Case series of gallstone ileus: only enterolitotomy, one stage or two stage surgery?

Biliary ileus is a rare disease and an infrequent cause of intestinal obstruction, occasionally occurs in frail elderly patients and has a certain predilection for the female sex. The diagnosis is complex and requires a high clinical suspicion and complementary examinations such as abdominal radiography and contrasted abdominal tomography. Treatment should be individualized according to the clinical characteristics of each patient, with the alternatives being resolution only by enterolithotomy, one stage surgery and two stage surgery. We report 3 cases of biliary ileus, each one managed with a different surgical procedure. The decision was aimed at resolving the intestinal obstruction by enterolithotomy, and the definitive management was performed according to the clinical characteristics of each patient; however, there is no consensus or algorithm that recommends the ideal surgical technique. The recommended surgical procedure for the resolution of biliary ileus will be discussed.

Uneventful pregnancy and delivery in a patient with idiopathic pulmonary hypertension: a case report

Idiopathic pulmonary hypertension is a rare disease characterized by sustained elevation of the pulmonary artery pressure and pulmonary vascular resistance, normal pulmonary artery wedge pressure, in the absence of a known cause. Prior reports suggest a very high maternal mortality in patients with idiopathic pulmonary hypertension undergoing pregnancy, and for that the recommendation has been avoidance of pregnancy (or termination if the patient is already pregnant). On the other hand, there have been multiple reports of patients with idiopathic pulmonary hypertension sustaining pregnancy and labor without major complications. This case report illustrates the course of pregnancy and labor in a patient diagnosed with idiopathic pulmonary hypertension. At age 24, the patient started with symptoms of shortness of breath and chest pain, and upon evaluation she was found with moderately severe idiopathic pulmonary hypertension. One year and 8 months later the patient becomes pregnant, and begins follow up with gynecology and cardiology. During this time the patient was asymptomatic, and did not have any clinical evidence of pulmonary hypertension. The risks of pregnancy were discussed with the patient, and she decided to continue pregnancy. She had an uneventful pregnancy, complicated only by preterm labor at 34 weeks and 5 days of gestation. She had spontaneous labor and delivered vaginally a healthy baby boy, weighting 4 pounds and 12 ounces. No invasive monitoring was used. The mother and the baby were discharged home 48 hours postpartum. Seven months later the patient returned for evaluation, presenting evidence of severe pulmonary hypertension. She has been followed up ever since by a cardiologist and currently is stable but symptomatic. This report adds to the amount of evidence that suggests that pregnancy and labor in a patient with idiopathic pulmonary hypertension may have a better outcome than previously reported. The decision of undertaking and/or continuing pregnancy in a patient with idiopathic pulmonary hypertension relies ultimately on the patient's choice, but should be done on an individual basis after careful evaluation of the risks. Finally, the need of close follow up with a multidisciplinary team is mandatory in the patient with idiopathic pulmonary hypertension that wishes to undergo pregnancy.

Primary pulmonary hypertension and pregnancy

Primary pulmonary hypertension (PPH) is a disorder intrinsic to the pulmonary vascular bed characterized by sustained elevation in pulmonary artery pressure and pulmonary vascular resistance with normal pulmonary artery wedge pressure, in the absence of a known cause. Cardiovascular disorders are the most common cause of morbidity and mortality in pregnant women. Risk is so great with some cardiovascular abnor-malities that recommendation of avoidance or interruption of pregnancy is supportable, one of these conditions is pulmonary hypertension. In this article two patients with primary pulmonary hypertension who sustained two pregnancies each are described. Both patients had uneventful pregnancies and deliveries, with all neonates surviving. When evaluating primary pulmonary hypertension and pregnancy, early studies reported a maternal mortality rate as high as 50%. More recent studies report a maternal mortality of 30%. In this article, cases of primary pulmonary hypertension undergoing pregnancy from 1978 to 2005 were reviewed, revealing a 22% maternal mortality for the total number of pregnancies. Despite advances in treatment, primary pulmonary hypertension continues to carry considerable maternal morbidity and mortality, and prevention of pregnancy is still the main recommendation. Early diagnosis and treatment is critical and a multi-disciplinary approach is required when dealing with a patient with PPH who desires to continue pregnancy.

Update in atrial fibrillation

Atrial fibrillation (AF) is the most common sustained arrhythmia in adults. It is a significant public health problem in the United States where it affects 2.2 million Americans and almost 10% of the population older than 80 years. It should be emphasized that the prevalence of AF increases with advancing age and with worsening cardiac function. AF is an independent risk factor for death and greatly increases the risk for embolic stroke. In addition, this arrhythmia can be associated with hemodynamic instability, tachycardia-induced cardiomyopathy, and systemic embolism. The management of atrial fibrillation today is directed toward the prevention of thromboembolism, control of the ventricular rate and conversion to sinus rhythm. It is the purpose of this review to summarize the most recent information about the clinical implications and treatment of this common rhythm disorder.