Diverticulitis aguda del intestino delgado como causa infrecuente de abdomen agudo en el adulto mayor: Reporte de caso / Acute diverticulitis of small bowel as rare cause of acute abdomen inthe elderly: Case report

Introducción. El dolor abdominal es uno de los principales motivos de admisión a urgencias y una de las causas más frecuentes es la enfermedad diverticular, que aumenta su prevalencia en el adulto mayor. Sin embargo, la diverticulitis del intestino delgado es una enfermedad infrecuente y en la mayoría de casos es asintomática. No obstante, la perforación de un divertículo intestinal es una complicación común de esta patología, por lo que debe ser considerado como un diagnóstico diferencial de abdomen agudo en este grupo poblacional. Caso clínico. Paciente masculino de 71 años, quien consultó por dolor abdominal de inicio súbito, con signos de irritación peritoneal al examen físico. Dado su deterioro hemodinámico fue llevado a cirugía y en la laparotomía exploratoria se halló una diverticulitis aguda perforada de yeyuno e íleon distal. Resultados. El paciente cursó con una adecuada evolución postoperatoria, sin reingresos. Conclusión. La diverticulitis aguda yeyuno-ileal es una causa importante, pero no frecuente de perforación intestinal. Hay muy pocos casos reportados en la literatura, lo que la convierte en un reto diagnóstico para el médico de urgencias y el cirujano general. No obstante, debe ser considerado como un diagnóstico diferencial en adultos mayores con abdomen agudo.

Introduction. Abdominal pain is one of the main reasons for admission to the emergency room and one of the most frequent causes is diverticular disease, which increases its prevalence in the elderly. However, diverticulitis of the small bowel is rare and in most cases asymptomatic. However, perforation of an intestinal diverticulum is a common complication of this pathology and should be considered as a differential diagnosis of acute abdomen in this population group. Clinical case. A71-year-old male patient presented with abdominal pain of sudden onset, with signs of peritoneal irritation. Given his hemodynamic deterioration, he was taken to surgery and in the exploratory laparotomy an acute perforated diverticulitis of the jejunum and distal ileum was found. Results. The patient had an adequate postoperative evolution, without readmissions. Conclusion. Acute jejuno-ileal diverticulitis is an important but uncommon cause of intestinal perforation. There are very few cases reported in the literature, which makes it a diagnostic challenge for the emergency physician and general surgeon. However, it should be considered as a differential diagnosis in older adults with acute abdomen.

Neumatosis quística intestinal, un reto diagnóstico: reporte de caso / Cystic intestinal pneumatosis, a diagnostic challenge: case report

Introducción. La neumatosis quística intestinal se describe como la presencia de gas dentro de la pared intestinal. Es una entidad poco frecuente, con una incidencia del 0,03 % en la población global. Aparece con predilección en el género masculino después de los 45 años yse localiza principalmente en el intestino delgado (42 %) y el colon. Se puede asociar a varias condiciones que en ocasiones requieren manejo quirúrgico. Caso clínico. Se presenta el caso de un hombre 75 años, con antecedente de hipertensión arterial, quien consultó por un cuadro de 15 días de evolución consistente en distensión abdominal, dolor y estreñimiento. En urgencias se solicitó una radiografía de tórax que mostró neumoperitoneo y varios niveles hidroaéreos, por lo que el cirujano de turno consideró una posible ruptura de víscera hueca. Resultados. Fue llevado a laparotomía exploratoria, donde se identificó neumatosis quística intestinal y estómago muy aumentado de tamaño, compatible con gastroparesia. Como resultado del tratamiento brindado, el paciente tuvo un desenlace satisfactorio logrando alta médica, apoyado con cuidados básicos de enfermería. Conclusiones. Si bien los casos de neumatosis quística intestinal son de presentación inusual, se puede encontrar en pacientes con hallazgos imagenológicos de neumoperitoneo. Por eso, se debe realizar un análisis concienzudo de cada paciente e individualizar el caso para el correcto diagnóstico.

Introduction. Cystic pneumatosis intestinalis is described as the presence of gas within the intestinal wall. It is a rare entity, with an incidence of 0.03% in the global population. It appears with a predilection in the male gender after 45 years of age and is located mainly in the small intestine (42%) and the colon. It can be associated with several conditions that sometimes require surgical management. Clinical case. The case of a 75-year-old man with a history of high blood pressure is presented, who consulted for a 15-day history consisting of abdominal distention, pain and constipation. In the emergency room, a chest x-ray was requested, which showed pneumoperitoneum and several air-fluid levels. The surgeon on call considered a possible rupture of the hollow viscus. Results. The patient was taken to exploratory laparotomy, where intestinal cystic pneumatosis and a greatly enlarged stomach were identified, compatible with gastroparesis. As a result of the treatment provided, the patient had a satisfactory outcome, achieving medical discharge, supported with basic nursing care. Conclusions. Although cases of intestinal cystic pneumatosis have an unusual presentation, it can be found in patients with imaging findings of pneumoperitoneum. Therefore, a thorough analysis of each patient must be carried out and the case individualized for the correct diagnosis.

Novedades en la evaluación y tratamiento de la obstrucción intestinal alta

La obstrucción intestinal mecánica es un problema quirúrgico significativo en términos de prevalencia, morbimortalidad y costos económicos asociados. En los últimos años se han realizado avances en: detectar mecanismos fisiopatológicos del desarrollo de adherencias, optimizar el diagnóstico de pacientes aptos para manejo conservador, valorar la utilidad intraoperatoria de herramientas que definan la necesidad de resección intestinal y hallar terapias preventivas. El objetivo de esta revisión narrativa es sintetizar la evidencia científica actualizada, publicada referente al diagnóstico y tratamiento de una obstrucción intestinal alta mecánica.

