ABSTRACT
Resumen El dolor torácico es un motivo de consulta muy frecuente en el servicio de urgencias. El abordaje adecuado del paciente en el que se incluye el diligenciamiento de la historia clínica, el examen físico y la toma de paraclínicos iniciales son cruciales para determinar cuáles son los posibles diagnósticos diferenciales. A continuación, presentamos el caso de un paciente de 71 años que ingresa al servicio de urgencias por un dolor retroesternal intenso posterior al consumo de alimentos, en quien, ante la persistencia del dolor, biomarcadores cardíacos negativos y patología aórtica descartada, se realiza una endoscopia que evidencia un hematoma disecante del esófago. En general, el pronóstico es bueno, pero es de gran importancia una buena historia clínica para su sospecha.
Abstract Chest pain is a very common reason for consultation in the emergency department. An adequate approach to the patient, including medical history, physical examination and initial laboratory tests, is crucial for determining possible differential diagnoses. The following is the case of a 71-year-old patient that visited the emergency room due to severe retrosternal pain after food consumption. In view of the persistence of pain and negative cardiac biomarkers, and after ruling out aortic disease, the patient underwent an endoscopy that showed dissecting hematoma of the esophagus. The prognosis is generally favorable, but a thorough medical history is required to suspect it.
Subject(s)
Humans , Male , Aged, 80 and over , Esophagus , Hernia, Hiatal , Pathology , Patients , Surgical Mesh , Eating , Emergencies , EndoscopyABSTRACT
A história natural do hematoma intramural (HI) e da úlcera penetrante (UP) é muito variável, já que podem progredir para a formação de aneurisma, ruptura, dissecção, e podem até mesmo regredir, no caso específico do HI. Exames de imagem têm crescente papel no manejo clínico e operatório da UP e do HI. Ao contrário das projeções semelhantes a úlcera, achados de lagos sanguíneos não são relatados nos estudos tomográficos de pacientes com HI. O entendimento das características da imagem e do curso natural de cada uma dessas entidades ajudará clínicos e cirurgiões a identificar os pacientes com maior risco para um mau prognóstico e pode melhorar os desfechos. A fisiopatologia dessas entidades, as controvérsias no que se refere a suas histórias naturais e os fatores prognósticos das imagens tomográficas são discutidos neste artigo
The natural histories of intramural hematoma (IMH) and penetrating atherosclerotic ulcer (PAU) are highly variable as they may progress to aneurysm formation, rupture, or dissection, or even resolve, in the specific case of IMH. Imaging plays an increasingly important role in clinical and surgical management of IMH and PAU. In contrast to ulcer-like projections, images of intramural blood pools have not been widely reported in CT studies of patients with IMH. Understanding the imaging characteristics and the natural course of each of these entities would help clinicians and surgeons to identify patients at greatest risk for bad prognosis and may improve outcomes. This paper discusses the pathophysiology of these entities, the controversies regarding their natural history, and the prognostic factors that should be identified in CT scans
Subject(s)
Humans , Male , Female , Aged , Aged, 80 and over , Aorta, Thoracic , Ulcer , Hematoma , Prostheses and Implants , Ulcer , Vasa Vasorum , Aged , Tomography/methods , Aortic Aneurysm, Abdominal , Aortic DissectionABSTRACT
The most common presentation of esophageal hematoma is pain, dysphagia and hematemesis. We report two patients with the condition. A 77 years old female presenting with retrosternal pain and odynophagia after ingesting a pig bone. An upper gastrointestinal endoscopy showed a lineal hematoma, protruding to the lumen in the upper portion of the esophagus. The patient was managed with nil per os (NPO) and parenteral hydration and discharged 72 hours later. An 87 years old male presenting with two episodes of hematemesis and weight loss, an upper gastrointestinal endoscopy showed a dissecting hematoma involving the entire esophageal wall. The patient was managed with NPO and hydration and discharged in good conditions 11 days after admission.
El hematoma intramural esofágico es infrecuente, existiendo pocos casos registrados en la literatura. Generalmente se presenta posterior a un trauma, por ejemplo asociado a procedimientos endoscópicos (escleroterapia), o en forma espontánea. La presentación clínica más frecuente es la tríada de dolor torácico, odinofagia/disfagia y/o hematemesis. Generalmente el tratamiento consiste en un manejo expectante con medidas de soporte habitual. Se exponen 2 casos clínicos presentados en nuestro centro durante el año 2009 y se realiza una revisión de la literatura.
