tipo de nutrición y la escala de evaluación fisiológica APACHE II como predictor de pronóstico. La información se obtuvo de las historias clínicas. Las variables cualitativas se resumieron utilizando frecuencias absolutas y porcentajes. Para las cuantitativas se utilizó la media y la desviación estándar. Resultados: Se complicaron con peritonitis 26 de 298 pacientes ingresados en el período (8,7 ), la edad media fue de 60 años, predominó el sexo femenino (57,7 por ciento). Se complicaron más con este diagnóstico los pacientes perforados postcolonoscopia (50 por ciento). El disbalance hidroelectrolítico (73,1 por ciento) fue la complicación asociada más frecuente. Se usó precozmente la nutrición enteral en 57,7 por ciento y los antibióticos más utilizados fueron ceftriaxone, amikacina y metronidazol. Predominó la evolución favorable a pesar que el score APACHE II se mantuvo en valores elevados. Conclusiones: Las perforaciones intestinales después de una colonoscopía tienen un alto riesgo de sufrir peritonitis secundaria, pero si se realiza un diagnóstico y tratamiento precoz su evolución es favorable(AU)

Introduction: Endoscopic dilatation is the first therapeutic option to eliminate benign esophageal stenosis and improve the symptoms and the quality of life of those patients who suffer from it. Objective:To describe the results of endoscopic dilatation in patients with benign esophageal stenosis treated in the National Center for Endoscopic Surgery from January 2015 to December 2016. Material and Methods:A case series longitudinal observational study was conducted in 59 patients with benign esophageal stenosis. Dilatations were done with Savary-Gilliard bougie and balloons. Results:The mean age was 52,5 years, and the condition predominated in 37 male patients (62,7 percent). Post-surgical, peptic, and caustic were the most frequent etiologies with 25, 14, and 6 cases, respectively. Short stenosis predominated in 51 cases. Bougies were used in 48 patients for a total of 149 dilatations, corresponding to a mean of 3,1 dilatations/ patients. Correction of the stenosis was made in 1-3 sessions in 47 percent of patients; 11 cases were dilated with balloon, corresponding to a mean of 1- 3 dilatations/ patients. Four patients from the group that were dilated with Savary-Gilliard bougies showed refractoriness. A perforation, and two bleedings occurred. After the dilatations, dysphagia improved or disappeared in 93,2 percent of patients. Conclusions:Endoscopic therapy through dilatation of benign esophageal stenosis indicated to be a good alternative method in achieving corrections in a few dilatation sessions, with a low number of complications, and an improvement of the dysphagia(AU)

Etiología aerobia de apendicitis aguda en adultos: Estudio multicéntrico de la sepsis abdominal en Argentina / Aerobic etiology of acute appendicitis in adults. Multicenter study of abdominal sepsis in Argentina

El tratamiento antibiótico de las apendicitis agudas se decide empíricamente basándose en la información epidemiológica. Las resistencias son variables entre regiones y los datos de Argentina son escasos. En el contexto de un estudio multicéntrico, observacional, de infecciones abdominales, se efectuó el análisis de los pacientes adultos con diagnóstico de apendicitis, incorporados al estudio entre enero 2014 y junio 2015, en 16 centros de 5 provincias argentinas. El objetivo fue analizar los gérmenes aeróbicos prevalentes, su resistencia a antibióticos y el patrón de prescripción antimicrobiana. Se estudiaron 131 apendicitis. Se aislaron 184 bacterias aerobias (1.4 bacterias/episodio): Escherichia coli 106 (57.6%), Klebsiella spp 16 (8.7%), Pseudomonas aeruginosa 19 (10.3%), Enterobacter spp. 2 (1%), otros bacilos Gram negativos 5 (2.7%). Enterococcus spp. 16 (8.7%) y otros cocos Gram positivos 20 (10.9%). La resistencia de E. coli y enterobacterias a ampicilina/sulbactam fue mayor a 34% y a ciprofloxacina mayor a 31%. En cambio, la resistencia de enterobacterias a piperacilina/tazobactam fue 4.8%, a ceftriaxona 9.5% y no se halló resistencia a carbapenemes. Respecto a amikacina fue 3.6% y a gentamicina 8.2%. En función de los resultados, el uso de quinolonas o de ampicilina/sulbactam para el tratamiento de las apendicitis debiera ser desaconsejado. Los esquemas basados en aminoglucósidos debieran ser jerarquizados en función de la sensibilidad hallada y su bajo impacto en la inducción de resistencias.

