Hemorragia suprarrenal neonatal en el contexto de ictericia neonatal isoinmune. Reporte de caso / Neonatal adrenal hemorrhage in the context of isoimmune neonatal jaundice. Case report

La hemorragia de las glándulas suprarrenales en el período neonatal se produce secundariamente a traumatismos del parto y a modificaciones de la presión venosa. La ictericia neonatal tiene como causa infrecuente la presencia de un hematoma suprarrenal. Los casos sintomáticos son poco frecuentes y, si se manifiestan, suele ser como ictericia prolongada.Se presenta el caso de un neonato que ingresó a las 20 horas de vida por ictericia isoinmune anti-A. Por aumento de bilirrubina directa, se solicitó una ecografía abdominal a los 10 días de vida, que mostró una masa suprarrenal derecha no vascularizada, de 50 x 21 mm, con imágenes quísticas en su interior, compatible con hemorragia de glándula suprarrenal derecha. La ecografía seriada mostró una resolución progresiva hasta desaparecer, y el paciente se mantuvo asintomático y sin ictericia. Cuando persiste una ictericia en el período neonatal, hay que evaluar la posibilidad de una hemorragia suprarrenal significativ

Hemorrhage of the adrenal glands in the neonatal period happens secondarily to birth trauma and to changes in venous pressure. Neonatal jaundice has as an infrequent etiology the presence of an adrenal gland hematoma. Symptomatic cases are rare, and if they manifest, it is usually as prolonged jaundice.We present the case of a neonate who was admitted at 20 hours of life due to isoimmune jaundice. Due to an increase in conjugated bilirubin, an abdominal ultrasound was requested at 10 days of life, which showed a non-vascularized right adrenal mass, 50 x 21 mm, with cystic images inside, compatible with bleeding of the right adrenal gland. Serial ultrasound showed a progressive resolution until its disappearance, keeping the baby asymptomatic and without jaundice. In cases of prolonged jaundice in the neonatal period, the possibility of significant adrenal hemorrhage must be assessed.

Protocolo de embolizacion arterial como parte del control de la hemorragia por fractura pélvica: serie de casos en un centro de referencia de trauma / Arterial embolization protocol as control of pelvic fracture hemorrhage: case series in a trauma reference center

Introducción Las fracturas pélvicas se asocian a sangrado arterial y/o venoso, ocasionando mortalidad elevada. El objetivo del estudio es diseñar, implementar y evaluar un protocolo para el tratamiento de fracturas pélvicas Materiales y métodos estudio prospectivo observacional, de pacientes con fractura pélvica que ingresaron a la clínica Medical. Variables: edad, sexo, arteria comprometida, lesión unilateral o bilateral, tipo de fractura pélvica (clasificación de Tile), indicación de la arteriografía, acceso uni o bilateral, éxito angiográfico, complicaciones del procedimiento, lesiones asociadas, mortalidad a 30 días, mecanismo de trauma, días de estancia en cuidado intensivo. Resultados 56 pacientes con fractura pélvica, 17 pacientes se llevaron a arteriografía pélvica por sospecha de sangrado, 14 pacientes tenían sangrado arterial, promedio de 36 años, las arterias más comúnmente lesionadas fueron la arteria hipogástrica, arteria sacra lateral y la arteria obturatriz. la mayoría de sangrados se asociaron a fracturas tipo C, las lesiones asociadas se encontraron en un 34% de casos, la indicación de la arteriografía fue inestabilidad hemodinámica al momento del ingreso, el control del sangrado se logró en el 86% de casos, la punción fue única en el 100% de casos, se requirió empaquetamiento pélvico 12% de casos. Discusión El trauma pélvico asociado a accidentes de motocicleta es común, el manejo multidisciplinario y la oportuna intervención del cirujano vascular es decisiva para el diagnóstico y tratamiento temprano de las lesiones vasculares pélvicas; la realización de un protocolo de manejo con un algoritmo de embolización mostró ser efectivo y seguro para el control del sangrado pélvico. Nivel de Evidencia: III

