Sangrado variceal duodenal secundario a trombosis venosa mesentérica: a propósito de un caso / Duodenal variceal bleeding secondary to mesenteric vein thrombosis

La trombosis venosa mesentérica corresponde a un factor obstructivo del sistema venoso intestinal intraluminal, trayendo consecuencias clínicas dadas por isquemia intestinal y aumento de la circulación colateral debido a una dificultad del drenaje sanguíneo. Raramente, esto podría generar várices ectópicas, pero esta descrito en la literatura la existencia de várices duodenales producto de este mecanismo. En este articulo se presenta un reporte de un caso, que presenta un sangrado variceal de origen duodenal secundaria a una trombosis venosa portal y mesentérica, sin causa aparente.

Mesenteric vein thrombosis is an intraluminal obstruction of the intestinal venous system with clinical consequences due to intestinal ischemia and an increase in collateral circulation caused by compromised venous return. It very rarely generates ectopic varicose veins but duodenal varicose veins caused by this mechanism have been described in the literature. In this article we report the case of duodenal variceal bleeding secondary to a portal and mesenteric venous thrombosis with no apparent cause.

Enfermedad de Still del Adulto, a propósito de un caso / Still's disease, a clinical case

La enfermedad de Still del Adulto es una variante sistémica del universo llamado "artritis idiopática juvenil", cuya diferencia es la edad de aparición, recibiendo este nombre cuando el cuadro se manifiesta en personas mayores de 15 años. Es una enfermedad autoinflamatoria caracterizada por fiebre intermitente, artritis, rash evanescente y linfadenopatías, asociado a manifestaciones de compromiso sistémico. Es una patología de baja prevalencia, pero es importante considerarla como uno de los principales diagnósticos etiológicos de la fiebre de origen desconocido.

Adult-onset Still's disease is a systemic variant of Still's disease distinguished from juvenile idiopathic arthritis by its onset age of over 15. It is an auto-inflammatory disease characterized by intermittent fever, arthritis, short-lived rash and lymphadenopathies. It has low prevalence but is important to consider as one of the principle etiological diagnoses of fever of unknown origin.

Hemorragia digestiva alta por várices gástricas secundarias a trombosis de vena esplénica tratada con esplenectomía / Upper gastrointestinal bleeding due to gastric varices secondary to splenic vein thrombosis treated by splenectomy

Upper gastrointestinal bleeding secondary to acute variceal hemorrhage is a medical emergency, with significant morbidity and mortality, which usually requires a multidisciplinary approach from gastroenterologists, intensive care physicians, and surgeons. The most common cause of variceal bleeding is the one that arises from portal hypertension associated with cirrhosis, and best described in terms of prevention, initial management and following treatment that in the minority of cases can be definitive without complex interventions, including liver transplant in cirrhotic patients. Within the etiologies not arising from portal hypertension, splenic vein thrombosis is one of the most important. Characterized by an endoscopic appearance of fundal or isolated gastric varices, without esophageal involvement, a variable number of cases manifest clinically as variceal hemorrhage. Based on different pathophysiology compared to esophageal varices, response to initial treatment is different, endoscopic management involve the use of adhesives (e.g. cyanoacrylate) as treatment of choice, and, in selected cases, surgical treatment can provide a definitive solution. Here we present a clinical case of an adult patient, without history of cirrhosis, who presented to the emergency department with severe upper gastrointestinal bleeding secondary to gastric varices, admitted in Intensive Care Unit and treated with endoscopy. Complementary studies with abdominal CT showed spleen vein thrombosis, enlarged spleen and multiple varicesin gastric body and fundus. After stabilization, splenectomy was performed as definitive treatment, with regression of gastric varices on ambulatory control with an upper endoscopy...

La hemorragia digestiva alta por sangrado variceal agudo constituye una emergencia médica, con morbimortalidad significativa asociada, requiriendo manejo multidisciplinario de gastroenterólogos, intensivistas y cirujanos. El sangrado variceal por hipertensión portal secundario a daño hepático crónico es el más habitual y mejor caracterizado en prevención, enfrentamiento inicial y manejo posterior, que en la minoría de los casos puede ser definitivo, sin intervenciones complejas, incluyendo trasplante hepático en pacientes cirróticos. Dentro de las causas de sangrado variceal no asociadas a hipertensión portal, la trombosis de vena esplénica es una de las principales. Caracterizada por presentarse en endoscopia como várices gástricas fúndicas o aisladas sin compromiso esofágico, se manifiestan clínicamente como sangrado variceal agudo en un porcentaje variable de casos. Por tener etiopatogenia distinta a las várices por hipertensión portal, la respuesta frente a las medidas terapéuticas iniciales es distinta, el tratamiento endoscópico de elección es el uso de adhesivos tipo cianoacrilato, y en casos seleccionados, el enfrentamiento quirúrgico puede ofrecer una solución definitiva. Presentamos el caso de una paciente sin antecedentes de daño hepático crónico, que se presentó con hemorragia digestiva alta por sangrado de várices gástricas, con manejo inicial en unidad de paciente crítico y hemostasia por vía endoscópica. En estudio complementario se objetivó trombosis de la vena esplénica con esplenomegalia y múltiples formaciones varicosas en fondo y cuerpo gástrico. Posterior a estabilización se realizó esplenectomía como manejo definitivo, logrando regresión de várices gástricas en endoscopia de control...

