Reporte de un caso: Muerte súbita de Origen Ginecoobstétrico / Sudden death of gyneco-obstetric origin: Case report

Resumen La muerte súbita de origen ginecoobstétrico es poco frecuente tanto en paises americanos como del viejo continente, sin embargo, este tipo de defunciones es por concepto relevante para la legislación de Costa Rica al ser criterio de autopsias médico legales, donde se responde no solo la causa de muerte, sino también otros objetivos propias de la necropsia, como la manera de muerte, donde debe descartarse una diferente a la natural. Los embarazos ectópicos rotos tienen significancia en los registros actuales según la razón de mortalidad materna, con repercusión en la salud reproductiva de las pacientes que lo padecen, convirtiéndose en una patología relevante para el registro médico clínico como forense.

Abstract Sudden death of gyneco-obstetric origin is rare in both American countries and the old continent, however, this type of death is conceptually relevant to Costa Rican legislation as it is the criterion of medical-legal autopsies, where not only the cause is answered of death, but also other objectives typical of the autopsy, such as the way of death, where one other than the natural one must be ruled out. Broken ectopic pregnancies are significant in current records according to the reason of maternal mortality, with repercussions on the reproductive health of patients who suffer from it, becoming a relevant pathology for clinical medical and forensic records.

Splenic Rupture following Colon Polypectomy: A Case Report and Review of Literature / 대한소화기학회지

Colonoscopy is a safe procedure performed routinely worldwide. Splenic rupture is a rare complication of colonoscopy with several reported cases since 1974. We report the first case of a complication in the Republic of Korea. The literature on this rare complication is also reviewed here, with focus on the analysis of risk, diagnosis, and treatment. A 77-year-old patient receiving oral aspirin underwent colonoscopy with polypectomy. After 24 hours, the patient experienced dizziness and hypotension. Colonoscopy was performed to exclude intestinal bleeding, which could be diagnosed with hemoperitoneum. A computed tomography scan showed copious abdominal free blood and a splenic rupture. An urgent splenectomy was performed, which was the recognized procedure of choice. Physicians should have greater awareness of the possibility of splenic rupture following colonoscopy in order to avoid delay of diagnosis and treatment for this life-threatening complication.

Hemoperitoneum due to Ruptured Gastric Gastrointestinal Stromal Tumor / 대한소화기학회지

The stomach is the most frequent site of gastrointestinal stromal tumor (GIST). The common clinical manifestation of GIST are melena and hematochezia caused by gastointestinal bleeding. However, hemoperitoneum due to GIST rupture is a very rare condition. We describe a 33-year-old man with gastric GIST causing hemoperitoneum. A preoperative CT scan demonstrated large amount of fluid collection and extraluminal mass lesion in gastric antral area. He underwent an emergent laparotomy. The antral mass was polypoid shaped and showed ruptured focus. We performed a distal gastrectomy. The tumor was revealed as GIST with intermediate malignant risk by pathologic examination. The patient had an uneventful postoperative course and remains well.

An unusual case of hemoperitoneum owing to acute splenic torsion in a child with immunoglobulin deficiency.

Wandering spleen is an uncommon clinical entity, which rarely affects children and adolescents. It is usually described in adults, being most common in the multiparous women of childbearing age. A case of a 14-year-old girl with a past history of splenomegaly and immunoglobulin A (IgA) deficiency, who presented with a sudden onset of abdominal pain, is presented. Diagnosis of hemoperitoneum secondary to torsion of a wandering spleen was made by computed tomography scan and Doppler ultrasound. Laparoscopy revealed hemoperitoneum owing to a ruptured and infarcted spleen. Laparotomy was undertaken and open splenectomy was successfully performed. The patient was discharged after an uneventful postoperative course that was not punctuated by any major complication. Management of this rare surgical emergency is discussed. Based on the details of this case, the authors hypothesize that IgA deficiency causes splenomegaly, which in turn predisposes to ligamentous laxity and splenic torsion.