Background Pelvic fractures are frequently associated with arterial and / or venous bleeding, leading to high mortality (10 and 50%). Aim of study is to show our experience, based on an institutional protocol developed for the management of the patient with major pelvic trauma. Methods We conducted a prospective observational study for a 3 years period of time. The variables analyzed were: age, sex, artery involved, unilateral or bilateral lesion, type of pelvic fracture (Tile classification), indication of arteriography, unilateral or bilateral access, angiographic success, complications of the procedure, associated injuries, mortality at 30 days, trauma mechanism, days of stay in ICU and floor. Results We found 56 patients with pelvic fracture, 17 patients were taken to pelvic arteriography due to suspected bleeding, 14 patients had arterial bleeding, with an average age of 36 years, the arteries most commonly injured were the hypogastric artery, lateral sacral artery and the obturator artery, 50% of cases the bleeding was bilateral, the majority of bleeds were associated with type C fractures, associated lesions were found in 34% of cases, the indication of arteriography was hemodynamic instability at the time of admission, control of bleeding was achieved in 86% of cases (n: 15), the puncture was unique in 100% of cases (n: N: 14), pelvic packing was required in 2 patients (12%) Discussion Pelvic embolization for pelvic fracture is a safe and feasible procedure. A multidisciplinary approach and a high suspicion of pelvic arterial injury must be always in mind. Mortality in our trial was very low comparative with previous reports. Evidence Level: III

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.

Severe iron-deficiency anemia as initial manifestation of pulmonary hemosiderosis in a child / Anemia ferropriva grave como manifestaçao inicial de hemossiderose pulmonar em criança

ABSTRACT Idiopathic pulmonary hemosiderosis is a potentially fatal disease that results from episodes of alveolar hemorrhage of unknown origin. The clinical spectrum is varied, and anemia may constitute the only manifestation of illness, preceding other signs and symptoms by several months. We present the case of a 4 year-old child presenting with fever, vomiting and prostration, associated with pallor. He had microcytic and hypochromic anemia refractory to iron therapy. Gastrointestinal bleeding was ruled out after negative extensive etiological investigation. Subsequently, pulmonary infiltrates suggestive of alveolar hemorrhage were observed in the chest radiography. The cytological exam of the bronchoalveolar lavage showed hemosiderin-laden macrophages. After the etiological study, the diagnosis of idiopathic pulmonary hemosiderosis was made by exclusion. He was initiated on corticosteroid therapy, later associated to an immunosuppressive agent, with subsequent correction of anemia and of the radiological pattern. The patient is currently asymptomatic.

RESUMO A hemossiderose pulmonar idiopática é uma doença potencialmente fatal que cursa com episódios de hemorragia alveolar de etiologia desconhecida. As manifestações clínicas são variadas, e a anemia pode constituir o único sinal de doença, precedendo em vários meses os outros sinais e sintomas. Apresenta-se o caso de criança de 4 anos, com febre, vômitos e prostração, associados à palidez. Apresentava anemia microcítica e hipocrômica, refratária à terapêutica com ferro. A hipótese diagnóstica de sangramento gastrintestinal foi excluída, após investigação etiológica extensa, inconclusiva. Posteriormente, em radiografia torácica, foram observados infiltrados sugestivos de hemorragia alveolar. O exame citológico do lavado broncoalveolar mostrou macrófagos com depósitos de hemossiderina. Após estudo etiológico, assumiu-se, por exclusão, o diagnóstico de hemossiderose pulmonar idiopática. Foi iniciada terapêutica com corticoides, associada posteriormente a imunossupressor, com correção subsequente da anemia e do padrão radiológico, encontrando-se, atualmente, assintomático.

Time-dependent low-field MRI characteristics of canine blood: an in vitro study

This study was conducted to assess time-sensitive magnetic resonance (MR) changes in canine blood using low-field MR. Arterial and venous blood samples were collected from eight healthy beagle dogs. Samples were placed in 5-mL tubes and imaged within 3 hours of collection at 1 day intervals from day 1 to day 30. The following sequences were used: T1-weighted (T1W), T2-weighted (T2W), fluid-attenuated inversion recovery (FLAIR), short tau inversion recovery (STIR), and T2-star gradient-echo (T2*-GRE). Visual comparison of the images revealed that four relatively homogenous blood clots and twelve heterogeneous blood clots developed. The margination of the clot and plasma changed significantly on day 2 and day 13. On day 2, heterogeneous blood clots were differentiated into 2 to 3 signal layers in the T2W, T1W, and especially the STIR images. Hypointense signal layers were also detected in the blood clots in STIR images, which have T2 hypo, FLAIR hypo, and T1 hyper intense signals. In all images, these signal layers remained relatively unchanged until day 13. Overall, the results suggest that hematomas are complex on low-field MRI. Accordingly, it may not be feasible to accurately characterize hemorrhages and predict clot age based on low-field MRI.

