Rol de la laparoscopía diagnóstica en un departamento de emergencia / Importance of the diagnostic laparoscopy in an urgency care department

Diagnostic laparoscopy is a surgical diagnostic procedure used to examine the organs inside the abdomen by mean of an optic fiber. The patient with acute abdominal pain and with a not clearly etiology, can represent a great challenge at the moment to perform a definitive diagnosis at urgency. The paraclinic studies must be required considering the particular characteristics of each patient and its clinical presentation at the moment of the medical attention. Considering the more frequent indications for the laparoscopic approach, the diagnostic laparoscopy, occupies the third place after the acute appendicitis and the acute cholecistitis. The aim of this report was to consider a casuistic of 356 patients with acute abdominal pain of uncertain etiology, studied by the authors. Of these patients, the 88% were females. From the rsults obtained, it becomes evident that the video diagnostic laparoscopy proved to be an effective technique in the emergency department with benefit for the patients, mainly for acute cases

Tratamiento del abdomen agudo quirúrgico por cirugía endoscópica / Acute surgical abdomen treatment by endoscopic surgery

Introducción: Actualmente, casi todas las operaciones abdominales han podido ser realizadas por vía laparoscópica, lo que ha dado la posibilidad de aplicarla a la cirugía abdominal de urgencia. Objetivo: Mostrar los resultados del tratamiento del abdomen agudo quirúrgico mediante la cirugía endoscópica en el Hospital General Docente Comandante Pinares. Método: Se realizó un estudio descriptivo, longitudinal y prospectivo con un total de 135 pacientes con el diagnóstico de abdomen agudo quirúrgico intervenidos por cirugía endoscópica en dicho hospital, ubicado en el municipio de San Cristóbal, provincia Artemisa desde marzo del 2011 hasta noviembre del 2013. Se analizaron variables como la edad, el sexo, factores etiológicos, tratamientos utilizados y las complicaciones transoperatorias y posoperatorias. Resultados: El periodo de edad más atendido fue el de 16 - 25 años sin despreciar la edad pediátrica. La apendicitis aguda fue la entidad tratada con más frecuencia. El tiempo quirúrgico promedio fue menor de una hora. La estadía posoperatoria disminuyó considerablemente. Conclusiones: Quedó demostrado que el tratamiento laparoscópico del abdomen agudo quirúrgico es un método confiable y seguro para esta entidad(AU)

Introduction: Nowadays, virtually all abdominal operations have been performed laparoscopically, which has made it possible its application to the emergency abdominal surgery. Objective: To show the results of the acute surgical abdomen treatment through endoscopic surgery in Comandante Pinares General Teaching Hospital. Method: A descriptive, longitudinal and prospective study was carried out with a total of 135 patients with the diagnosis of acute surgical abdomen and operated by endoscopic surgery in the aforementioned hospital, located in the municipality of San Cristóbal, Artemisa Province, from March 2011 to November 2013. Variables such as age, sex, etiological factors, treatments used, and transoperative and postoperative complications were analyzed. Results: The most attended period of age was 16-25 years, without ruling out the pediatric age. Acute appendicitis was the most frequently treated entity. The average surgical time was less than one hour. The postoperative stay decreased considerably. Conclusions: Laparoscopic treatment of acute surgical abdomen was proved to be a reliable and safe method for this entity(AU)

Acute Abdomen Secondary to Ruptured Epithelial Ovarian Cancer during Pregnancy: The Relevance of Teamwork / Abdome agudo secundário à ruptura do câncer do ovário epitelial durante a gravidez: a importância do trabalho em equipe

Abstract Acute abdomen secondary to epithelial ovarian cancer rupture during pregnancy is a rare event. Our aim is to present how the work of a coordinated multidisciplinary team in a case of ruptured epithelial ovarian cancer during pregnancy is feasible to obtain the best results possible. A 34-year-old woman during the 37th week of her first gestation presented with an acute abdomen. During laparotomy, a ruptured 16.5-cm left ovarian tumor was detected; the tumor was extirpated and sent to pathologic evaluation. In the meantime, a Kerr cesarean section was performed, and a healthy female neonate was born. The tumor was diagnosed as a cystadenocarcinoma; therefore, the family and the combined surgical team (obstetricians and a surgical oncologist) decided to complete a definitive radical ovarian cancer surgery: hysterectomy, right salpingooophorectomy, lymphadenectomy, omentectomy and appendectomy. The patient's postoperative evolution was uneventful, and she was sent to adjuvant chemotherapy.

