Sigmoid gallstone ileus: a challenging diagnosis

Gallstone ileus is a rare (1%­4%) complication of gallstone disease. Gallstones entering the gastrointestinal tract by penetration may cause obstruction at any point along their course through the tract; however, they have a predilection to obstruct the smaller-caliber lumen of the small intestine (80.1%) or stomach (14.2%). The condition is seen more commonly in the elderly who often have significant co-morbidities. Gallstone ileus causing large bowel obstruction is rare. We report the case of a 95-year-old woman who presented with a history of abdominal pain without fever, nausea, vomiting, or diarrhea. Computed tomography of the abdomen and pelvis with oral contrast revealed a high-density structure within the lumen of the distal sigmoid colon, initially suspected to be a foreign body. Medical management failed and surgical intervention was not possible. Autopsy revealed peritonitis and a rupture of the sigmoid colon at the site of a cylindrical stone found impacted in an area of fibrotic narrowing with multiple diverticula. A necrotic, thick-walled gallbladder had an irregular stone in its lumen that was a fracture match with the stone in the sigmoid. Adhesions, but no discrete fistula, were identified between the gallbladder and the adjacent transverse colon. The immediate cause of death was peritonitis caused by colonic perforation by the gallstone impacted at an area of diverticular narrowing. To our knowledge, such autopsy findings have not been previously reported.

Idosos em situação de rua ou vulnerabilidade social: facilidades e dificuldades no uso de ferramentas computacionais / Elderlies in street situation or social vulnerability: facilities and difficulties in the use of computational tools / Ancianos en situación de calle o vulnerabilidad social: facilidades y dificultades en el uso de herramientas computacionales

Este estudo teve por objetivo identificar as facilidades e dificuldades encontradas por idosos em situação de rua ou vulnerabilidade social, no uso do computador ou internet. É uma pesquisa qualitativa do tipo exploratório, de que participaram cinco idosos assistidos em uma Organização não Governamental situada na cidade de São Paulo. Os discursos foram analisados pela Técnica de Análise de Conteúdo e evidenciaram como facilidades, dentre outras, esclarecer dúvidas com os monitores, o estímulo para novas descobertas aliada a proatividade e curiosidade, desenvolvimento de novas habilidades. As dificuldades estavam relacionadas a questões físicas ou cognitivas, à falta de instrutor e de conhecimento para interagir com a máquina. Os estudos voltados para a população idosa em situação de rua ou vulnerabilidade social podem contribuir com evidências que direcionem a formulação de políticas públicas voltadas para essa parcela da população.

This study aimed to identify the advantages and difficulties encountered by older people living on the streets or social vulnerability, to use the computer or internet. It is an exploratory qualitative research, in which five elderlies, attended on a non-governmental organization located in the city of São Paulo, have participated. The discourses were analyzed by content analysis technique and showed, as facilities, among others, to clarify doubts with the monitors, the stimulus for new discoveries coupled with proactivity and curiosity, and develop new skills. The mentioned difficulties were related to physical or cognitive issues, lack of instructor, and lack of knowledge to interact with the machine. The studies focusing on the elderly population living on the streets or in social vulnerability may contribute with evidence to guide the formulation of public policies to this population.

Este estudio tuvo como objetivo identificar las facilidades y dificultades encontradas por las personas mayores en situación de calle o vulnerabilidad social, en el uso de computadores o internet. Se trata de una investigación cualitativa exploratoria, a la que asistieron cinco personas mayores, asistidos en una Organización no Gubernamental ubicada en la ciudad de São Paulo. Los discursos fueron analizados por la técnica de análisis de contenido y evidencian como facilidades, entre otras cosas, aclarar dudas con los monitores, el estímulo para nuevas descubiertas asociadas a la pro actividad y curiosidad y al desarrollo de nuevas habilidades. Las dificultades se relacionaban con cuestiones físicas o cognitivas, a la falta de instructor y falta de conocimiento para interactuar con la máquina. Los estudios direccionados para la población anciana en situación de calle o vulnerabilidad social pueden contribuir con evidencias que direccionen la formulación de políticas públicas en beneficio de esa parcela de la población.