Antibiotic treatment for acute appendicitis is empirically chosen, based on epidemiological information. Resistance rates are different between regions and there are limited data on the situation in Argentina. As a part of a multicenter, observational study of abdominal infections, we performed the analysis of adult patients diagnosed with appendicitis, enrolled in 16 centers of 5 provinces, between Jan/01/2014 and Jun/30/2015. The aim was to analyze the prevalent aerobic pathogens, their resistance rates and the antimicrobial prescription pattern. On a total of 131 appendicitis cases analyzed, we found 184 aerobic pathogens (1.4 bacteria/episode): Escherichia coli 106 (57.6%), Klebsiella spp 16 (8.7%), Pseudomonas aeruginosa 19 (10.3%), Enterobacter spp. 2 (1%), other Gram negative bacilli 5 (2.7%); Enterococcus spp. 16 (8.7%) and other Gram positive cocci 20 (10.9%). The resistance rate of E. coli and enterobacteria to ampicillin/sulbactam was greater than 34% and greater than 31% to ciprofloxacin. However, the resistance of enterobacteria to piperacillin/tazobactam was 4.8%, to ceftriaxone 9.5%, to amikacin 3.6% and 8.2% to gentamicin. No resistance to carbapenems was found. The choice of quinolones or ampicillin/sulbactam for the treatment of appendicitis should be discouraged in our context, due to the high rates of resistance found in this prevalent etiology. Aminoglycoside-based treatments should be considered, given the findings of high antibiotic susceptibility and their low impact on the induction of resistance.

Influencia de la inmunonutrición sobre el estado general, nutricional y estancia hospitalaria en pacientes postoperados de sepsis abdominal / Influence of immunonutrition on the general and nutritional state, and on the in-hospital stay, of patients operated secondary to abdominal sepsis

Objetivo: Valorar el efecto del uso de glutamina con alimentación temprana, en pacientes con sepsis abdominal resuelta quirúrgicamente, sobre el estado general de salud (Apache II), el catabolismo proteico (nitrógeno ureico urinario), las complicaciones y la duración de la estancia hospitalaria. Sede: Hospital General de México. Diseño: Ensayo clínico controlado. Analisis estadístico: Prueba t de Student. Método: Se seleccionaron 24 pacientes con sepsis abdominal que requirieron resolución quirúrgica en la Unidad de Urgencias en el Hospital General de México. Luego de 24 a 72 h del evento quirúrgico, se inició la alimentación enteral en dos grupos: el primero con glutamina más alimentación estándar y el segundo con alimentación estándar. El día 1 y en el 3ro del postoperatorio se midieron niveles de laboratorio y nitrógeno ureico urinario, para determinar la clasificación Apache II, las complicaciones infecciosas y las no infecciosas, el balance nitrogenado y la duración de la estancia hospitalaria. Resultados: No se encontró diferencia significativa en ninguno de los parámetros medidos entre el grupo de glutamina y el control; sin embargo, sí lo hubo en el valor de Apache II en el grupo de glutamina comparando intragrupo entre el primer día y el tercero (P < 0.05). Conclusiones: La alimentación enteral temprana suplementada con glutamina no presenta diferencia temprana en cuanto a la respuesta metabólica al trauma, estado nutricional ni utilización proteica.

Objective: To assess the effect of glutamine, together with early enteral nutrition in patients with surgically resolved abdominal sepsis, on the general health status (Apache II), protein catabolism (urinary urea nitrogen test), complications, and duration of in-hospital stay. Setting: General Hospital of Mexico. Design: Controlled clinical trial. Statistical analysis: Student's t test. Method: We chose 24 patients with abdominal sepsis from the Emergency Ward in the General Hospital of Mexico, who required surgical resolution. After 24 to 72 h of the surgery, enteral nutrition was started in two groups: the first with glutamine plus standard nutrition and the second with standard nutrition. On days 1 and 3 of the postoperative period, laboratory tests were performed and urinary urea nitrogen was measured to determine Apache II classification, infectious and non-infectious complications, the nitrogen balance, and duration of in-hospital stay. Results: No statistically significant difference was found in any of the measured parameters between the two groups (glutamine and control); however, a significant difference was found in the value of the Apache II in the glutamine group when compared intragroup on the first and third days (p < 0.05). Conclusions: Early enteral nutrition supplemented with glutamine does not reveal an early difference in terms of the metabolic response to trauma, nutritional state, or protein utilization.