Resumo O abdome agudo secundário à ruptura do câncer do ovário epitelial durante a gravidez é um evento raro. Nosso objetivo é apresentar como o trabalho de uma equipe multidisciplinar coordenada em um caso de ruptura do câncer de ovário epitelial durante a gravidez é viável para obter os melhores resultados possíveis. Umamulher de 34 anos de idade, durante a 37a semana de sua primeira gestação, apresentou um abdome agudo. Durante a laparotomia, foi detectado um tumor ovariano esquerdo com ruptura de 16,5 cm; O tumor foi extirpado e enviado para avaliação patológica. Enquanto isso, uma cesariana de Kerr foi feita, e uma recém-nascida saudável nasceu. O tumor foi diagnosticado como um cistoadenocarcinoma; então, a família e a equipe cirúrgica combinada (obstetras e oncologista cirúrgico) decidiram concluir uma cirurgia radical definitiva do câncer de ovário: histerectomia, salpingo-ooforectomia direita, linfadenectomia, omentectomia e apendicectomia. A evolução pós-operatória da paciente foi sem intercorrências, e ela foi enviada para quimioterapia adjuvante.

Cateterismo de artéria mesentérica para tratamento de trombose de veia porta / Catheterization of the mesenteric artery to treat portal vein thrombosis

A trombose de veia porta é uma causa rara de abdome agudo vascular e está diretamente relacionada a trombofilias hereditárias ou adquiridas. O caso de um paciente de 60 anos, sexo masculino, com quadro clínico de isquemia mesentérica confirmada por exame de imagem é apresentado. Foi submetido a enterectomia e enteroanastomose e, após esplenoportografia que detectou trombose de veia porta, indicou-se tratamento medicamentoso com infusão contínua de ativador tecidual do plasminogênio recombinante (Alteplase) através de cateterismo seletivo da artéria mesentérica superior. Trata-se de um tratamento inovador. Obteve-se sucesso na recanalização do sistema porta. O paciente evoluiu com quadro de sepse abdominal, necessitando de assistência em terapia intensiva por 25 dias. Evoluiu bem e recebeu alta hospitalar com o uso de anticoagulante. O artigo apresenta uma breve revisão de literatura e discussão do caso clínico

Portal vein thrombosis is a rare vascular cause of acute abdomen and it is directly related to hereditary or acquired thrombophilias. This article presents the case of a 60-year-old male patient, with clinical signs of mesenteric ischemia that was confirmed by imaging examination. He underwent enterectomy and enteroanastomosis and, after detection of portal vein thrombosis by splenoportography, he was prescribed drug-based treatment with continuous infusion of recombinant tissue plasminogen activator (Alteplase) via selective catheterization of the superior mesenteric artery. This is a treatment innovation. The portal system was successfully recanalized. However, the patient developed abdominal sepsis and required intensive care for 25 days. His clinical status improved and he was discharged with a prescription for oral anticoagulant. This article presents a brief review of the literature and a discussion of portal vein thrombosis

Diagnóstico e manejo da diverticulite aguda / Diagnosis and management of acute diverticulitis

O presente trabalho destina-se a elucidar o tratamento recomendado para as diferentes fases da diverticulite, assim como também esclarece aspectos da progressão da doença diverticular para o processo inflamatório que ocorre no intestino.

This paper is intended to elucidate the recommended treatment for the different stages of diverticulitis, as well as light aspects of diverticular disease progression to the inflammatory process that occurs in the intestine.

Abdome agudo não-obstétrico durante a gravidez: aspectos diagnósticos e manejo / Non-obstetrical acute abdomen in pregnancy: diagnostic and management aspects

O abdome agudo na gravidez é entidade rara, cujo diagnóstico é dificultado devido às alterações fisiológicas típicas da gravidez que tornam os achados menos evidentes. Embora o abdome agudo obstétrico seja mais comum, a dor abdominal não obstétrica apresenta considerável impacto na morbimortalidade materno-fetal. Sua etiologia inclui, principalmente, apendicite aguda, doença biliar, obstrução intestinal, pancreatite e trauma abdominal. O diagnóstico e o tratamento devem ser instituídos precocemente com o intuito de reduzir complicações para mãe e feto. Diante da importância do tema, o presente artigo tem por objetivo realizar atualização sobre os aspectos etiológicos, diagnósticos e de manejo do abdome cirúrgico não obstétrico.