Pancreatic panniculitis: a rare complication of pancreatitis secondary to ERCP

Panniculitis is an uncommon and rare complication of systemic fat necrosis in patients with pancreatic diseases. The skin manifestations are independent of the severity of the pancreatic pathology and can occur at any time. The lesions can preceed, be concomitant with or rarely follows the pancreatic illness. We report a case of acute pancreatitis post Endoscopic Retrograde Cholangio Pancreatography [ERCP] for common bile duct stone, with subcutaneous panniculitis. We noted a complete resolution within two weeks after the treatment of the pancreatic pathology

Prevalence of Helicobacter spp in chronic cholecystitis and correlation with changes on the histological pattern of the gallbladder / Prevalência do Helicobacter spp na colecistite crônica calculosa e correlação com as alterações histológicas da vesícula biliar

PURPOSE: Establish the prevalence of Helicobacter spp in chronic cholecystitis and its correlation with the gallbladder's histological findings. METHODS: 100 patients were operated for chronic cholecystitis with cholecystolithiasis. In pathological examination of the gallbladder, were evaluated the presence of metaplasia, dysplasia, lymphoid follicles, anaplasia and tumors that might be related to the presence of Helicobacter plus the presence of the bacilli Giemsa by optical microscopy. From the DNA extracted from the gallbladder's bile, PCR was performed by using specific primers for the identification of Helicobacter spp with amplification of the 400bp segment of rRNA gene16S, with positive control DNA from Helicobacter pylori. All the cases negative for isolation of genetic material were excluded. The cases of PCR and Giemsa were used as negative control group. The histological findings were compared to the presence of bacilli and PCR data using a chi-square and Fisher's Exact test (CI = 95.0 percent, p <0.05). RESULTS: Of 68 patients, 42 (61.8 percent) were PCR for Helicobacter spp and 19 (27.9 percent) had Giemsa. There was no correlation between the two findings. The PCR for Helicobacter spp was not correlated to the histological findings. The presence of lymphoid follicles and metaplasia was related to the Giemsa (p = 0.025 and p= 0.039). CONCLUSION: There is high prevalence of Helicobacter spp in patients with chronic cholecystitis and cholecystolithiasis without be correlated with the histological patterns studied.

OBJETIVO: Estabelecer a prevalência do Helicobacter spp nos doentes com colecistopatia crônica calculosa e correlacioná-la com as alterações histológicas da vesícula biliar. MÉTODOS: Foram operados 100 doentes portadores de colecistite crônica calculosa. No anátomo-patológico foram avaliadas a presença de, metaplasias, displasias, folículos linfóides, anaplasias e tumores que pudessem se relacionar à presença do helicobacter e a presença de bacilos Giemsa à microscopia. A partir do DNA extraído da bile foi realizada PCR utilizando-se primers específicos para identificação de Helicobacter spp com amplificação de segmento de 400bp do gene16S rRNA, com controle positivo de DNA de Helicobacter Pylori. Os casos negativos para isolamento de material genético na bile foram excluídos. Os casos de PCR e Giemsa negativos foram utilizados como grupo controle. Os achados histológicos foram comparados ao Giemsa e à PCR utilizando-se Teste do Qui-Quadrado e Exato de Fisher (IC=95,0 por cento; p<0,05). RESULTADOS: De 68 doentes, 42(61,8 por cento) apresentaram PCR para Helicobacter spp e 19(27,9 por cento) Giemsa. Não houve correlação entre os dois achados. Não houve correlação entre alterações histológicas e a PCR (p=0,378). A presença de folículos linfóides e metaplasia estiveram relacionadas ao Giemsa (p=0,025 e 0,039). CONCLUSÃO: Há prevalência elevada de Helicobacter spp nos doentes com colecistite crônica calculosa sem haver correlação com os achados histológicos estudados.

Exploración laparoscópica de la vía biliar y manejo actual de la coledocolitiasis: análisis de los primeros 30 casos / Laparoscopic common bile duct exploration and current management of choledocholithiasis