Hemoperitoneo secundario a la rotura espontánea de la vena mesentérica / Abdominal bleeding due to spontaneous mesenteric vein rupture

La cirrosis hepática es la principal causa de hipertensión portal y se asocia con el desarrollo de venas esplácnicas varicosas. La rotura de várices intraabdominales es una causa rara de hemoperitoneo. Se presenta el caso de hemoperitoneo espontáneo por rotura de vena mesentérica superior varicosa. Caso clínico: varón de 43 años con antecedentes de cirrosis alcohólica (estadio C de Child-Pugh) y múltiples internaciones por hemorragia digestiva variceal. Consulta por episodios sincopales y distensión abdominal. Al examen físico se presento: vigil, orientado, hipotenso, con tilt test positivo, distensión abdominal, estigmas cutáneos de hepatopatía crónica. Laboratorio: anemia, plaquetopenia, rolongación de los tiempos de coagulación. TAC de abdomen: líquido libre en cavidad peritoneal. Laparotomía exploradora: se extraen tres litros de sangre de cavidad abdominal. Se visualiza vena mesentérica superior varicosa con una zona en forma de pezón que muestra punto de sangrado en jet, intermitente. No se evidenció daño de otro órgano. Se procedió a la rafia de la lesión lográndose hemostasia. El paciente evolucionó favorablemente abandonando el hospital 10 días después del ingreso. Objetivo: presentar un paciente con una causa poco común de hemoperitoneo y remarcar la buena evolución, ya que este tipo de patología suele tener alta mortalidad.

Hepatic cirrhosis is the leading cause of portal hypertension and is usually associated with the development of splacnic varices. Variceal intraabdominal rupture is a rare cause of hemoperitoneum. A case of spontaneous mesenteric vein rupture is reported. Clinical case: 43 year old man with hepatic cirrhosis (Child-Pugh C stage) and previous bleeding of esophageal varices, admitted to hospital because of orthostatic hypotension episodes (positive tilt test) and abdominal distention. Laboratory: anemia, low platelet count and abnormal coagulation tests. CT scan showed abdominal fluid. Exploratory laparotomy was performed and 3 liters of blood were found into the abdominal cavity. The mesenteric vein had a ruptured variceal dilatation with intermitent jet bleeding. No organ abnormalities were found. Repair of the dilated vein was performed. The patient evolved well and was dismissed from hospital ten days after admittance. Objective: To present a case in which a rare cause of intraabdominal bleeding, usually associated with high mortality rate, is follawed by a good clinical evolution.

Spontaneous Uterine Rupture in the First Trimester: A Case Report

Uterine rupture is one of the most feared obstetric complications affecting the pregnant woman and fetus. Most of the cases have various risk factors and mainly occur during the second or third trimester. However, spontaneous uterine rupture during the first trimester is extremely rare. We experienced a case of spontaneous uterine rupture in a 36-yr-old multiparous woman without definite risk factors. The initial impression was a hemoperitoneum of an unknown origin with normal early pregnancy. Intensive surgical method would be needed for accurate diagnosis and immediate management in bad situation by hemoperitoneum even though a patient was early pregnancy.

Experience in diagnosis and treatment of bleeding complications in severe acute pancreatitis by TAE / 华中科技大学学报（医学）（英德文版）

The experience in diagnosis and treatment of bleeding complications in severe acute pancreatitis (SAP) by transcatheter arterial embolization was summarized. The clinical data of 19 SAP patients complicated with intra-abdominal bleeding in our hospital from Jan. 2000 to Jan. 2003 were analyzed retrospectively and the therapeutic outcome of TAE was evaluated statistically. The results showed that the short-term successful rate of hemostasis by TAE was 89.5% (17/19), the incidence of re-bleeding after TAE was 36.8% (7/19) and the successful rate of hemostatis by second TAE was 71.4% (5/7). It was concluded that the intra-abdominal bleeding in SAP was mainly caused by the rupture of erosive/infected pseudoaneurysm. Mostly, the broken vessels were splenic artery and gastroduodenal artery; In terms of emergence hemostatis, TAE is the most effective method. Surgical hemostasis is necessary if hemostasis by TAE is failed or re-bleeding occurs after TAE.

Clasificación de las colecciones abdominales diagnosticadas por ecografía en pacientes traumatizados / Classification of abdominal collections with ultrasound studies in traumatized patients