Acute abdomen in pregnancy is a rare condition with a difficult diagnosis because of the typical physiological alterations of pregnancy that make the findings less evident. Although obstetric acute abdomen is more common, non-obstetric abdominal pain has a marked impact on the morbidity and mortality of the mother and fetus. The etiology of non-obstetric acute abdomen includes mainly: acute appendicitis, biliary disease, intestinal obstruction, pancreatitis, and abdominal trauma. The diagnosis and treatment should be established early to reduce complications for the mother and fetus. Considering the importance of the subject, the objective of the present paper was to report an update on the etiological aspects, diagnosis and management of non-obstetric surgical abdomen.

Acute abdomen at El Obeid Hospital, Western Sudan

Acute abdominal pain is the presenting complaint in emergency departments of all hospitals worldwide, resulting in a huge drain of human and non-human resources. To study the pattern, causes and management outcomes of patients presenting with acute abdomen to El Obeid Hospital, Western Sudan. This was a prospective study. All patients who presented with acute abdomen to the University Surgical Unit at El Obeid Hospital between January 1999 and December 2000 were included. The patient characteristics, clinical features, investigations, management and postoperative care were recorded in a pre-designed sheet. There were 421 patients. 242 were males [57.5%]. Acute appendicitis was the commonest cause accounting for 63% of the patients, followed by acute intestinal obstruction 20.4% and abdominal trauma 11.6%. One third of the patients with acute appendicitis reported with complications. The majority of acute intestinal obstruction cases were due to obstructed and/or strangulated hernia. Acute cholecystitis and perforated duodenal ulcers were not common. Perforated typhoid ulcers and tuberculous peritonitis were less frequent but had high mortality. The overall mortality was 8.5% and those deaths occurred mostly in patients presenting late with generalized peritonitis. Acute abdomen was a common surgical emergency at El Obeid Hospital, Western Sudan. The leading causes were acute appendicitis, acute intestinal obstruction and abdominal trauma. Awareness of the seriousness of the condition and better hospital facilities and care may reduce an unacceptable high mortality

Abdômen agudo / acute abdomen

O abdome agudo configura um quadro clínico de dor dos mais importantes efreqüentes na prática clínica. Pela sua gravidade necessita de condutas diagnósticas eterapeuticas urgentes. Pode ser decorrente de inúmeras doenças. O texto discorre sobre diferentesetiopatogenias e as bases do quadro clínico, essenciais para o diagnóstico e tratamento.

The acute abdomen is one of the major and most frequently occurring syndromesin clinical practice and, since it can be caused by various different diseases, it demands an urgentdiagnosis and treatment. The present text expatiates upon the different etiopathogeneses of thissyndrome as well as upon its bases, which are crucial for the diagnosis and treatment of an acuteabdomen.

Abdômen agudo / Acute abdomen

O abdômen agudo pode ser definido como uma dor abdominal de aparecimento súbito, não traumático, que pode necessitar de intervenção cirúrgica ou não. A anamnese detalhada direcionando o exame físico será a base que orientará a condução do tratamento precoce e o restabelecimento do paciente. Considerando o grande número de doenças que podem se manifestar como abdômen agudo, o objetivo desta revisão é produzir uma sistemática de abordagem, para facilitar o diagnóstico e evitar exames desnecessários ou que retardem o tratamento específico, melhorando o atendimento e o manejo do paciente, conseqüentemente propiciando um retorno às atividades habituais precocemente.

The acute abdomen can be defined as an acute, non-traumatic abdominal painthat needs medical care, and in some situations surgical intervention. This clinical scenario is veryfrequent, in the emergency room. Detailed anamnesis directs the physical examination, and will bethe guideline to conduct the early treatment and the reestablishment of the patient. Due to the greatnumber of diseases related with this syndrome, our goal was to review the literature and to producean objective and practical methodology, with the aim to facilitate the diagnosis and to preventunnecessary exams, which may delay the specific treatment, improving the assess and care of thepatient.

