Rotura aneurismática de la arteria hepática común / Ruptured common hepatic artery aneurysm

RESUMEN Los aneurismas de la arteria hepática son una patología poco frecuente. Cuando son sintomáticos, se debe sospechar un sufrimiento aneurismático y su tratamiento está indicado. Presentamos el caso clínico de un paciente con mal terreno cardiovascular, que consultó por un cuadro clínico de dolor epigástrico, repercusión hemodinámica e ictericia. La imagenología evidenció la presencia de un aneurisma de la arteria hepática común complicado con compromiso del origen de la arteria hepática propia y la arteria gastroduodenal. La presencia de una vascularización arterial hepática "no convencional" con una arteria hepática derecha proveniente de la arteria mesentérica superior, en la angiotomografía, permitió cambiar la táctica quirúrgica haciéndose prescindible la realización de un bypass. Este caso resalta la importancia de determinar en el preoperatorio no solo la extensión del aneurisma, sino también la anatomía vascular hepática a fin de planificar mejor la cirugía, disminuyendo así la morbimortalidad de esta enfermedad.

ABSTRACT Hepatic artery aneurysms are rare. Expanding aneurysms should be suspected in case of symptoms and treatment is indicated. We report the case of a patient with a history of cardiovascular disease who sought medical care due to epigastric pain, hemodynamic instability and jaundice. The imaging tests showed the presence of an aneurysm of the common hepatic artery complicated with involvement of the origin of the proper hepatic artery and the gastroduodenal artery. The surgical approach could be changed due to presence of a "non-conventional" hepatic arterial variant with a right hepatic artery originating from the superior mesenteric artery in the computed tomography angiography as bypass surgery was not necessary. This case highlights the importance of determining the extent of the aneurysm in the preoperative period and the anatomy of the hepatic vessels to better plan the surgery, thus reducing morbidity and mortality of this disease.

Hematocele y hemoperitoneo como manifestación inicial de carcinoma hepatocelular: caso clínico / Hematocele and hemoperitoneum as initial manifestation of hepatocellular carcinoma: report of one case

Hepatocellular carcinoma (HCC) rupture is a rare complication, with a higher prevalence in countries of Asia and Europe. Its clinical manifestations can be nonspecific, from abdominal pain and bloating to hemodynamic involvement. We report a 70-year-old male patient with a history of chronic liver disease, presenting with an enlargement and ecchymosis of the scrotum, associated with abdominal bloating. The initial abdominal ultrasound study showed increased liquid content in the scrotal sac and regional edema. A CT of the abdomen and pelvis showed a liver mass with characteristics of hepatocellular carcinoma, associated with extensive hemoperitoneum that drained into the scrotal sac. The patient was treated with embolization of the right hepatic artery and later with surgical resection of the tumor mass, with a good clinical evolution.

Enterocolitis necrotizante del adulto, ¿una presentación atípica de la isquemia mesentérica? / Adult necrotizing enterocolitis, an atypical presentation of mesenteric ischemia?

La enterocolitis necrosante en adultos (ECNA) es una enfermedad de etiología incierta, muy infrecuente, con apenas casos descritos en la literatura y con elevada mortalidad. Existe una fuerte correlación entre eventos vasculares e infecciosos implicados en la patogenia de necrosis intestinal masiva en esta entidad.

Necrotizing enterocolitis in adults (ECNA) is a disease of uncertain etiology, very rare, with very few cases described in the literature and with high mortality. There is a strong correlation between vascular and infectious events involved in the pathogenesis of massive intestinal necrosis in this entity.

Tumor estromal gastrointestinal como causa infrecuente de hemoperitoneo / Gastrointestinal Stromal Tumor as a Rare Cause for Hemoperitoneum

RESUMEN El tumor estromal gastrointestinal es el tumor mesenquimático más frecuente y se caracteriza por la expresión de un receptor de factor de crecimiento tirosina kinasa, CD117 c-KIT/CD 117. Se diferencia del resto de los tumores mesenquimáticos en que no expresa esta proteína. Alrededor del 70 - 80 por ciento de estos tumores son benignos, la mayoría se localizan en estómago e intestino delgado (> 90 por ciento). Los tumores estromal gastrointestinal malignos son generalmente de gran tamaño (> 5 cm), con índice mitótico alto y pueden dar metástasis a hígado y peritoneo. El tratamiento es la resección quirúrgica. Presentamos una paciente con 65 años de edad que acudió al cuerpo de guardia por sufrir caída de sus pies y quejarse de dolor abdominal. Como datos positivos al examen físico se constató palidez cutáneo mucosa y los complementarios de urgencia. El ultrasonido y la tomografía axial computarizada informaron líquido libre en cavidad con cifras de hemoglobina en 6,4 g/L. La punción abdominal constató sangre roja que no coagulaba. Se realizó laparotomía exploratoria encontrando hemoperitoneo y gran tumoración en cara anterior del antro gástrico, con otra pequeña en la porción alta del cuerpo; se realizó resección local con bordes libres de tumor y se suturaron los bordes gástricos. El resultado de la biopsia informó tumor del estroma gastrointestinal de células fusiformes con bajo índice mitótico, que midió 13 x 8 x 8 cm, con marcada angiogénesis y zonas de calcificación(AU)