Antecedentes: La ecografía abdominal como método de estudio en el manejo de los pacientes con traumatismo cerrado de abdomen, ha pasado a tener una gran importancia, a punto tal, que se le ha otorgado un lugar prioritario en los distintos protocolos de atención. Objetivo: Aplicar una clasificación de las colecciones abdominales diagnosticadas por ecografia en pacientes traumatizados, y evaluar su posible utilidad como complemento de la clínica para la toma de decisiones terapéuticas en este tipo de pacientes. Lugar de Aplicación: Servicio de Emergencia y de Cirugía General hospitalarios. Diseño: Estudio observacional retrospectivo basado en criterios básicos y descripción de hallazgos clínicos (serie de casos). Población: Muestra consecutiva de 1.214 casos de pacientes politraumatizados, con certero o posible traumatismo cerrado de abdomen, a los cuales se les efectuó ecografía abdominal como método de estudio inicial para la detección de colecciones, en el periodo comprendido entre 1/1/97 y el 30/6/99. Método: Se analizaron la historias clínicas de los pacientes de la población en estudio para determinar qué casos presentaron ecografías positivas, y aplicar en ellos una clasificación por grados de las colecciones observadas. Se analizó el tipo de tratamiento realizado inicialmente en los casos correspondientes a los distintos grados y se estudió la evolución clínica de los pacientes en los que se tomó conducta no operatoria, junto al número de casos en los que se debió modificar la conducta expectante tomada inicialmente. Resultados: Se observaron colecciones abdominales (estudios positivos) en 86 casos (7,08 por ciento). La distribución por grados fue: Grado II 22,09 por ciento, Grado III 29,06 por ciento, Grado IV 23,25 por ciento y Grado V 10,46 por ciento. Se realizó inicialmente tratamiento quirúrgico en 66 casos (76,75 por ciento) y no operatorio en 20 casos (23,25 por ciento). De los que no fueron explorados inicialmente, en el 100 por ciento de los casos de Grado I y II la evaluación fue satisfactoria y no requirieron intervención quirúrgica, en el 50 por ciento de los de Grado III y en el 100 por ciento de los Grados IV y V se debieron realizar laparotomías por descompensación hemodinámica

Rol de la relaparoscopía en las complicaciones postoperatorias de procedimientos laparoscópicos / Rol of relaparoscopy in abdominal complicactions after laparoscopic surgery

Antecedentes: El tratamiento de complicaciones abdominales de operaciones laparoscópicas por medio de una nueva laparoscopía es objeto de controversias. Objetivo: Evaluar el rol de la relaparoscopia en algunas complicaciones abdominales luego de cirugía laparoscópica analizando su utilidad diagnóstica, eficacia diagnóstica, eficacia terapéutica y morbimortalidad. Lugar de aplicación: Hospital privado de Comunidad. Población: Veintidos pacientes con relaparoscopias, efectuadas en 3983 operaciones laparoscópicas desde junio/96 a mayo/2000: 2076 colecistectomías (52.1 por ciento). 1065 hernioplastías (26,7 por ciento), 473 apendicectomías (11,9 por ciento), 211 laparoscopías exploradoras (5,3 por ciento), 63 eventroplastías (1,6 por ciento), 53 operaciones de Nissen (1,3 por ciento), 10 colocaciones de bandas gástricas (0.3 por ciento), 8 suprarrenalectomías (0,2 por ciento) y 7 esplenectomías (0,2 por ciento). Diseño: Estudio retrospectivo de casos clínicos. Método: Se estudiaron los 22 pacientes en los que se efectuó una relaparoscopía, registrándose la efectividad diagnóstica y terapéutica del procedimiento y sus complicaciones. Resultados: Se realizaron 22 relaparoscopías en 4 coleperitoneos, 6 hemoperitoneos, 5 obstrucciones intestinales, 3 abscesos intraabdominales y 4 perforaciones de víscera hueca con peritonitis. Se resolvieron satisfactoriamente por la vía laparoscópica los 4 coleperitoneos, 4 hemoperitoneos, 2 obstrucciones intestinales y 1 perforación gástrica. Hubo alta morbilidad en los abscesos intraabdominales relaparoscopiados, que disminuyó en las relaparoscopías de las obstrucciones intestinales. La incidencia de conversiones fue del 40.9 por ciento. Conclusiones: La reiteración del abordaje laparoscópico en las complicaciones abdominales de las operaciones laparoscópicas, tuvo buena utilidad diagnóstica y eficacia terapéutica en los pacientes con coleperitoneo y hemoperitoneo. La mayor morbilidad se registró en los enfermos con abscesos intraabdominales, y a pesar de su eficacia diagnóstica en las obstrucciones intestinales y las perforaciones de víscera hueca, la relaparoscopía tuvo menos terapéutica en nuestros casos con estas patologías

Evaluation of blunt abdominal trauma with a protocol using both diagnostic peritoneal lavage and computed tomography