Se trata de un estudio descriptivo, prospectivo, longitudinal que incluyó a 30 pacientes que consultaron con indicaciones de exploración laparoscópica de la vía biliar. Se describe la técnica utilizada para la exploración transcística y por coledocotomía, tanto con guía fluoroscópica como el uso del coledocoscopio. Se estudiaron las variables, efectividad, conversión, tiempo quirúrgico, complicaciones tiempo de hospitalización, litiasis residual. La exploración laparoscópica de la vía biliar fue efectiva en el 84% de los casos. Las causas de conversión fueron cálculos enclavados y cálculos intrahepáticos. El 32% de los casos se resolvió por la vía transcística , mientras que el resto (68%) se resolvió mediante coledocotomía. La morbilidad asociada la técnica fue de 6,6% dada por diarrea postoperatoria y biliperitoneo luego del retiro del tubo en “t”. El tiempo promedio de hospitalización fue de 3,5 días. Sin casos reportados de litiasis residual. La exploración laparoscópica de la vía biliar (ELVB) es una alternativa terapéutica segura y efectiva en el tratamiento de la obstrucción de la vía biliar principal por cálculos. Sin embargo, queda claro que el éxito del procedimiento depende del dominio de técnicas endoscópicas y laparoscópicas avanzadas y la disponibilidad de recursos tecnológicos de primera.

Report the experience in laparoscopic common bile duct exploration in the Surgery Department III of the Hospital Universitario de Caracas. Descriptive, prospective, longitudinal study of patients admitted with indication of laparoscopic common bile duct exploration. We describe the transcystic approach and choledochotomy technique, using fluoroscopic guidance or choledochoscope. Success rate, conversion, operative time, complications, length of stay and residual lithiasis were studied. Laparoscopic common bile exploration was successful in 84% of the patients. Conversión causes were embedded stones and intrahepatic lithiasis. Transcystic approach was used in 32% of the cases and choledochotomy was performed in 68% of the patients. Morbidity rate was 6,6% due to diarrhea and biliary peritonitis after "t" tube removal. Median length of stay was 3,5 days. No cases of residual stones were reported. Laparoscopic common bile duct exploration is a safe and effective procedure in patients with common bile duct obstruction due to choledocholithiasis However, the success rate is in relation with endoscopic and advanced laparoscopic techniques mastery and technologic resources availability.

Colecistectomía por Laparoscopia en pacientes asistidos en el Hospital Militar Cap. (Av) Guillermo Hernández Jacobsen Enero 2005-Junio 2007 / Laparoscopic cholecystectomy in patients assisted at the Hospital Militar Cap. (Av) Guillermo Hernández Jacobsen january 2005-june 2007

La laparoscopía es un método importante en la cirugía. Presentamos la experiencia en pacientes con Colecistitis asistidos en nuestro hospital, mediante técnica laparoscópica. Durante enero-2005 a junio-2007 retrospectivamente analizamos hallazgos y tiempo quirúrgico, estancia hospitalaria, complicaciones postoperatorias y tiempo de seguimiento. De 156 pacientes, 140 presentaron litiasis, no en casos restantes. Predominó el sexo femenino. La edad media fue de 39,5 años (rango 19-78). 107 casos debutaron como abdomen agudo, 26 con dolor crónico y 22 de forma casual. La laparoscopia es una técnica válida para manejar La colecistitis. Este abordaje trata la patología de manera reglada.

Is conventional sphincterotomy possible in patients with common bile duct stones impacted at the ampulla of Vater?

BACKGROUND: Needle knife precut papillotomy has been used to gain access or remove impacted common bile duct stones at the ampulla of Vater. However, precut papillotomy is a risky procedure with high complication rates and is presumably best dealt with by the expert. We attempted to find out the feasibility of performing conventional endoscopic sphincterotomy in patients with impacted stones at the ampulla. METHODS: All patients undergoing endoscopic retrograde cholangiopancreatography for stones impacted at the ampulla between the years 2000 and 2005 were enrolled in the study. All attempts were made to achieve biliary cannulation through the conventional route including use of the long route or guidewire to cannulate the papilla. Needle knife papillotomy was resorted to only if attempts to cannulate the papilla through the conventional route failed. The success and complications of the procedures were recorded. RESULTS: Thirty-two patients were enrolled. The impacted bile duct stone could be removed in all the patients. Conventional endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy were performed in 23 patients with impacted stones. The long route had to be employed in seven patients while guidewire cannulation of the papilla was needed in four patients. Needle knife papillotomy was needed in only nine patients. None of the patients in whom the conventional route was employed developed complications, whereas bleed requiring endoscopic management was observed in three (33%) of the nine patients in whom needle knife papillotomy was performed. CONCLUSIONS: Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy can be performed by the conventional route in the majority of patients with impacted stones at the ampulla. This approach appears to be safer than needle knife papillotomy. However, needle knife papillotomy may be required in patients in whom biliary access cannot be gained through the conventional approach.