Mechanical small bowel obstruction is a significant surgical problem in terms of prevalence, morbimortality, and associated economic costs. In recent years, advances have been made in: detection of physio pathological mechanisms of adhesion genesis, improvement in diagnosis of patients suitable for conservative treatment, assessment the efficacy of intraoperative tools that define the need for intestinal resection, and development of preventive therapies. The objective of this narrative review is to synthesize the updated scientific evidence published, regarding the diagnosis and treatment of mechanical small bowel obstruction.

Hemorragia digestiva por intususcepción de un lipoma ulcerado en yeyuno / Gastrointestinal bleeding due to ulcerated intussuscepted jejunal lipoma

RESUMEN Los lipomas yeyunales son tumores gastrointestinales benignos e infrecuentes, de origen mesenquimático, compuestos por adipocitos que suelen estar confinados a la submucosa. Generalmente son asintomáticos y se descubren de manera incidental al realizar estudios por imágenes o endoscópicos. Sin embargo, aquellos mayores de 2 cm pueden presentar síntomas como resultado de complicaciones, como intususcepción intestinal, obstrucción o rara vez, hemorragias. Presentamos un caso infrecuente de intususcepción de un lipoma yeyunal ulcerado en un adulto, diagnosticado en el contexto de un cuadro de hemorragia digestiva.

ABSTRACT Jejunal lipomas are rare benign mesenchymal tumors made up of adipocytes confined to the submucosa layer. They are usually asymptomatic and are incidentally found during imaging or endoscopic tests. Those measuring > 2 cm may become symptomatic as a result of complications as intestinal intussusception, obstruction and bleeding. We herein report a rare case of intussusception of an ulcerated jejunal lipoma in an adult patient, that was diagnosticated in the setting of an intestinal hemorrhage.

Tumor glómico de intestino delgado / Glomus tumor of the small bowel

RESUMEN Los tumores glómicos (TG) son neoplasias vasculares benignas de tejidos blandos en zonas acrales periféricas. La mayoría de los TG intraabdominales se producen en el estómago; su presentación intestinal es de muy baja incidencia. Se presenta el caso de una mujer de 26 años, que consultó por dolor abdominal crónico de baja intensidad en región umbilical sin otra signo sintomatología. Se completó su estudio imagenológico y se detectó una lesión abdominopélvica heterogénea con componente sólido vascularizado, y líquido con proyecciones papilares. El informe de la patología de la pieza quirúrgica arrojó el diagnóstico de TG de intestino delgado. Se realizó una consulta que demuestra su baja incidencia: afecta a personas entre 26 y 88 años de ambos sexos en igual proporción, sin una distribución geográfica predominante. Los TG deben considerarse como un raro diagnóstico diferencial ante tumores del intestino delgado (ID).

ABSTRACT Glomus tumors (GTs) are benign vascular neoplasms of soft tissues that occur in peripheral acral areas. Most intra-abdominal GTs develop in the stomach; the incidence of intestinal presentation is very low, We report the case of a 26-year-old female patient with chronic mild pain in the umbilical region with no other symptoms or signs. The imaging tests demonstrated a heterogeneous abdominopelvic mass with a solid vascularized component, and a cystic component with papillary projections. The pathology examination of the surgical specimen reported the diagnosis of GT of the small bowel (SB). We conducted a review of the literature and found their low incidence, affecting both men and women between 26 and 88 years without a predominant geographic distribution. Glomus tumors should be considered as a rare differential diagnosis in the presence of small SB tumors.

Consenso colombiano de Falla Intestinal Crónica en Síndrome de Intestino Corto / Colombian Consensus on Chronic Intestinal Failure in Short Bowel Syndrome

Introducción. Los términos falla intestinal crónica, síndrome de intestino corto (SIC) y nutrición parenteral total son muy frecuentes en la práctica clínica cotidiana.El objetivo de esta guía fue establecer un marco de referencia de práctica clínica basado en el mejor de nivel de evidencia en pacientes con falla intestinal crónica secundaria a síndrome de intestino corto. Métodos. Se estableció un grupo de expertos interdisciplinarios en el manejo de la falla intestinal crónica quienes, previa revisión de la literatura escogida, se reunieron de manera virtual acogiendo el método Delphi para discutir una serie de preguntas seleccionadas, enfocadas en el contexto terapéutico de la falla intestinal crónica asociada al síndrome de intestino corto. Resultados. La recomendación del grupo de expertos colombianos es que se aconseje a los pacientes con SIC consumir dietas regulares de alimentos integrales que genere hiperfagia para compensar la malabsorción. Las necesidades proteicas y energéticas dependen de las características individuales de cada paciente; la adecuación del régimen debe ser evaluada a través de pruebas clínicas, antropométricas y parámetros bioquímicos. Se sugiere, especialmente a corto plazo después de la resección intestinal, el uso de análogos de somatostatina para pacientes con yeyunostomía de alto gasto en quienes el manejo de líquidos y electrolitos es problemático. En pacientes con SIC, que son candidatos a tratamiento con enterohormonas, Teduglutida es la primera opción. Conclusión. Existen recomendaciones en el manejo integral de la rehabilitación intestinal respaldadas ampliamente por este consenso y es importante el reconocimiento de alternativas terapéuticos enmarcadas en el principio de buenas prácticas clínicas.