Effects of low-dose recombinant human growth hormone on acute phase response in patients with abdominal sepsis / 肠外与肠内营养

Objective: To examine the effects of recombinant human growth hormone on the acute phase response in abdominal sepsis patients.Methods: Prospective unblinded trial was made with each patient serving as his/her own control.Eighteen abdominal sepsis patients were enrolled ranging in age from 24 to 60 yrs.All patients received 10 U/d of GH 48 hrs after performing drainage and for 7days.Results: Serum concentration of constitutive proteins,acute phase protein and cytokines were measured before and 1,3,5 and 7 days after GH administration.GH notablely increased serum constitutive protein levels(prealbumin,transferrin,fibronectin) and decreased serum acute phase protein level(CRP).Cytokine TNF-?,IL-1? and IL-6 had significant change after GH administration,but the changes were not relative to the change of acute phase response.Conclusion: Low-dose rhGH effectively modulated the acute phase response by attenuating production of the hepatic acute phase protein and increasing the synthesis of constitutive proteins.

Combined use of early enteral nutrition, growth hormone and fibrin glue improves healing of intestinal anastomosis in intra-abdominal sepsis rats / 肠外与肠内营养

Objective: To investigate the effects of combined use of early enteral nutrition, growth hormone and fibrin glue on early healing of intestinal anastomosis in intra-abdominal sepsis rats. Methods: Male Wistar rats were randomized into 3 groups. In Control group, antimesenteric transverse enterotomy of 4mm was performed, a second laparotomy was subsequently performed after 24 hours, 6cm of the intestine in the middle of the fistula segment was resected. An end-to-end single layer anastomosis was constructed using 8 interrupted 6-0 polypropylene sutures; In EN group, anastomosis was constructed using 4 interrupted sutures and sprayed fibrin glue, enteral nutrition was given on the second postoperative day for 12 days; In EN/GH group, the animals were treated as EN group, and growth hormone(3.0 U/kg/d) was injected subcutaneously every 24 hours for 14 days. The anastomotic bursting pressure and breaking strength, hydroxyproline content and histology were measured as indicators of wound healing. Results: Anastomotic bursting pressure, anastomotic breaking strength and hydroxyproline content in EN+GH group were higher than that in control and EN groups. Conclusions: Combined use of early enteral nutrition , growth hormone and fibrin glue improves early healing of intestinal anastomosis in intra-abdominal sepsis rats.

Healing mechanism of intestinal anastomosis in intra-abdominal sepsis rats / 医学研究生学报

Objective: To investigate the mechanism of intestinal anastomosis in a rat model of intra-abdominal sepsis.Methods:Male Wistar rats were randomized into 2 groups.Control rats underwent intestinal anastomosis.Sepsis group underwent intestinal anastomosis after intestinal fistula operation.fibronectin(FN),?-smooth muscle actin(?-SMA),vascular endorthelial growth factor(VEGF) and apoqtosis in anastomoses were measured.Results:FN,?-SMA,VEGF in control group were higher than sepsis group and apoptosis were lower than the other.Conclusion:It is indicated that the repair of tissue was out of balance after infection,and the organization repair was retarded.The collagenoblast and the epithelial cell migration were slowed down,and the blood capillary regeneration was slowly.Not only the granulation organization was reduced,but also apoptosis was prematurely appeared.

Antibioticoterapia no trauma abdominal penetrante com lesão gastrintestinal: estudo comparativo entre dois esquemas terapêuticos / Antibiotic therapy in penetrating abdominal trauma with gastrointestinal lesion: randomized clinical trial with two therapeutics schemes

OBJETIVO: Comparar a eficácia de dois esquemas terapêuticos de antibióticos em vítimas de trauma penetrante de abdome com lesão gastrintestinal. MÉTODO: O estudo selecionou de forma prospectiva e randomizada, vítimas de trauma abdominal penetrante com lesão gastrintestinal, dividindo-os em dois grupos, conforme o esquema terapêutico: cefoxitina perioperatória exclusivamente (Grupo 1) e associação de gentamicina e metronidazol por cinco dias (Grupo 2). Os grupos foram estratificados em três níveis de acordo com o Abdominal Trauma Index (ATI) e os desfechos analisados foram complicações infecciosas em nível de sitio cirúrgico e não cirúrgico. Escores de trauma e diversas variáveis foram coletadas, como mecanismo e intervalo trauma - tratamento, choque à admissão, volume transfundido, tempo cirúrgico e lesões de cólon. RESULTADOS: Ambos os grupos foram semelhantes e perfeitamente comparáveis, demonstrando não haver diferença na eficácia entre os esquemas antibióticos. CONCLUSÃO: Para vítimas de trauma abdominal penetrante com lesão gastrintestinal, o uso de cefoxitina restrito ao perioperatório é perfeitamente válido.