Hemorragia abdominal espontánea: evaluación por imágenes / Abdominal hemorrhage spontaneous: imaging evaluation

Se define como hemorragia intraabdominal espontánea a aquella que no es de causa traumática. Su presentación clínica es inespecífica, por lo que el diagnóstico suele realizarse en base a los hallazgos imagenológicos. El estudio de imágenes cumple tres funciones básicas: realizar el diagnóstico al detectar la presencia de sangre intraabdominal, localizar el origen del sangrado y determinar la presencia o no de extravasación arterial activa. Las causas del hemoperitoneo no traumático son diversas y se pueden clasificar, según el órgano de origen, en hepáticas, esplénicas, pancreáticas, adrenales, renales, gineco-obstétricas, vasculares y de partes blandas (peritoneales y musculares)

It defines spontaneous abdominal hemorrhage that is not traumatic. Its clinical presentation is nonspecific and usually not suspected by the emergency physician, so the diagnosis is usually made based on imaging findings. The study of images serves three basic functions, which are to perform the diagnosis by detecting the presence of blood intraabdominal, locating the source of bleeding and determining the presence or absence of active arterial extravasation. The causes of non traumatic hemoperitoneum are diverse and can be classified according to the organ of origin in liver, spleen, pancreas, adrenal, kidney, obstetric-gynecology, vascular and soft tissue (peritoneal and muscular)

Hemorragias poco usuales en pacientes con hemofilia / Unusual bleeding in hemophilic patients

La hemofilia es una enfermedad hemorrágica grave con gran heterogeneidad fenotípica. Los sangramientos músculo-articulares constituyen la manifestación clínica más frecuente y significativa por las secuelas crónicas que originan. Sin embargo, existen otros sitios de sangramiento menos reiterados que pueden ser graves e invalidantes, y la posibilidad de reconocerlos tempranamente evita las consecuencias adversas. Se presentan dos pacientes de edad pediátrica que acudieron al servicio de urgencias por eventos hemorrágicos en sitios poco usuales: mediastinal, pulmonar y de rectos anteriores. A todos se les realizó un diagnóstico temprano del proceso patológico basado en un interrogatorio y examen físico detallados, apoyado con estudios imagenológicos (radiografía y ultrasonido) que permitieron manejar estas hemorragias de forma adecuada con terapia sustitutiva oportuna, sin complicaciones ulteriores. De esta forma se evidencia que el diagnóstico precoz es elemento fundamental en el seguimiento de los pacientes con hemofilia para evitar complicaciones de esta enfermedad(AU)

Hemophilia is a serious hemorrhagic disease with marked phenotypic heterogeneity. Muscle and joint bleedings are the most common clinical manifestation and they stand out by the resultant chronic sequelae. However, there are other less frequent types of bleeding disorders that can be severe and disabling and the possibility to recognize them early avoids adverse consequences. We present two pediatric patients who attended the emergency service with bleeding events in unusual places: mediastinal, pulmonary and rectus. These patients were early diagnosed based on a detailed interview and physical examination supported by imaging studies such as radiography and ultrasound which enabled the appropriate handling of these bleedings with opportune replacement therapy and without further complications. It is evident that early diagnosis is the key element in monitoring patients with hemophilia to prevent complications of the disease(AU)

Ultrasonographic and histopathological study of the endometrium in women with perimenopausal bleeding

Transvaginal gynecological ultrasonography as well as pathological examination of the endometrium were performed on 20 females with perimenopausal bleeding as well as on 10 age matching controls, to evaluate a screening role in these cases. A cut off point of >8 mm single layer endometrial thickness for both anterior and posterior walls, accurately predicted the endometrial hyperplasia in patients with no organic pelvic disease