Introduction. The terms chronic intestinal failure, short bowel syndrome (SBS), and total parenteral nutrition are very common in daily clinical practice. The objective of this guideline was to establish a reference framework for clinical practice based on the best level of evidence in patients with chronic intestinal failure secondary to short bowel syndrome. Methods. A group of interdisciplinary experts in the management of chronic intestinal failure was established who, after reviewing the selected literature, met virtually using the Delphi method to discuss a series of selected questions, focused on the therapeutic context of chronic intestinal failure associated with short bowel syndrome. Results. The recommendation of the Colombian expert group is that patients with SBS be advised to consume regular diets of whole foods that generate hyperphagia to compensate malabsorption. Protein and energy needs depend on the individual characteristics of each patient; the adequacy of the regimen must be evaluated through clinical, anthropometric tests and biochemical parameters. The use of somatostatin analogue is suggested, especially in the short term after bowel resection, for patients with high-output jejunostomy in whom fluid and electrolyte management is problematic. In SBS, who are candidates for enterohormonal therapy, Teduglutide is the first choice. Conclusion. There are recommendations on the comprehensive management of intestinal rehabilitation that are widely supported by this consensus and it is important to recognize therapeutic alternatives framed in the principle of good clinical practice.

Neumoperitoneo secundario a neumatosis intestinal masiva: un reporte de caso / Pneumoperitoneum secondary to massive intestinal pneumatosis: a case report

Introducción. La neumatosis intestinal se define como la presencia de quistes aéreos en la pared del tracto digestivo, a nivel submucoso o subseroso, que comprometen principalmente el intestino delgado. Las manifestaciones clínicas son inespecíficas y los hallazgos imagenológicos son fundamentales en el enfoque diagnóstico. El manejo puede ser médico o quirúrgico, dependiendo del compromiso intestinal y las complicaciones asociadas. Caso clínico. Hombre de 78 años, que ingresó por cuadro de dolor abdominal crónico, con hallazgos imagenológicos de neumoperitoneo. Al ser llevado a intervención quirúrgica se encontró neumatosis intestinal masiva del íleon, requiriendo resección intestinal. Resultado. El paciente presentó una evolución postoperatoria satisfactoria y fue dado de alta, sin complicaciones. Conclusión. La neumatosis intestinal es una enfermedad poco frecuente, que se presenta principalmente en hombres. La sospecha diagnóstica se confirma con imágenes tomográficas. Los pacientes candidatos para el manejo médico deben presentar causas con curso benigno, sin compromiso hemodinámico ni complicaciones. El manejo quirúrgico se reserva para pacientes con abdomen agudo o signos de sepsis.

Introduction. Intestinal pneumatosis is defined as the presence of air cysts in the wall of the digestive tract at the submucosal or subserosal level, mainly compromising the small intestine. The clinical manifestations of the disease are nonspecific, and the imaging findings are essential in the diagnostic approach. Management can be conservative and/or surgical depending on the intestinal compromise and associated complications. Clinical case. The following is the case of a 78-year-old man, who was admitted due to chronic abdominal pain with imaging findings of pneumoperitoneum. Patient underwent surgery and a massive ileum pneumatosis was found, requiring intestinal resection. Results. The patient ́s postoperative course was uneventful, and he was discharged without further complications. Conclusions. Intestinal pneumatosis is an uncommon disease, which mostly affect men population. Clinical suspicion of this condition should be confirmed with abdominal tomography. Candidates for medical management are those with benign course pathologies without hemodynamic compromise and/or complications. Surgical management should be reserved for patients with acute abdomen or sepsis.

Congenital Paraduodenal Hernia: A Case Report

Paraduodenal hernia is a rare congenital anomaly that arises from an alteration in the midgut rotation during embryogenesis. Consequently, the small intestine becomes trapped in a sac of the posterior mesentery of the colon. This entity can compromise the intestinal segment's viability and the patient's life. Its diagnosis is difficult, rarely suspected, and often confused with other causes of abdominal pain. We present the case of a 29-year-old male patient with a documented paraduodenal hernia during surgery, its correction, and follow-up, in which no complications were reported.

La hernia paraduodenal es una anomalía congénita poco frecuente que surge de una alteración en la rotación del intestino medio durante la embriogénesis. En consecuencia, el intestino delgado queda atrapado en un saco del mesenterio colónico posterior. Dicha entidad puede comprometer la viabilidad del segmento intestinal y la vida del paciente. Su diagnóstico es difícil, pocas veces sospechado y muchas veces confundido con otras causas de dolor abdominal. Presentamos el caso de un paciente de 29 años con una hernia paraduodenal documentada durante la cirugía, su corrección y seguimiento, en el cual no se documentaron complicaciones.

Melanoma metastásico en intestino delgado: causa infrecuente de perforación: reporte de caso / Metastatic melanoma in the small intestine: infrequent cause of perforation: case report / Melanoma metastático em intestino delgado: causa rara de perfuração: relato de caso

El intestino delgado es el sitio de asiento más frecuente del melanoma metastásico. Su diagnóstico es un desafío por cursar asintomático o con síntomas inespecíficos. Son pocos los casos que presentan complicaciones, siendo infrecuente la peritonitis por perforación. El objetivo del trabajo es comunicar el caso clínico de una peritonitis por perforación de una metástasis de melanoma en intestino delgado. Caso clínico: Paciente de sexo masculino de 66 años con diagnóstico de melanoma de cuello y secundario óseo, encefálico y pulmonar, fue intervenido de urgencia por peritonitis aguda por perforación de metástasis en intestino delgado. El estudio histológico confirmó secundarismo de melanoma cutáneo. Conclusión: Sabiendo que el yeyuno íleon es el sitio de asiento más frecuente de las metástasis de melanoma, ante la presencia de síntomas digestivos inespecíficos o anemia se debe sospechar su compromiso y evaluar posibles alternativas terapéuticas.

