Cecoscopia, domo de la base del apéndice como localizador de la válvula ileocecal / Cecoscopy, appendix dome for identifying ileocecal valve

Introduction: Ileoscopy during colonoscopy or retrograde enteroscopy, is increasingly required and is considered a quality criteria in colonoscopy. The appendix is found in most cases with his mesoappendix oriented medially in the direction of the ileocecal valve. Because of this, the location of the dome of the base of the appendix should indicate the direction of the ileocecal valve. Methods: Observational study. We included 100 consecutive colonoscopies, in which adequate visualization of cecal pole, appendiceal orifice and its dome, was achieved. We excluded patients with sub-optimal colon preparation and those who had previous appendectomy or right hemicolectomy. The procedures were performed between September 2009 and April 2010, by two experienced operators. Success in finding the ileocecal valve was considered if the direction of the dome of the appendix provided guidance to the location of it and the entrance to distal ileum. Results: We evaluated 100 procedures, in which the distal ileum was entered following the direction of the dome of the appendix in 98 patients (98 percent). In two patients (2 percent) the ileocecal valve was not in the direction provided by the dome of the appendix. In one of them the valve was exactly in the opposite direction of the dome, and in the other was at 90º of it. Conclusions: As described in our series, it seems recommendable to use the dome of the appendicular base for the location of the ileocecal valve and terminal ileum access.

Introducción: La ileoscopia durante la colonoscopia o la enteroscopia retrógrada, es cada vez más requerida y se considera criterio de calidad en colonoscopia. El apéndice se encuentra en la mayoría de los casos con su mesoapéndice orientado hacia medial en la dirección de la válvula ileocecal. Debido a esto, la localización del domo de la base apendicular, debería señalar la dirección de la válvula ileocecal. Material y Métodos: Estudio observacional. Se incluyeron 100 colonoscopias consecutivas, en las cuales se logró una adecuada visualización del polo cecal, y del orificio apendicular y su domo. Se excluyeron los pacientes con preparación de colon sub-óptima, apendicectomizados y hemicolectomizados de colon derecho. Los procedimientos fueron realizados entre septiembre de 2009 y abril de 2010, por dos operadores experimentados. Se consideró éxito en encontrar la válvula ileocecal, si la dirección del domo del apéndice orientaba a la ubicación de ésta y la entrada al íleon distal. Resultados: Se evaluaron 100 procedimientos, en los cuales se ingresó al íleon distal siguiendo la dirección del domo del apéndice en 98 pacientes (98 por ciento). En dos pacientes (2 por ciento) la válvula ileocecal no se encontraba en la dirección que orientaba el domo del apéndice. En uno de ellos la válvula estaba exactamente en la dirección opuesta a la que mostraba el domo, y en el otro estaba a 90º de éste. Conclusiones: Según lo descrito en nuestra serie, parece recomendable utilizar el domo de la base apendicular para la localización de la válvula ileocecal y el acceso al íleon terminal.

Ictericia obstructiva secundaria a migración de fragmentos de hepatocarcinoma a la vía biliar / Obstructive jaundice secondary to hepatocellular carcinoma fragments migrated to common bile duct

Obstructive j aundice is a rare presentation of hepatocellular carcinoma (HC), and when it occurs, usually is due to progressive damage from cirrhosis, or extensive tumor infiltration. Tumor growth through the bile duct is being described with increasing frequency as a cause of obstructive j aundice. Rarely, it may be hepatocarcinoma fragments that migrate to the bile duct, obstructing it. We present a case of obstructive jaundice due to migration of fragments of hepatocellular carcinoma to the bile duct in a patient treated 7 years before, for an HC with a curative resection.

La ictericia obstructiva es una presentación poco común en un hepatocarcinoma (HC). Cuando en estos casos existe ictericia, habitualmente se debe a daño progresivo por cirrosis, o a infiltración tumoral extensa. El crecimiento o vaciamiento tumoral hacia la vía biliar se ha descrito ocasionalmente como causa de ictericia obstructiva. En raras ocasiones, puede tratarse de fragmentos de hepatocarcinoma que migran hacia la vía biliar, obstruyéndola. Presentamos un caso de ictericia obstructiva por migración de fragmentos de hepatocarcinoma a la vía biliar, en un paciente tratado 7 años antes por un HC, con resección curativa.

Colitis quística profunda: caso clínico / Colitis cystica profunda: report of a case

A 56 year old woman without a history of colonic symptoms with family history of colorrectal cancer was submitted to a survey colonoscopy. Endoscopic findings suggested a sub-mucosal lesion. Trans-rectal endoscopic ultrasound showed the presence of cystic lesions containing liquid and gas. Colitis cystica profounda. (CCP) is a rare benign lesion usually localized in the rectum and sigmoid colon. Different types are described as localized, segmented and diffuse forms. The differential diagnoses are extensive and include polyps and different malignant lesions. Symptoms are variable and non specifics, association to other pathological conditions including rectal prolapse and solitary rectal ulcer are observed. The different options of treatment are analyzed.

Se presenta el caso clínico de una paciente de sexo femenino de 56 años asintomática, sometida a colonoscopía por antecedente de cáncer de colon familiar. En la colonoscopía se observó una lesión de aspecto submucoso en el colon descendente. La endosonografía objetivó lesiones quísticas con contenido líquido y aéreo. La colitis quística profunda (CQP) es una lesión intestinal, benigna e infrecuente localizada de preferencia en recto medio y sigmoides y puede ser localizada, segmentaria o difusa. El diagnóstico diferencial, es con diferentes patologías entre ellas pólipos o cáncer colo-rectal. La expresión clínica, es variable e inespecífica. Se asocia a otras patologías entre ellas el prolapso rectal y la úlcera solitaria del recto. Se analizaron los diferentes tipos de tratamiento.

Abdomen agudo en el adulto mayor / Acute abdomen in the elderly

Background: Nearly 10% of emergency consultations are due to acute abdominal pain. In people over 65 years old, it can have atypical presentations, that retard the correct diagnosis and worsens prognosis. Aim: To study the causes, evolution and prognosis of acute abdomen in the elderly. Material and methods: Prospective study of 45 patients aged more than 65 years old (mean age ± SD, 75.7±7.7, 51% men) and 221 patients of less than 65 years old (mean age ± SD, 36.7±14.0, 48% men), consulting for acute abdomen in the emergency room. Results: Sixty six percent of elderly patients had concomitant diseases, that were multiple in 63%. In this age group, the causes accounting for 71% of acute abdominal pain were bilio-pancreatic diseases (31.1%), intestinal adhesive obstruction (17.7%), complicated abdominal wall hernia (13.7%), and complications of peptic ulcer disease (8.9%). Sixty four percent required surgical treatment and, in almost 50% the surgical risk was classified in ASA III or IV, according to the American Society of Anesthesiology. Thirty one percent had postoperative complications. Compared with their younger counterparts, elderly patients required significantly (p<0.05) more admissions to intensive care units (2.7 and 24.2% respectively), more connections to mechanical ventilation (1.4 and 8.9% respectively) and longer hospital stays (5.4±7.4 and 12.4±10.9 days, respectively). In this series overall mortality was 6.7%, being 0.6% for young patients and 11.1% for the surgical group over 65 years old. Conclusions: Acute abdomen in the elderly has a high rate of complications and mortality. According to the causes of acute abdomen in this group, evaluation in the emergency setting with an ultrasonography may be very useful. In the elderly, elective correction of potential causes of acute abdomen should be done.