Incontinencia fecal del adulto / Fecal incontinence in adults

The aim of this paper is to review the knowledge of this pathology by highlighting the clinical evolution, study and treatment. These different aspects need a multidisciplinar approach, because of their complex physiopathology, possible association with urinary incontinence and prolapse of the three compartments of the pelvis. The fecal incontinence (FI) constitutes a highly prevalent pathology that affects at least 2 percent of the population and up to 45 percent of the patients in nursing homes. This pathology can cause serious problems in physical, psychological, social, and economical levels. The clinical evaluation may identify or suspect the cause, and guide the study of FI. The initial treatment of the FI should always be medical one, often associated to biofeedback and the surgical treatment should be only reserved for refractory FI. Sphincteroplasty is indicated by defined defaults of the external sphincter, with good initial results (at least 70 percent) that fall to 50 percent in 5 years. The artificial neosphincter and the dynamic graciloplasty represent an option for patient without sufficient sphincter mass for a plasty. In the last few years new techniques have appear with promising results, as the neuromodulation that uses electrodes in the sacral plexus or applied to the posterior tibial nerve. In conclusion the IF is a problem of large prevalence but kept in shadows because the patients tend to have reticence to declare it, and the doctors to inquire about. The focus should be multidisciplinary and the initial treatment must be medical one. The surgical treatment should be reserved for refractory FI.

El propósito de esta revisión es actualizar los conocimientos sobre esta patología, destacando su evolución clínica, estudio y tratamiento, aspectos que ameritan un enfoque multidisciplinario, ya que, además de su compleja fisiopatología, puede asociarse a incontinencia urinaria y prolapso de los tres compartimentos de la pelvis. La incontinencia fecal (IF) constituye una patología altamente prevalente que afecta al menos un 2 por ciento de la población y hasta el 45 por ciento de los pacientes en casas de reposo; cuyas consecuencias pueden ocasionar al paciente serios problemas físicos, psicológicos, sociales y económicos. La evaluación clínica puede identificar o sospechar la causa de la IF, y guiar el estudio de la misma. El tratamiento inicial de la IF debe ser siempre médico, a menudo asociado a biofeedback, y el tratamiento quirúrgico reservarse para la IF refractaria a estas medidas. La esfinteroplastía está indicada en defectos definidos del esfínter externo, con buenos resultados iniciales (al menos 70 por ciento) que caen hasta el 50 por ciento al cabo de 5 años. El neoesfínter artificial y la graciloplastía dinámica representan opciones para pacientes sin masa esfinteriana suficiente para una plastía. En los últimos años han aparecido técnicas más promisorias como la neuromodulación que utiliza electrodos en el plexo sacro o aplicados al tibial posterior. En conclusión la IF es un problema de gran prevalencia, pero soterrado, ya que los pacientes son reticentes a declararla y los médicos a indagarla. Su enfoque debe ser multidisciplinario y su tratamiento inicial, médico, reservando la cirugía para casos refractarios.

Manejo de la constipación crónica del adulto: Actualización: [revisión] / Constipation in adults: An update: [review]

Constipation affects 2 percent to 27 percent of individuals. It is associated to irritable bowel syndrome in 59 percent of cases, to a pelvic floor dysfunction in 29 percent and to a low transit time in 13 percent. During assessment of patients with constipation the effects of medications and chronic diseases must be discarded and the ideal is to determine which type of functional disorder it present. An algorithm for the management of chronic idiopathic constipation, that includes a recommendation to increase fiber and liquid intake as an initial approach and an orientation to the use of different laxatives, is presented. The usefulness of biofeedback in patients with pelvic floor dysfunction and without organic cause of constipation, is also discussed.