The small intestine is the most frequent site of metastatic melanoma. However, its diagnosis continues to be a challenge since it is usually asymptomatic or with non-specific symptoms. Few cases result in complications, peritonitis due to perforation being infrequent. The objective of the work is to report a clinical case of peritonitis due to perforation of a melanoma metastasis in the small intestine. Clinical case: A 66-year-old male patient diagnosed with melanoma of the neck and secondary bone, brain and lung melanoma, underwent emergency surgery for acute peritonitis due to perforation of metastasis in the small intestine, which was resected and anastomosed. The histology confirmed the secondary nature of the cutaneous melanoma. Conclusion: Knowing that the jejunum-ileum is the most frequent site of melanoma metastases, in the presence of non-specific digestive symptoms or anemia, its involvement should be suspected and possible therapeutic alternatives should be evaluated.

O intestino delgado é o local mais frequente de melanoma metastático. O diagnóstico é um desafio por ser assintomático ou apresentar sintomas inespecíficos. Há poucos casos que apresentam complicações, sendo pouco frequente a peritonite por perfuração. O objetivo deste trabalho é relatar um caso clínico de peritonite por perfuração de metástase de melanoma no intestino delgado. Caso clínico: Paciente do sexo masculino, 66 anos, diagnosticado com melanoma no pescoço com metástase óssea, cefálica e pulmonar. Foi submetido a cirurgia de emergência por peritonite aguda por perfuração de metástases do intestino delgado. O estudo histológico confirmou melanoma cutâneo. Conclusão: Sabendo que o jejuno e o íleo é o local mais frequente de metástase de melanoma, na presença de sintomas digestivos inespecíficos ou anemia deve-se suspeitar de seu acometimento e avaliar possíveis alternativas terapêuticas.

Morphological investigation of protective effects of CDP-choline on liver and small intestine in an experimental sepsis model in rats / Investigación morfológica de los efectos protectores de la CDP-colina en el hígado y el intestino delgado en un modelo experimental de sepsis en ratas

SUMMARY: Fifty male Wistar albino rats were divided into 5 groups; Group 1 as a sham group. Group 2 as a control group, Group 3 as 100 mg/kg CDP-choline administered group, Group as 200 mg/kg CDP-choline administered group, and Group 5 as sepsis group. The sepsis model was performed by ligating and perforating the caecum of rats. Liver and small intestine tissues were assessed either histologically or quantitatively and qualitatively. There was a significant difference between the sepsis and CDP-choline groups for liver and intestinal damage evaluated in tissue samples. (p <0.001). CDP-choline treatment partially improved dose-dependent the clinical parameters of sepsis and septic shock, reversed micro-anatomical damage caused by sepsis.

Cincuenta ratas albinas Wistar macho se dividieron en 5 grupos; Grupo 1 como grupo control simulador, el grupo 2 como grupo de control, el grupo 3 como grupo al que se administró 100 mg/kg de CDP-colina, el grupo 4 como grupo al que se administró 200 mg/kg de CDP-colina y el grupo 5 como grupo con sepsis. El modelo de sepsis se realizó ligando y perforando el intestino ciego de las ratas. Los tejidos del hígado y del intestino delgado se evaluaron histológicamente o cuantitativa y cualitativamente. Hubo una diferencia significativa entre los grupos de sepsis y CDP-colina para el daño hepático e intestinal evaluado en muestras de tejido (p<0,001). El tratamiento con CDP-colina mejoró parcialmente, según la dosis, los parámetros clínicos de sepsis y shock séptico y revirtió el daño micro anatómico causado por la sepsis.

Vasculitis intestinal y hallazgos en la videocápsula endoscópica: reporte de caso y revisión de la literatura / Intestinal Vasculitis and Endoscopic Video Capsule Findings: Case Report and Literature Review

Resumen Las vasculitis sistémicas pueden llegar a afectar los vasos sanguíneos de todos los tamaños, provocando necrosis e inflamación. La granulomatosis con poliangitis (GPA) es una vasculitis de vasos pequeños y medianos. Las presentaciones clínicas pueden ser locales o difusas en el tracto gastrointestinal. Presentamos el caso de un paciente con diagnóstico de vasculitis sistémica asociada a anticuerpos anticitoplasma (ANCA) mieloperoxidasa (MPO) (poliangitis microscópica) confirmada con biopsia renal, con clínica de 15 días consistente en astenia, adinamia, oliguria subjetiva, edema de miembros superiores e inferiores, hiporexia y melenas. En el examen físico, el tacto rectal fue positivo para melenas, posteriormente presentó anemización secundaria a melenas, por lo que se realizó videocápsula endoscópica en la que se evidenciaron hallazgos compatibles con vasculitis entérica. Durante su estancia presentó compromiso multisistémico dado por la afectación renal, pulmonar, neurológica y gastrointestinal, manejada en la unidad de cuidados intensivos (UCI), donde se iniciaron pulsos de esteroide sistémico y hemodiálisis. Conclusión: la vasculitis gastrointestinal es una complicación rara; sin embargo, ocurre y causa una grave amenaza para la vida de los pacientes. El diagnóstico diferencial debe cubrir otras enfermedades inflamatorias, especialmente la enfermedad de Crohn. Su adecuado reconocimiento influencia de forma significativa el pronóstico, pues el inicio rápido de la terapia con esteroides puede cambiar el curso de la enfermedad.