The purpose of this study is to try to evaluate blunt abdominal trauma patients for presence of intra-abdominal injury rapidly and effectively .A protocol is tested combining and selecting the use of physical examination, diagnostic peritoneal lavage [DPL] and abdominal computed tomography [C.T] with the aim to avoid missing injuries or to do non therapeutic laparotomies and also aiming to reduce health cost. Preprotocol period [20 months] include 651 cases that were triaged according to haemodynamic stability and result of abdominal examination, into 3 groups. Group I [stable patients with suspicious or unreliable abdominal examination] include 150 patients that were evaluated by abdominal CT. Group II [unstable patients] include 52 patients that were evaluated by DPL alone. Group III [stable patients with reliable and normal or mildly symptomatic abdomen] include 449 patients that were evaluated by physical examination alone. The protocol period [16 months] include 512 patients that were triaged, as in the pre-protocol period, into group l[153 patients], group ll[26 patients] and group III [333 patients]. Evaluation in groups II and III were the same as in the pre protocol period while in group I cases were evaluated by DPL followed in positive cases by abdominal C.T to decide upon conservative treatment. The results in groups II and III were comparable in both pre-protocol and protocol groups. However in group I in the protocol period there is drop in the use of emergency C.T from 23% to 8%, drop in missed injuries from 6% to zero% and no non therapeutic laparotomies were done in either the protocol or pre-protocol period. This protocol is recommended to be used in the evaluation of blunt abdominal trauma patients

Ruptured true aneurysm of the splenic artery: an unusual cause of haemoperitoneum.

True aneurysm of the splenic artery is rare. Two cases of ruptured true splenic artery aneurysms are presented. The first patient was a 62-year-old female who presented within 6 hours of the onset of symptoms. The other was a 27-year-old non-alcoholic male patient who was admitted in a state of shock after 2 days of observation in a peripheral hospital. Both patients had haemoperitoneum and were subjected to exploratory laparotomy. Aneurysmectomy was performed in both the patients in addition to left splenopancreatectomy in the first case and splenectomy in the second. However, due to the prolonged preoperative shock, the second patient succumbed on the third postoperative day.

Primary peritoneal pregnancy implanted on the uterosacral ligament: a case report

Peritoneal pregnancies are classified as primary and secondary. Primary implantation on the peritoneum is extremely rare in extrauterine pregnancy and is a potentially life-threatening variation of ectopic pregnancy within the peritoneal cavity, representing a grave risk to maternal health. Secondary abdominal pregnancies are by far the most common and result from tubal abortion or rupture, or less often, after uterine rupture with subsequent implantation within abdomen. Early diagnosis and appropriate surgical management, regardless of stage of gestation, appear to be important in achieving good results. We report a case of primary peritoneal pregnancy in a 28-year-old woman, who had severe lower abdominal pain one day before laparotomy for a preoperative diagnosis of ectopic pregnancy. The conceptus was implanted on the left uterosacral ligament. A fresh embryo of approximately 8 weeks' gestation was found in the conceptus.

Hemoperitoneo secundario a perforación de mioma uterino / Hemoperitoneum secondary to uterine myoma perforation

Se presenta un caso clínico de hemoperitoneo causado por crecimiento exagerado de un mioma pediculado, el que provocó ruptura de 3 mm de serosa que lo cubría, área en la cual existía un trayecto vascular arterial que fue comprometido

Hemoperitônio espontâneo por ruptura de carcinoma hepático primário em fígado cirrótico tratado por hepatectomia esquerda / Spontaneous hemoperitoneum by ruptura of primary hepatic carcinoma in a cirrhotic liver treated with left hepatectomy

Os autores apresentam o caso de um paciente de 62 anos de idade com hemoperitônio espontâneo devido à ruptura de carcinoma hepatocelular associado à cirrose hepática. É relatada a pouca freqüência dessa complicaçao e discutido o melhor tratamento a ser empregado que, nesse caso foi a hepatectomia lateral esquerda.

Traumatismos hepaticos cerrados: rol de la tomografia axial computada en la terapeutica no quirurgica / Close hepatic injuries: role of computerized axial tomography in the non-surgical therapy

Se estudiaron 33 pacientes con traumatismo abdominal que tuvieron compromiso hepático y presencia de hemoperitoneo, en quienes se adoptó una actitud no quirúrgica, analizando la evolución tomográfica de las imágenes intraparenquimatosas y del hemoperitoneo. Salvo un paciente, con estalido del lóbulo izquierdo hepático el hematoma centrohepático, las fracturas lobares y los hematomas subcapsulares. En 2 casos se necesitó realizar drenaje de colecciones intrahepáticas persistentes. La presencia de hemoperitoneo fue motivo de indicación quirúrgica. Los resultados confirman las actuales tendencias sobre el tratamiento conservador con control evolutivo, tomográfico y ecográfico, de las diferentes lesiones intrahepáticas, en pacientes hemodinámicamente estables