BACKGROUND: To compare the effectiveness of two antibiotics schemes in victims of penetrating abdominal trauma with gastrointenstinal lesions. METHOD: In this prospective and randomized trial, victims of penetrating abdominal trauma with gastrointestinal lesions were distributed into two groups: peroperative cefoxitin only (Group 1) and five days treatment with gentamicin associated to metronidazol (Group 2). The groups were stratified in three levels, in agreement with the Abdominal Trauma Index (ATI). End points were infectious complications at surgical and non surgical sites. Additional trauma scores and data regarding the mechanism of trauma, treatment interval, incidence of shock at the admission, transfused blood volume, surgical time and trans-operative data were collected. RESULTS: Both groups were similar and perfectly comparable, demonstrating that there was no difference in the effectiveness between the antibiotic schemes. CONCLUSIONS: For victims of penetrating abdominal trauma with gastrointestinal lesions, the use of the restricted peroperative cefoxitin scheme is valid.

Healing mechanism of growth hormone and fibrin glue on intestinal anastomosi in intra-abdominal sepsis rats / 肠外与肠内营养

Objective: To investigate the mechanism of combined growth hormone and fibrin glue on early healing of intestinal anastomosis in intra-abdominal sepsis rats.Methods: Male Wistar rats of abdominal sepsis were randomized into 3 groups.Control rats were given intestinal anastomosis after intestinal fistula operation.Glue group was given intestinal anastomosis and fibrin glue after intestinal fistula.GH group was given intestinal anastomosis and fibrin glue and growth hormone after intestinal fistula.FN,?-SMA,VEGF,and apoptosis in anastomoses were measured.Results: Expression of intestinal FN,?-SMA,and VEGF in GH group were higher than those in other groups and apoptosis were lower than others.Conclusion: It is indicated that combined growth hormone and fibrin glue ameliorates healing of intestinal anastomosis in intra-abdominal sepsis rats.

Enteral fish oil immunonutrition prevents pulmonary dysfunction during intra-abdominal sepsis and hypertension in rats / 肠外与肠内营养

Objective:To investigate whether an enteral fish oil immunonutrition during intra-abdominal sepsis and hypertension dose improve pulmonary function.Methods: We divided 25 rats into three groups.The rats were supplemented by gavage with:(Ⅰ)normal saline as control group(9);(Ⅱ)fish oil(0.3%,8) and(III)fish oil(0.6%,8).The cytokine levels were analyzed.The lungs were harvested,stained with hematoxylin-eosin,and analyzed. Results:Intra-abdominal sepsis and hypertension induced thickening of alveolar walls and inflammatory reaction.Fish oil decreased expression of pro-inflammatory cytokines(TNF-? and IL-1?),inhibitted infiltration of MPO positive cells,and protected pulmonary structure.Conclusion: The lung may be protected by an enteral fish oil nutrition through attenuating inflammatory reaction.

Fish oil ameliorates the intra-abdominal sepsis and hypertension-induced ileus / 肠外与肠内营养

Objective:To investigate whether the fish oil improves intestinal motility function during intra-abdominal sepsis and hypertension.Methods: 25 rats were divided into three groups.The rats were supplemented by gavage with: ①normal saline as control group(n=9);②fish oil(0.3%,n=8)and ③fish oil(0.6%,n=8)for 4 weeks before operation.The rats were killed on the 24th hour after operation.In vitro ileual smooth muscle contractions were recorded.Ileum sections were assessed pathologically.Immunopositivity of c-kit as markers of ICC-MY by confocal microscopy were evaluated.Results: In the bowel segment with NS,muscles showed a significant reduction in the frequency of contraction compared to that with FO.This change was associated with the changes of ICC-MY network.Conclusion:The intestinal motility may be protected by an enteral fish oil nutrition through attenuating injury of ICC-MY network.