Abstract Systemic vasculitis can affect blood vessels of all sizes, causing necrosis and inflammation. Granulomatosis with polyangiitis (GPA) is a vasculitis of small and medium blood vessels. Clinical manifestations may be local or diffuse in the gastrointestinal tract. We present a patient's case with systemic vasculitis associated with anti-cytoplasmic antibodies (ANCA), myeloperoxidase (MPO) antibodies (microscopic polyangiitis) confirmed through renal biopsy, presenting a 15-day clinical picture consisting of asthenia, adynamia, subjective oliguria, edema of the upper and lower limbs, hyporexia, and melena. The digital rectal examination was positive for melena in the physical examination, later presenting melena with secondary anemization. An endoscopic video capsule was performed, showing findings compatible with enteric vasculitis. During his stay, he presented multisystemic involvement due to renal, pulmonary, neurological, and gastrointestinal involvement, managed in the intensive care unit (ICU), where systemic steroid pulses and hemodialysis started. Conclusion: although gastrointestinal vasculitis is a rare complication, it occurs and threats patients' lives. Differential diagnosis should cover other inflammatory diseases, especially Crohn's disease. Gastrointestinal vasculitis early diagnosis significantly influences prognosis, as prompt steroid therapy can change the course of the disease.

Diverticulosis de intestino delgado, hallazgo intraoperatorio / Diverticulosis of the small bowell, intraoperative finding / Diverticulose do intestino delgado, achado intraoperatório

La diverticulosis puede presentarse en cualquier sector del tubo digestivo. La topografía de intestino delgado es infrecuente, se presenta sobre todo a nivel del yeyuno y en un 35% de los casos se asocia con diverticulosis colónica. Es más frecuente en mayores de 40 años. Los divertículos van disminuyendo de tamaño y número hacia el sector distal. Habitualmente el diagnóstico es incidental, sin embargo, pueden presentar complicaciones de las cuales se destacan por frecuencia el sangrado gastrointestinal y la diverticulitis. Se plantea que la deficiencia de fibra dietética generaría anomalías en el peristaltismo intestinal, lo que junto con fenómenos pseudo-obstructivos y alta presión intraluminal, actuaría en áreas de debilidad focal provocando la lesión. Presentamos el caso de una paciente de 88 años con una oclusión de colon a la cual se le realizó una cirugía de Hartmann, en el intraoperatorio se identificó divertículos de yeyuno sin elementos complicaciones.

Fibromatosis mesentérica solitaria. Reporte de caso y revisión de la literatura / Sporadic mesenteric fibromatosis. A case report. Literature review / Fibromatose mesentérica solitária. Relato de caso. Revisão da literatura

Resumen: La fibromatosis mesentérica es un subtipo profundo de tumor desmoide (TD), un tumor benigno de origen fibroblástico localmente agresivo por su tendencia a infiltrar los tejidos adyacentes. Son raros, esporádicos y pueden asociarse con el síndrome de Gardner. El tratamiento de elección es la resección completa, evitando la recurrencia local. Comunicamos el caso clínico de una paciente con fibromatosis intrabdominal mesentérica única, bien circunscripta, que simulaba por la imagenología una masa de origen pelviano.

Summary: Mesenteric fibromatosis is a deep sub-type of desmoid tumors consisting of a benign tumor of fibroblastic origin which is locally aggressive given its tendency to infiltrate adjacent tissues. They are unusual and sporadic, and may be associated to Gardner's Syndrome. Complete resection is the treatment of choice, avoiding local recurrence. The study reports the clinical case of a patient with intra-abdominal sporadic mesenteric fibromatosis, well circumscribed that appeared to be a pelvic mass in MR imaging.

Resumo: A fibromatose mesentérica é um subtipo profundo de tumor desmóide (DT); é um tumor benigno de origem fibroblástica que é localmente agressivo devido à sua tendência a infiltrar tecidos adjacentes. São raros, esporádicos e podem estar associados à síndrome de Gardner. O tratamento de escolha é a ressecção completa, evitando recidiva local. Relatamos o caso clínico de uma paciente com fibromatose mesentérica intra-abdominal única e bem circunscrita que simulava uma massa de origem pélvica na imagem.

Experience in the Use of Video Capsule Endoscopy in Patients with Unexplained Iron Deficiency Anemia / Experiencia con el uso de la videocápsula endoscópica en pacientes con anemia ferropénica inexplicada

Abstract Introduction: The prevalence of iron deficiency anemia in developed countries has been estimated between 2-5 %, associated with high morbidity and mortality. Etiological identification is sometimes difficult and requires diagnostic methods, such as video capsule endoscopy (VCE). Aim: This study intends to characterize the findings of this technique in patients with unexplained iron deficiency anemia. Materials and methods: Descriptive observational retrospective study. We describe the VCE findings (PillCamSB2-SB3) in all patients seen between 2011 and 2019. The findings were interpreted according to the Saurin classification: normal (P0), uncertain potential (P1), and high bleeding potential (P2). Results: Of the 490 VCEs performed during the study period, 155 indicated iron deficiency anemia; 106 were women (68.4 %), and the mean age was 57.1 ± 16.6 years. The main comorbidities were cardiovascular in 23 (18.3 %) and arterial hypertension in 16 (12.6 %). Antiplatelets were present in 18 (15.4 %) and anticoagulants in six (5.1 %). Small bowel lesions were vascular in 44 studies (28.4 %), inflammatory in 33 (21.2 %), and neoplastic in seven (4.5 %). Angiectasias were the most frequent lesions in 33 cases (21.3 %). P2 lesions were present in 53 VCEs (34.2 %). Conclusions: VCE is helpful in the study of iron deficiency anemia and helps detect positive findings in the midgut in three out of four patients for which it is indicated. The most frequent significant P2 lesions were vascular. These findings allow providing adequate treatment.