ABSTRACT Gastrointestinal stromal tumor is the most frequent mesenchymal tumor and is characterized by expression of a tyrosine kinase growth factor receptor, CD117 c-KIT/CD 117. It is different to the rest of mesenchymal tumors in that it does not express this protein. About 70-80 percent of these tumors are benign. The majority are located in the stomach and small intestine (more than 90 percent). Malignant gastrointestinal stromal tumors are usually large (over 5 cm in size), with a high mitotic index, and can metastasize to the liver and peritoneum. The treatment is surgical resection. We present a 65-year-old patient who came to the emergency room due to having fallen on her own feet and complaining of abdominal pain. As positive data to the physical examination, mucous and skin whitening and the emergency complement tests were analyzed. Ultrasound and CT scan reported free fluid in cavity with hemoglobin values at 6.4 g/L. The abdominal puncture showed red blood that did not clot. The exploratory laparotomy showed a hemoperitoneum and a large tumor in the anterior face of the gastric antrum, with a small one in the upper portion of the body; local resection with tumor-free borders was performed and the gastric borders were sutured. The result of the biopsy reported a spindle cell gastrointestinal stromal tumor with a low mitotic index, measuring 13x8x8 cm, with marked angiogenesis and areas of calcification(AU)

Colecistitis hemorrágica: reporte de caso y revisión de la literatura / Hemorrhagic cholecystitis: case report and literature review

Resumen Introducción: La colecistitis hemorrágica es una complicación poco frecuente de la colecistitis aguda con una alta mortalidad. Materiales y Método: Paciente con dolor abdominal en hipocondrio derecho e ictericia. Los exámenes de laboratorio y ultrasonido hepatobiliar mostraron datos sugestivos de colecistitis aguda; durante su estancia hospitalaria presenta deterioro de su estado general, realizándose tomografía computarizada mostrando imágenes sugestivas de colecistitis hemorrágica y hemoperitoneo. Resultados: Laparotomía de urgencia, corroborando los hallazgos tomográficos y resolviéndose satisfactoriamente con la colecistectomía. Discusión: El diagnóstico de colecistitis hemorrágica es difícil ya que sus manifestaciones clínicas de inicio no difieren de la colecistitis aguda, por lo que la sospecha clínica y el adecuado estudio de imagen son importantes para su detección. Conclusión: A pesar que la colecistitis hemorrágica con perforación y hemoperitoneo es una patología muy poco común, de diagnóstico confuso, es importante establecer la realización de una tomografía computarizada abdominal con contraste endovenoso en pacientes con sospecha de colecistitis aguda grave.

Introduction: Hemorrhagic cholecystitis is a rare complication of acute cholecystitis with a high mortality. Materials and Method: Patient with abdominal pain in right hypochondrium and jaundice. Laboratory analyses and hepatobiliary ultrasound suggested acute cholecystitis, however, general worsening during hospital stay was observed and a computed tomography was performed, revealing hemorrhagic cholecystitis and hemoperitoneum. Results: Urgent laparotomy which confirmed tomographic results, successfully solved with cholecystectomy. Discussion: Hemorrhagic cholecystitis diagnosis is difficult as symptoms at the beginning do not differ from acute cholecystitis, then, clinical suspicion and a correct image analysis is crucial for its detection. Conclusion: Although, perforated hemorrhagic cholecystitis with hemoperitoneum is a very rare entity with confused diagnosis, an abdominal computed tomography with intravenous contrast is very important in any patient with severe acute cholecystitis suspicion.

Evaluation of focused abdominal sonography for trauma [FAST] in Baghdad Teaching Hospital

Focused Abdominal Sonography for Trauma [FAST] is widely applied in the initial management of trauma patients, Being non invasive, repeatable and without risk of irradiation, make it attractive tool in evaluation of trauma patients. Evaluation FAST sensitivity and specificity in detection of hemoperitoneum in abdominal trauma victims. Prospective study conducted in the emergency department of Baghdad teaching hospital for one year period .The FAST done by a general surgeon or emergency physician during the secondary survey of blunt and penetrating abdominal trauma victims with equivocal clinical findings. Ninety three [93] patients included in the study, with over all sensitivity of FAST was 80.9% and specificity 95.8%. In blunt abdominal trauma the sensitivity was 92.3% and specificity was 96% while in penetrating abdominal trauma the sensitivity was only 62.5% and specificity 95.2%. FAST is highly sensitive and specific in detection of hemoperitoneum after blunt abdominal trauma, but its lower sensitivity in penetrating abdominal injury require modification in the protocols like repetition of the scan or application of extra views. Its high specificity make it suitable as "rule in" test in both blunt and penetrating abdominal injury

evaluation of the role of ultrasonography and ultrasound-guided aspiration as an initial screening test in blunt abdominal trauma

The role of ultrasonography [US] as an initial screening test was evaluated in 3000 consecutive cases of blunt abdominal trauma [BAT]. Seventy-three were positive for free fluid collection or organ injury. US-guided aspiration was used to rule out the hollow visceral injury in those referred to nonsurgical therapy. Sixty patients underwent laparotomy. These included 53 clinically unstable patients, three stable patients with positive US-guided aspiration for bile or intestinal contents and four who deteriorated upon conservative treatment. The remaining patients with US negative for fluid had some evidence of abdominal injury on clinical examination. Ultrasonography complemented the clinical examination. Both the sensitivity and specificity of US for the detection of free fluid were 100%. The overall sensitivity was 92% in spleen injuries, 88% in liver injuries and 100% in kidney injuries, with a positive predictive value of 96%, 100% and 100% and a specificity of 97%, 100% and 100% respectively. Retrospective correlation of US with laparotomy findings regarding free fluid showed that 50-100 mL of free fluid was minimal, 100-500 mL moderate, and above 500 mL significant. Thirteen patients completed conservative treatment with an uneventful course in the hospital. Both the US findings and the clinical condition of the patient should be considered in decision-making in BAT. Unnecessary laparotomies can be avoided when the major bleeding site is not in the abdomen and such patients can be safely observed after excluding the hollow visceral injury by US-guided aspiration. US, being rapid to perform, sensitive and easily repeatable, is quite useful as an initial screening test in BAT patients