Abdomen agudo: consideraciones generales / Acute abdomen: general considerations

Abdomen agudo es una terminología ampliamente utilizada y que se aplica a una serie de cuadros clínicos de diversas naturalezas y etiología. Clínicamente se consideran como abdómenes agudos cuadros caracterizados por intenso dolor abdominal de comienzo súbito o gradual pero rápidamente progresivo. Entre los abdómenes agudos los hay quirúrgicos y médicos, los que se diferencian por la existencia o no de signos peritoneales.

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.

La asociación propinox-clonixinato de lisina en dolor abdominal agudo / The association propinox-lysine clonixinate in acute abdominal pain

Se estudiaron 1625 pacientes portadores de dolor cólico abdominal agudo (cólico intestinal y renal, discinesia biliar con o sin litiasis, dispepsia no ulcerosa, dismenorrea, movilización del DIU y criocirugía del cuello uterino) que presentaron al momento de la incorporación dolor de intensidad moderada o severa. Fueron asignados al azar y doble ciego en 2 grupos expermientales con Clonixinato de lisina 125 mg asociado a Propinox 10 mg (CLP) (N=818) o N-butilbromuro de hioscina 10 mg asociado a Paracetamol 500 mg (PB) (N=807). El tratamiento consistió en un comprimido, de igual aspecto en ambas drogas, como dosis única. El efecto analgésico-antiespasmódico fue evaluado horariamente durante un lapso de 4 hs. En cada control se estabaleció la evolución del dolor, como así también de otros síntomas acompañantes, mediante escala visual análoga (EVA) de 10 cm y escala de categorización verbal de 4 niveles. Asimismo, en cada oportunidad se indagaron la frecuencia de eventos adversos. En el control final de las 4 horas el paciente y el médico efectuaron una evaluación global sobre la eficacia y tolerancia al tratamiento. Ambos grupos fueron equivalentes entre sí en lo referente a condiciones basales (características demográficas, etiológicas y dolor espontáneo), por lo que se asume que se trata de muestras homogéneas y comparables entre sí. Con ambos métodos de registro se demostró una reducción progresiva de la intensidad del dolor, que se hizo significativa a partir del control de la 1a. hora, con una reducción para los 2 tratamientos en alrededor de un 43 por ciento respecto del valor inicial.La actividad analgésica sostenida queda demostrada para ambos tratamientos en razón que en el control final de las 4 hs los valores de EVA fueron menores de 1. La salida del ensayo por ineficacia en el control de la 1a. hora fue similar: 14 por ciento por el CLLP y 12 por ciento para PB. No se demostraron diferencias estadísticas en las intensidades de dolor en cada tiempo entre los 2 tratamientos. Los signos y síntomas asociados a la patología de inclusión (cefaleas, náuseas y diarrea) se redujeron significativamente entre la 1a. y 2da. hora de control. Se observó un ligero incremento (no significtivo) en la incidencia de boca seca y visión borrosa. La evaluación global de eficacia analgésica fue considerada buena en el 81 por ciento (CLP) y 80 por ciento (PB) de las opiniones de médico y en un 78 por ciento y 79 por ciento respectivamente cuando lo hizo el paciente

Endometriosis intestinal como urgencia quirúrgica / Surgical energencies due to intestinal endometriosis

Se presenta un caso de una mujer de 31 años, núbil con endometriosis estadio IV, la cual fue manejada con danazol vía oral y goserelina en implantes y que posteriormente a la suspensión del tratamiento presenta cuadro doloroso abdominal y datos de oclusión intestinal, ameritando una laparotomía exploradora de urgencia con resección del íleo terminal y ciego, y unión íleo-cólica con anastomosis término-terminal. En una segunda cirugía ginecológica por dolor abdominal y dismenorrea persistentes, se le realiza tratamiento definitivo de la endometriosis con una histerectomía total abdominal con salpingooforectomía bilateral seguida de terapia hormonal de reemplazo. La endometriosis y la endometriosis intestinal es raramente encontrada por el cirujano general por lo que deberá ser considerada para su diagnóstico diferencial y hacer equipo para su tratamiento