Resumen Introducción: la prevalencia de la anemia ferropénica en países desarrollados se ha estimado entre 2 %-5 %, asociada con una alta morbimortalidad. La identificación etiológica a veces es difícil, y requiere de métodos diagnósticos, como la videocápsula endoscópica (VCE). Objetivo: el objeto del presente estudio fue caracterizar los hallazgos de esta técnica en pacientes con anemia ferropénica inexplicada. Materiales y métodos: estudio descriptivo, observacional y retrospectivo. Se describen los hallazgos de VCE (PillCamSB2-SB3) en todos los pacientes atendidos entre 2011 y 2019. Los hallazgos se interpretaron según la clasificación de Saurin: normal (P0), potencial incierto (P1) y alto potencial de sangrado (P2). Resultados: del total de 490 VCE realizadas durante el período del estudio, 155 se efectuaron con indicación de anemia ferropénica; 106 fueron mujeres (68,4 %) y la edad media fue de 57,1 ± 16,6 años. Las comorbilidades principales fueron cardiovasculares en 23 (18,3 %) e hipertensión arterial en 16 (12,6 %). La ingesta de antiplaquetarios se presentó en 18 (15,4 %) y anticoagulantes en 6 (5,1 %). Las lesiones en el intestino delgado fueron vasculares en 44 estudios (28,4 %), inflamatorias en 33 (21,2 %) y neoplásicas en 7 (4,5 %). Las angiectasias fueron las lesiones más frecuentes en 33 casos (21,3 %). En 53 VCE se presentaron lesiones P2 (34,2 %). Conclusiones: la VCE es útil en el estudio de la anemia ferropénica, y ayuda a detectar hallazgos positivos en el intestino medio en 3 de cada 4 pacientes en los cuales se indica su uso. Las lesiones P2 significativas más frecuentes fueron las vasculares. Estos hallazgos permiten enfocar un tratamiento adecuado.

Síndrome de Wilkie / Managment of a Patient with a Diagnosis of Wilkie Syndrome

Introducción: El síndrome de Wilkie es una causa infrecuente de obstrucción intestinal alta, debido a una compresión del duodeno entre la aorta abdominal y la arteria mesentérica superior, de diagnóstico preoperatorio difícil. El estudio baritado y la arteriografía son las pruebas diagnósticas por excelencia. Se ha invocado un manejo conservador en individuos con poco tiempo de evolución. Sin embargo, aquellos con enfermedad crónica habitualmente requieren corrección por medio de la intervención quirúrgica. Objetivo: Exponer el tratamiento de un paciente con diagnóstico de síndrome de Wilkie. Caso clínico: Masculino de 57 años con síndrome emético y pérdida ponderal más de 3 meses de evolución. La gastroduodenoscopia mostró dilatación de la segunda porción duodenal por probable comprensión extrínseca y la serie contrastada reveló stop a nivel de la unión duodenoyeyunal. Se realizó una duodenoyeyunostomía latero-lateral transmesocólica, sin drenaje de vecindad con evolución favorable. Conclusiones: Un alto índice de sospecha se requiere para un diagnóstico acertado de esta entidad. La duodenoyeyunostomía es el proceder quirúrgico que ofrece mejores resultados(AU)

Introduction: Wilkie syndrome is a rare cause for upper intestinal obstruction, due to a compression of the duodenum between the abdominal aorta and the superior mesenteric artery, of difficult preoperative diagnosis. Barium study and arteriography are the gold-standard diagnostics. Conservative management has been preferred in individuals with short time of evolution. However, those with chronic disease usually require correction by surgical intervention. Objective: To present the management of a patient diagnosed with Wilkie syndrome. Case report: A 57-year-old male patient with emetic syndrome and weight loss of more than three months of evolution. Gastroduodenoscopy showed dilatation of the second duodenal portion due to probable extrinsic compression, while the contrast series revealed stop at the duodenojejunal junction. A transmesocolic latero-lateral duodenojejunostomy was performed, without neighboring drainage and with favorable evolution. Conclusions: A high index of suspicion is required for an accurate diagnosis of this entity. Duodenojejunostomy is the surgical procedure that offers the best outcomes(AU)

O intestino delgado é amplamente afetado na doença de Behçet: um acompanhamento de longo prazo dos sintomas gastrointestinais / Small bowel is largely affected in behçet's disease: a long-term follow-up of gastrointestinal symptoms

ABSTRACT Background Behçet's disease is a rare immune-mediated disorder that can affect the gastrointestinal tract. The prevalence and extension of small bowel involvement is largely unknown. Objective The aim of this study was to describe the small bowel lesions diagnosed by double-balloon enteroscopy (DBE) and to verify if these findings were associated to the presence of gastrointestinal symptoms and disease activity after long-term follow-up. Methods This study included 19 Behçet's disease patients who underwent DBE. After a mean follow-up of 15 years the endoscopic findings were associated to the presence of gastrointestinal symptoms, disease activity and current therapy through collection of electronic medical records. Results A total of 63.2% patients were female and the mean age was 37 years at the time of DBE. Mean disease duration at baseline was 24 years. 11 patients had no gastrointestinal symptoms and eight patients presented either abdominal pain, gastrointestinal bleeding or diarrhea. The average procedure time was 1 hour and 30 minutes and the ileum was achieved in all patients but one. Small bowel ulcers were diagnosed in 78.9%, with 63.1% of jejunal involvement. Two patients presented only small bowel edema and two were normal by DBE. Eight patients had concomitant gastric ulcers. Gastrointestinal symptoms prior to DBE were present in 36.8% of the patients and, after follow-up, all of them persisted with some of the symptoms. Bleeding was reported by three patients at baseline and persisted in only one patient. The frequency of treatment with steroids and immunomodulators was 31.6% and 57.9% at baseline, respectively, and 21% in both at the end of the follow-up. No patient was treated with biologics at the time of the DBE procedure and the current rate of biologic use is 21%. Conclusion Small bowel involvement in Behçet's disease was frequently demonstrated by DBE even in asymptomatic patients. Understanding clinical evolution of the disease over the years and the impact of such diagnosis still represents a challenge, possibly with the need for novel treatment.