T-tube access for endoscopic sphincterotomy: a variant of combined percutaneous and endoscopic approach.

Selective deep cannulation of the common bile duct (CBD), which is essential for successful endoscopic sphincterotomy, may not be possible in all patients. Three patients with retained CBD stones with T-tube in situ in whom selective deep cannulation failed, underwent successful sphincterotomy using a combined percutaneous and endoscopic procedure through the T-tube. CBD stones were then extracted with a Dormia basket. In situ T-tube can provide percutaneous access for combined approach in patients with retained CBD stones in whom endoscopic cannulation is not successful.

Coledocolitiasis residual: Incidencia en la clínica IESS Ambato

El presente es un estudio retrospectivo para determinar la incidencia de la coledocolitiasis residual (CR en la clínica del IESS- Ambato, en el período comprendido entre abril/1991 a abril/1994, con la revisión de 192 casos sometidos a colecistectomía. La mayoría de pacientes fueron mujeres con el 69.8 por ciento (134 casos) y el 30.2 por ciento (58 casos) fueron hombres. La media de edad fue de 43.3 años- De los exámenes radiológicos preoperatorios, todos se sometieron a ultrasonografía. De los 192 pacientes colescistectomizados, fue realizada exploración de la vía biliar en 15 casos (7.8 por ciento). La coledocolitiasis residual fue determinada en 10 casos a través de métodos endoscópicos. Comprobamos que la incidencia en este estudio de la coledocolitiasis residual fue baja en relación a otros estudios similares...

Choledochocele [type 111 choledochal cyst]: case report and literature review

A twenty-nine year old female, presented with intermittent Jaundice and right hypochondrial pain. On laparatomy a cystic mass at the terminal common bile duct found. Histopathological examination revealed Choledochocele [Type III choledochal cyst]. No post operative complications were encountered. Previously 48 similar cases have been reported in the literature

Estudio comparativo entre papilotomía endoscopica y papiloesfinteroplastia transduodenal en el tratamiento de calculos en el conducto biliar común. Hospital Central "Antonio María Pineda". Barquisimeto, 1991-1992 / Comparative study between papilotomy endoscopic vs tranduodenal sphincteroplasty and treatment of bile duet calculi. Hospital Central \"Antonio María Pineda\". Barquisimeto, 1991-1992

Se realizó un estudio prospectivo para comparar dos técnicas, papilotomía endoscópica (PE) vs papiloesfinteroplastia transduodenal (PT) en 20 pacientes ( 16 F y 4 M) con edades comprendidas entre 13 y 60 años (PE=40.8 ñ 19.39, PT=33.9 ñ 14.94) que ingresaron al Departamento de Cirugía y Gastroenterología del H.C.A.M.P., con Dx. de litiasis vesicular y coledociana y/o enfermedad de la papila (estenosis). Se encontró un franco predominio del sexo femenino (80 por ciento). El motivo de consulta más frecuente fué, el dolor abdominal (HD) y con menor frecuencia la ictericia y los vómitos; el predominio de la estancia hospitalaria de PE fué 2.9 días y de PT 8.7 días (p< 0.001); al comparar la evolución post-operatoria en ambos (PE y PT) no se observó diferencia estadísticamente significativa (p=NS). Las complicaciones observadas fueron 20 por ciento en PE y 10 por ciento para PT, pero un paciente murio con PT por abceso peritoneal. Se concluye que la PE es el procedimiento de elección para cálculo del colédoco menor de 2 cm. en pancreatitis por cálculos del colédoco y en pacientes de alto riesgo

Prevalencia del cáncer de vesícula biliar en colecistectomías / Biliary gallblader cancer prevalence in cholecystectomy

De 2.090 colecistectomías efectuadas en el Servicio de Cirugía del Hospital Valparaíso entre 1988 y 1990, el 2,9% presentó cáncer vesicular. El promedio de edad de los pacientes con cáncer fue de sólo 49 años, siendo la distribución por sexo similar. El cáncer estuvo asociado siempre a colecistitis crónica litiásica; se presentó avanzado (tipo III y IV de Nevin) y correspondió casi siempre a adenocarcinomas indiferenciados. La cirugía practicada fue la simple colecistectomía. La sobrevida de los 61 pacientes operados con cáncer de vesícula fue de 10,5% al año