Laparoscopy-a diagnostic and therapeutic tool in management of acute abdomen

The role of laparoscopy in the management of patients presenting to one surgical firm with an acute abdomen is discussed. 37 laparoscopies were performed over a 24 months period and it altered the diagnosis in 24.3% of cases and the management in 13.5% of cases. At laparoscopy the diagnosis of appendicitis was made in 17 patients [76.4% were attempted laparoscopic appendectomies], pelvic inflammatory disease in 5 patients, torted fimbrical cyst in 2 patients and free pus in the right lower peritoneum as a result of a perforated appendix was seen in 4 patients. Normal laparoscopy was performed in 5 patients and 2 patients who presented with a perforated duodenal ulcer had the diagnosis confirmed at laparoscopy. 2 laparoscopies were performed on trauma patients, one stabbing and one blunt trauma to the right hypochondrium. It has been demonstrated that diagnostic laparoscopic is a useful adjunct to the general surgeon's armamentarium. It is suggested that the skill of laparoscopy is passed on to junior trainee surgeons who can use this technique to help attain a diagnosis in patients presenting with an acute abdomen

Monoterapia con cefoperazona sulbactam en infecciones intraabdominales / Monotherapy with cefoperazone sulbactam in intraabdominal infections

Se evaluó la eficacia y tolerancia de cefoperazona-sulbactam (CPZ-SBT) como monoterapia en pacientes con infección intraabdominal. Se incluyeron 30 pacientes con diagnóstico de infección intrabdominal que requerían de intervención quirúrgica y antibioticoterapia. Hemocultivos y cultivos de fluidos de la fuente de infección fueron realizados, determinandose la sensibilidad in vitro de los gérmenes aislados. Se realizó evaluación clínica y de laboratorio antes, durante y después de finalizar el tratamiento. De 3 a 9 grs endovenosos de CPZ-SBT, obteniéndose 68,4 por ciento de erradicación y 31,6 por ciento de superinfección. Clinicamente, hubo 80 por ciento de curación y 20 por ciento de fracaso. No hubo efectos adversos atribuibles al uso del antibiótico. La CPZ-SBT puede ser utilizada en el tratamiento de infecciones intraabdominales con alto índice de curación y buena tolerancia

Infección de la pared abdominal en el manejo de apendicitis aguda

La infección postoperatoria de la herida quirúrgica en pacientes que presentaron abdomen agudo inflamatorio es alarmante. El objetivo de este trabajo es determinar el índice de infección de la pared abdominal en nuestro Hospital y marcar pautas correctoras para disminuir la morbilidad hospitalaria por esta causa. El presente estudio prospectivo, abarca pacientes ingresados de enero a marzo de 1997 en el Servicio de Cirugía General del Hospital Carlos Andrade Marín con diagnóstico de Abdomen Agudo Inflamatorio. Se determinó tres grupos de estudio de acuerdo al tipo de cirugía: limpia contaminada, contaminada y sucia. Se incluyeron solo los pacientes con histopatológico positivo para enfermedad apendicular y se excluyó a pacientes con patologías adyuvantes y embarazadas. Nuestro trabajo concluyó que el mayor porcentaje de cirugías correspondían a limpias contaminadas 58.7 por ciento y el menor a sucias 11,7 por ciento. El índice de infección fue del 1,5 por ciento, 19,3 por ciento, 28,5 por ciento en estos tres grupos respectivamente. Nuestro estudio demostró la ineficacia de manejar la pared abdominal en forma primaria o diferida para evitar infeciones pues se encontró infección en ambos procesos con un porcentaje mayor en heridas diferidas 8,8 por ciento en cirugía contaminada y 25 por ciento en cirugía sucia y estableció que la única forma de reducir y prevenir la infección de herida es el manejo en la técnica operatoria.

Conduta na ulcera duodenal perfurada / Surgical management on perforated duodenal ulcer

Os autores, por meio de um questionario enviado aos cirurgioes do Estado de Santa Catarina, analisaram o tratamento cirurgico da ulcera duodenal perfurada em varias situacoes com: perfuracao recente; ulcera duodenal cronica em uso de antagonista H2; pacientes idosos em uso de anti-inflamatorio nao hormonais; perfuracao duodenal com peritonite e a experiencia com o tratamento conservador. Os resultados mostraram a preferencia por uma cirurgia definitiva (vagotomia troncular + resseccao gastrica) com excecao dos casos com peritonite. A maioria dos cirurgioes nao teve experiencia com tratamento conservador. Concluimos que o uso de novas drogas, a experiencia do cirurgiao e as condicoes clinicas do paciente podem influenciar no tratamento da ulcera duodenal perfurada.