RESUMO Contexto A doença de Behçet é uma doença imunomediada rara que pode afetar o trato gastrointestinal. A prevalência e extensão do envolvimento do intestino delgado é desconhecida. Objetivo O objetivo deste estudo foi descrever as lesões do intestino delgado diagnosticadas por enteroscopia de duplo balão (EDB) e verificar se esses achados estavam associados à presença de sintomas gastrointestinais e atividade da doença após seguimento de longo prazo. Métodos Este estudo incluiu 19 pacientes com doença de Behçet que foram submetidos a EDB. Após seguimento médio de 15 anos, os achados endoscópicos foram associados à presença de sintomas gastrointestinais, atividade da doença e terapia atual por meio de coleta de prontuário eletrônico. Resultados Um total de 63,2% dos pacientes eram do sexo feminino e a média de idade era de 37 anos no momento da EDB. A duração média da doença no início do estudo foi de 24 anos. 11 pacientes não apresentaram sintomas gastrointestinais e oito pacientes apresentaram dor abdominal, sangramento gastrointestinal ou diarréia. O tempo médio do procedimento foi de 1 hora e 30 minutos e o íleo foi atingido em todos os pacientes, exceto em um. Úlceras de intestino delgado foram diagnosticadas em 78,9%, sendo 63,1% de acometimento jejunal. Dois pacientes apresentaram apenas edema de intestino delgado e dois apresentaram EDB normais. Oito pacientes tinham úlceras gástricas concomitantes. Sintomas gastrointestinais prévios à EDB estavam presentes em 36,8% dos pacientes e, após o seguimento, todos persistiram com alguns dos sintomas. Sangramento foi relatado por três pacientes no início do estudo e persistiu em apenas um paciente. A frequência de tratamento com esteroides e imunomoduladores foi de 31,6% e 57,9% no início do estudo, respectivamente, e 21% em ambos ao final do seguimento. Nenhum paciente foi tratado com biológicos no momento da EDB e a taxa atual de uso de biológicos é de 21%. Conclusão O envolvimento do intestino delgado na doença de Behçet foi frequentemente demonstrado por EDB mesmo em pacientes assintomáticos. Compreender a evolução clínica da doença ao longo dos anos e o impacto de tal diagnóstico ainda representa um desafio, possivelmente com a necessidade de novos tratamentos.

Cuando la ileítis de Crohn no es solo ileítis / When Crohn's ileitis is not just ileitis

RESUMEN En una minoría de pacientes con ileítis de Crohn (EC) de larga evolución, la recrudescencia de los síntomas puede representar una neoplasia ileal, con una clínica indistinguible de la enfermedad basal y por ende poco sospechada. Frecuentemente la patología tumoral se diagnostica en la pieza quirúrgica, tras una intervención por hemorragia u obstrucción intestinal. El objetivo de este trabajo es destacar la importancia de un diagnóstico diferencial ante una ileítis terminal en un paciente con EC con mala respuesta a tratamiento médico.

ABSTRACT In a minority of patients with long-standing Crohn's ileitis, the recrudescence of symptoms may represent a neoplasm involving the ileum that is clinically indistinguishable from the baseline disease and therefore poorly suspected. Tumors are often diagnosed in the surgical specimen, after an intervention due to bleeding or bowel obstruction. The aim of this study is to emphasize the importance of the differential diagnoses of terminal ileitis in a patient with CD with poor response to medical treatment.

Risk factors for reoperation, morbidity, and mortality in patients with small bowel obstruction submitted to surgical treatment / Fatores de risco para reoperação e morbimortalidade em pacientes com obstrução de intestino delgado submetidos a tratamento cirúrgico

ABSTRACT - BACKGROUND: Small bowel obstruction (SBO) is a frequent cause of emergency department admissions. AIM: This study aimed to determine risk factors of reoperations, postoperative adverse event, and operative mortality (OM) in patients surgically treated for SBO. METHODS: This is a retrospective study conducted between 2014 and 2017. Exclusion criteria include gastric outlet obstruction, large bowel obstruction, and incomplete clinical record. STATA version 14 was used for statistical analysis, with p-value <0.05 with 95% confidence interval considered statistically significant. RESULTS: A total of 218 patients were included, in which 61.9% were women. Notably, 88.5% of patients had previous abdominal surgery. Intestinal resection was needed in 28.4% of patients. Postoperative adverse event was present in 28.4%, reoperation was needed in 9.2% of cases, and a 90-day surgical mortality was 5.9%. Multivariate analysis determined that intestinal resection, >3 days in intensive care unit (ICU), >7 days with nasogastric tube (NGT), pain after postoperative day 3, POAE, and surgical POAE were the risk factors for reoperations, while age, C-reactive protein, intestinal resection, >3 days in ICU, and >7 days with NGT were the risk factors for POAE. OM was determined by >5 days with NGT and POAE. CONCLUSIONS: Postoperative course is determined mainly for patient's age, preoperative level of C-reactive protein, necessity of intestinal resection, clinical postoperative variables, and the presence of POAE.