Subject(s)
Humans , Male , Female , Aged , Aged, 80 and over , Esophageal Diseases/diagnosis , Esophageal Diseases/therapy , Hematoma/diagnosis , Hematoma/therapy , Esophageal Diseases/complications , Hematemesis/etiology , Deglutition Disorders/etiologyABSTRACT
A ruptura dos vasa vasorum tem sido reconhecida como uma das causas do hematoma intramural da aorta há 90 anos. Esta breve revisão apresenta sistematicamente a fisiologia desses vasos e o seu papel na fisiopatologia das alterações parietais da aorta que ocorrem na hipertensão arterial, na arteriosclerose e na síndrome aórtica aguda. A hipótese defendida aqui é a de que a ruptura dos vasa vasorum ocorre como um fenômeno secundário e não como um dos fatores causais na fisiopatologia do hematoma intramural.
Rupture of vasa varorum has been recognized as one cause of intramural hematoma of the aorta for 90 years. This brief revision presents systematically, the physiology of these vessels and its role in the physiopathology of the alterations in the aortic wall secondary to hypertension, arteriosclerosis and in Acute Aortic Syndrome. The hypothesis is that rupture of vasa vasorum is a secondary phenomenon and not one causal factor in the physiopathology of intramural hematoma.
Subject(s)
Humans , Animals , Aged , Dogs , Aorta/physiopathology , Hypertension , Vasa VasorumABSTRACT
A continuación describimos un caso de una mujer de 78 años anticoagulada que presentó dolor abdominal, náuseas, vómitos y niveles elevados de tiempo de protrombina (INR= 9.07). La ecografía y tomografía abdominal mostraron un engrosamiento de las paredes del intestino delgado dependiente de duodeno y yeyuno. La endoscopía mostró un aspecto equimótico del duodeno y yeyuno. La paciente recibió tratamiento médico conservador logrando que sus síntomas remitan espontáneamente.
We describe a case of 78 year-old woman under anticoagulant therapy who presented abdominal pain, nauseas, vomiting and an elevated prothrombin time levels (INR = 9.03). The ultrasound and abdominal CT showed a thickened small bowel wall mainly involving duodenum and jejunum. The endoscopy showed an ecchymotic aspect of duodenum and jejunum. The patient received conservative medical treatment and her symptoms spontaneously subsided.
Subject(s)
Humans , Female , Aged, 80 and over , Anticoagulants , Hematoma , Intestine, SmallABSTRACT
El hematoma intramural del yeyuno es una complicación poco frecuente en los pacientes anticoagulados y puede llegar a ser un reto diagnóstico para el médico. Su presentación varía desde dolor abdominal leve y obstrucción intestinal hasta perforación de una víscera hueca. El tratamiento es médico y no se requiere intervención quirúrgica, excepto en los casos de perforación. Se presenta el caso de dos pacientes que desarrollaron dicha patología como complicación al uso de warfarina, quienes tuvieron un buen desenlace clínico y fueron tratados en forma médica.
Spontaneous intramural small-bowel hematoma is a rare complication in patients receiving anticoagulation therapy and may represent a diagnostic challenge. Its clinical presentation varies from mild abdominal pain and intestinal obstruction to perforation. Medical treatment is indicated and surgery is required only in cases of perforation. We present the cases of two patients who developed intramural spontaneous small-bowel hematoma as a complication of warfarin therapy and who had a good outcome after medical treatment.
Subject(s)
Abdominal Pain , Hematoma , Intestine, Small , WarfarinABSTRACT
Complications associated with an intramural hematoma of the bowel, is a relatively unusual condition. Most intramural hematomas resolve spontaneously with conservative treatment and the patient prognosis is good. However, if the symptoms are not resolved or the condition persists, surgical intervention may be necessary. Here we describe internal incision and drainage by endoscopy for the treatment of an intramural hematoma of the duodenum. A 63-yr-old woman was admitted to the hospital with hematemesis. The esophagogastroduodenoscopy (EGD) showed active ulcer bleeding at the distal portion of duodenal bulb. A total of 10 mL of 0.2% epinephrine and 2 mL of fibrin glue were injected locally. The patient developed diffuse abdominal pain and projectile vomiting three days after the endoscopic treatment. An abdominal computed tomography revealed a very large hematoma at the lateral duodenal wall, approximately 10X5 cm in diameter. Follow-up EGD was performed showing complete luminal obstruction at the second portion of the duodenum caused by an intramural hematoma. The patient's condition was not improved with conservative treatment. Therefore, 21 days after admission, endoscopic treatment of the hematoma was attempted. Puncture and incision were performed with an electrical needle knife. Two days after the procedure, the patient was tolerating a soft diet without complaints of abdominal pain or vomiting. The hematoma resolved completely on the follow-up studies.