Prevalencia de marcadores serológicos ANCA y ASCA en una población con colitis ulcerosa / Presence of antineutrophil cytoplasmic antibodies (ANCA) and anti Saccharomyces cerevisiae antibodies (ASCA) among patients with ulcerative colitis

Background: The diagnosis of inflammatory bowel disease is supported by clinical findings and complementary tests. The presence of specific serological markers could be helpful in the characterization of this condition. Aim: To assess the prevalence of ANCA and ASCA in a group of patients with ulcerative colitis (UC) and its association with clinical features. Material and Methods: Sixty four patients with UC in remission (age range 16-72 years, 33 males) were studied. In a venous blood sample ANCA were measured by indirect immunofluorescence and ASCA by enzyme immune assays for IgG and IgA. Results: Forty four percent of patients were positive for ANCA, 9 percent for ASCA and 6 percent for both markers. There was a significant correlation between the presence of ANCA and duration of the UC (<5 years 50 percent, 5-10 years 42.9 percent, 15 years 30 percent) and the number of crises (one crises 31 percent, 2-5 crises 51.9 percent and >5 crises 87.5). The proportion of colectomized patients with positive ANCA was higher (57.1 percent). Conclusions: The prevalence of ANCA in the studied population is similar to the published data. The presence of ANCA was significantly higher in UC patients with shorter evolution, higher number of crises and in those with a history of colectomy. There was a low prevalence of ASCA positive patients.

Sobrevida y calidad de vida dos años después de la unidad de cuidados intensivos / Survival and quality of life 2 years after intensive care unit

Objetive: to evaluate survival and quality of life in a group of patients admitted into a general intensive care unit (ICU) two years before, identifying factors, prognosis and differences by age groups. Design: prospective observational study. Location: general intensive care unit at a university hospital. Patients: 45 patients admitted between june and july 1999 and evaluated until august 2001. Measurements: information referring to age, sex, initial diagnosis, assessment according to the acute physiology and chronic health evaluation (APACHE) II, life quality survey upon admittance and telephone survey after two years, intrahospital mortality and postdischarge. Results: average age: 60. Older than 65:19 (42 percent). Males: 22 (49 percent). Intrahospital mortality: 12 (26 percent), mortality at 2 years: 21 (47 percent). Total mortality under age 65 versus over 65:10 to 9 (p0,7). Total mortality over age 80:100 percent (p 0,04). APACHE II average upon admittance: 14. APACHE II average of deceased at the hospital versus non deceased: 18 and 12 (p 0.03). APACHE II average of deceased during the study versus non deceased: 17 and 11 (p 0.002). Quality of life score upon admittance between those over and under 65:5.6 and 1.9 (p 0.002), daily life activities list between deceased and non deceased: 3,7 and 1.6 (p 0,023), 62 percent of the survivors (15 out of 24) maintained of improved their quality of life after two years of follow-up. Conclusions: A high mortality rate appeared throughout the two year follow-up. This was non related to age except for those patients over age 80. Those patients over age 65 had a worse quality of life upon admittance, while an indicator of greater mortality was a deterioration of day to day activities. Most of those that survived the two-year period were able to improve or maintain the quality of life level presented before admittance independently of the age group. APACHE II confirmed itself as a predictor of mortality, both intra and extrahospital

Calidad de vida después de la unidad de cuidados intensivos / Quality of life after intensive care unit

La evaluación en la calidad de vida que presentan los pacientes posterior a su estadía en UCI, tiende a ser en la actualidad el parámetro que evalúa la utilidad de las Unidades de Cuidados Intensivos. La no existencia de datos claros al respecto nos motivó a ubicar y luego utilizar una encuesta de fácil aplicación e interpretación que fuera reproducible intra e interlocutor. Esta encuesta fue aplicada a 47 pacientes que voluntariamente aceptaron responderla y que habían permanecido hospitalizados en la UCI de nuestro Hospital por más de 48 hrs, y fueron dados de alta 18 meses antes que se aplicara la encuesta. Los resultados obtenidos en los tópicos evaluados son comparables con los publicados en la escasa literatura que existe al respecto, y nos permite establecer un patrón de comparación para futuros estudios sobre el tema

Trombosis masiva de vena cava inferior asociada a déficit de proteína C: caso clínico / Massive inferior vena cava thrombosis associated to protein C deficiency: one case report

Inferior vena cava thrombosis is infrequent and in 30 percent of cases, the potential cause is an alteration of the natural anticoagulant protein system. We report a 18 years old male with an inferior vena cava thrombosis that was associated to a protein C deficiency. He was successfully treated with an infusion of intravenous streptokinase during 30 hours and intravenous heparin during 10 days, followed by oral anticoagulation therapy