RESUMO - RACIONAL: A obstrução do intestino delgado (OID) é uma causa frequente de admissões ao Serviço de Emergência. OBJETIVO: Determinar os fatores de risco de reoperações, eventos adversos pós-operatórios e mortalidade operatória (MO) em pacientes com OID tratados cirurgicamente. MÉTODOS: Estudo retrospectivo entre 2014 e 2017. Critérios de exclusão: obstrução da saída do estômago, obstrução do intestino grosso e história clínica incompleta. O STATA 14 foi utilizado para análise estatística, considerando significância estatística p<0,05 com IC de 95%. RESULTADOS: Duzentos e dezoito pacientes foram incluídos, 61,9% mulheres, 88,5% dos pacientes tinham cirurgia abdominal anterior. A ressecção intestinal foi necessária em 28,4% dos pacientes. O evento adverso pós-operatório (EAPO) esteve presente em 28,4%, a reoperação foi necessária em 9,2% dos casos e a mortalidade cirúrgica em 90 dias foi de 5,9%. A análise multivariada determinou que a ressecção intestinal, > 3 dias em UTI, > 7 dias com sonda nasogástrica (SNG), dor após o 3º dia de pós-operatório, EAPO cirúrgico foram fatores de risco para reoperações, enquanto idade, proteína C reativa, ressecção intestinal, > 3 dias em UTI, > 7 dias com SNG foram fatores de risco para EAPO. A MO foi determinada em > 5 dias com SNG e EAPO. CONCLUSÕES: A evolução pós-operatória é determinada principalmente pela idade do paciente, nível pré-operatório de proteína C reativa, necessidade de ressecção intestinal, variáveis clínicas pós-operatórias e presença de EAPO.

The intestinal microbiome in patients undergoing bariatric surgery: a systematic review / O microbioma intestinal nos pacientes submetidos a cirurgia bariátrica. revisão sistemática

ABSTRACT BACKGROUND: Dysbiosis of the gut microbiota is frequently found in cases of obesity and related metabolic diseases, such as type 2 diabetes mellitus. The composition of the microbiota in diabetics is similar to that of obese people, thereby causing increased energy uptake efficiency in the large intestine of obese people, maintenance of a systemic inflammatory state, and increased insulin resistance. Bariatric surgery seems to entail an improvement in gut dysbiosis, leading to an increased diversity of the gut microbiota. AIMS: This study aimed to present a literature review on obesity-associated gut dysbiosis and its status post-bariatric surgery. METHODS: A systematic review of primary studies was conducted in PubMed, SciELO, BIREME, LILACS, Embase, ScienceDirect, and Scopus databases using DeCS (Health Science Descriptors) with the terms "obesity," "intestinal dysbiosis," "bariatric surgery," and "microbiota." RESULTS: We analyzed 28 articles that had clinical studies or literature reviews as their main characteristics, of which 82% (n=23) corresponded to retrospective studies. The sample size of the studies ranged from 9 to 257 participants and/or fecal samples. The epidemiological profile showed a higher prevalence of obesity in females, ranging from 24.4 to 35.1%, with a mean age of around 25-40 years. There was a variation regarding the type of bariatric surgery, migrating between the Roux-en-Y bypass, adjustable gastric banding, and vertical gastrectomy. Of the 28 studies, 6 of them evaluated the gut microbiota of obese patients undergoing bariatric surgery and their relationship with type 2 diabetes mellitus/glucose metabolism/insulin resistance. CONCLUSIONS: The intestinal microbiota is an important influencer in the regulation of the digestive tract, and obese individuals with comorbidities (diabetes mellitus, hypercholesterolemia, and metabolic syndrome) present important alterations, with an unbalance normal state, generating dysbiosis and the proliferation of bacterial species that favor the appearance of new diseases. Patients who undergo bariatric surgery present an improvement in the intestinal microbiota imbalance as well as reversibility of their comorbidities, increasing their life expectancy.

RESUMO RACIONAL: A disbiose da microbiota intestinal é encontrada frequentemente em casos de obesidade e doenças metabólicas relacionadas, como a diabetes mellitus tipo 2. A composição da microbiota em diabéticos é semelhante à de obesos, causando um aumento da eficiência de captação de energia no intestino grosso de obesos, manutenção de um estado inflamatório sistêmico e maior resistência à insulina. A cirurgia bariátrica parece acarretar em uma melhora da disbiose intestinal, levando ao aumento de diversidade da microbiota intestinal. OBJETIVOS: Este artigo apresenta uma revisão de literatura sobre a disbiose intestinal associada a obesidade e seu status pós cirurgia bariátrica. MÉTODOS: Uma revisão sistemática de estudos primários foi realizada em bases de dados PubMed, SciELO, BIREME, LILACS, Embase, ScienceDirect e Scopus utilizando o Descritores em Ciência da Saúde (DeCS) com os termos: "obesidade", "disbiose intestinal", "cirurgia bariátrica" e "microbiota". RESULTADOS: Foram analisados 28 artigos que tinham como característica principal serem estudos clínicos ou revisões de literatura, dos quais 82%, n=23, correspondem a estudos retrospectivos. O tamanho das amostras dos estudos variou de 9 a 257 participantes e/ou amostras fecais. O perfil epidemiológico mostrou haver maior prevalência de obesidade no sexo feminino, variação de 24,4 a 35,1%, com idade média em torno dos 25 a 40 anos. Houve uma variação com relação ao tipo de cirurgia bariátrica, migrando entre a Bypass em Y-de-Roux, Banda gástrica ajustável e gastrectomia vertical. Dos 28 estudos, 6 deles avaliaram a microbiota intestinal de obesos submetidos à cirurgia bariátrica e sua relação com diabetes mellitus tipo 2/metabolismo da glicose/resistência insulínica. CONCLUSÕES: A microbiota intestinal é um importante influenciador na regulação do aparelho digestivo, e que indivíduos obesos com comorbidades (diabetes mellitus, hipercolesterolemia e síndrome metabólica) apresentam alterações importantes, com desequilíbrio do seu estado normal, gerando disbiose e a proliferação de espécies bacterianas que favorecem o aparecimento de novas doenças. Pacientes submetidos a cirurgia bariátrica apresentam melhora do desequilíbrio da microbiota intestinal, bem como uma reversibilidade de suas comorbidades, elevando a expectativa de vida.