[Differences between Chicago and traditional classifications in the diagnosis of esophageal motor disorders with high-resolution manometry and topography of esophageal pressure]. / Diferencias entre las clasificaciones de Chicago y la tradicional en el diagnóstico de los trastornos motores del esófago con manometría de alta resolución y topografía de la presión esofágica.

BACKGROUND: With the introduction of high resolution manometry (HRM) and esophageal topography a novel classification (Chicago Classification) has been proposed for the diagnosis of esophageal motor disorders (EMD). Clinical differences with the traditional classification are currently under evaluation. AIM: To investigate differences between the Chicago (CC) and traditional (TC) classifications in the diagnosis of EMD. METHODS: Consecutive patients with indication for esophageal manometry were studied. HRM was performed with a 36 sensors solid-state catheter and Manoview software (V2.0).Conventional manometric tracings were analyzed by an investigator blinded to the results of HRM. Diagnosis by CC and CT were compared. RESULTS: Two hundred patients were studied, 106 (53%) of them women (53%) with a mean patient age of 43.4 (range 16 - 84) years. Preoperative evaluation for GERD 152 (76%) was the most frequent indication. Achalasia (8), scleroderma (2) and peristaltic dysfunction (60 vs. 59) were similarly diagnosed by CC and CT. Spastic disorders were more frequently identified by CC: nutcracker esophagus (NC) in 3, spastic NC in3 and segmental NC in 11 patients versus TC: NC 5. Three patients had spasm with CC and 1 with TC. Non specific motor disorder was diagnosed by TC and 2 patients had functional obstruction with CC. Hypotensive lower esophageal sphincter was identified in 63 patients with CC vs.57 with TC. CONCLUSIONS: Spastic disorders and functional obstruction were the EMD better identified by HRM and CC.

[Traumatic diaphragmatic injury diagnosed preoperatively. A Case report]. / Ruptura diafragmática traumática diagnosticada preoperatoriamente. A propósito de un caso.

Traumatic diaphragmatic rupture represents a diagnostic challenge to any physician dealing with polytraumatized patients. This uncommon injury must be suspected in certain types of accidents, making knowledge of trauma mechanisms vital for its diagnosis. In this paper we present a case of traumatic diaphragmatic rupture with intrathoracic herniation of abdominal contents, which was surgically repaired. We also present a review of the clinical characteristics, diagnosis and treatment of this entity, emphasizing the importance of keeping a high index of suspicion in order to achieve a correct diagnosis.

Ruptura diafragmática traumática diagnosticada preoperatoriamente. A propósito de un caso / Traumatic diaphragmatic injury diagnosed preoperatively. A Case report

La ruptura diafragmática representa un reto diagnósticopara los médicos que se enfrentan al manejode pacientes politraumatizados. Esta lesión, aunquepoco común, debe sospecharse en ciertos tipos de accidentes,por lo cual es vital conocer su relación con lacinemática del trauma. En este trabajo presentamos uncaso de ruptura diafragmática con herniación intratorácicadel contenido abdominal que fue reparada quirúrgicamente.Así mismo hacemos una revisión del cuadroclínico, diagnóstico y tratamiento de esta patología, haciendohincapié en la importancia de mantener siempreun alto índice de sospecha para lograr un diagnósticooportuno (AU)

Traumatic diaphragmatic rupture represents adiagnostic challenge to any physician dealing with polytraumatizedpatients. This uncommon injury mustbe suspected in certain types of accidents, makingknowledge of trauma mechanisms vital for its diagnosis.In this paper we present a case of traumatic diaphragmaticrupture with intrathoracic herniation ofabdominal contents, which was surgically repaired.We also present a review of the clinical characteristics,diagnosis and treatment of this entity, emphasizing theimportance of keeping a high index of suspicion in orderto achieve a correct diagnosis (AU)

[Colon transverse volvulus; a case report]. / Volvulus de colon transverso: reporte de caso.

BACKGROUND: Colon transverse volvulus is an uncommon pathology which is associate with alterations of the colonic motility, mental disorders and congenital anomalies of the fixation of the colon sistem. Up to 1994, 72 cases has been reported in world-wide literature. AIM: To report a case of colon transverse volvulus and the treatment. CASE REPORT: A female 46 years old who show intense abdominal pain 2 days of evolution. The physical exploration show important abdominal distension and pain in left inferior quadrant. The Rx of abdomen with gas absence in rectal descendent colon and ampula with level and important distension of proximal colon. Colonoscopic study with impossibility to advance endoscopy throw colon transverse by zone of stenosis, wasn't made a contrast study, underwent laparotomy of urgency, it was done right hemicolectomy and ileocoloanastomosis with good evolution and given of discharge fourth postsurgical day. CONCLUSIONS: This possibility is due to have in mind diagnoses, the treatment is surgical secondary to a high index of recidivate, nevertheless recommends the colonoscopy study accomplishment in order to discard obstructive injuries mainly cancer.

[Anal malignant melanoma. Case report and literature review]. / Melanoma maligno anal. Reporte de casos y revisión de la literatura.

OBJECTIVE: To present two cases of anorectal malignant melanoma as due to its non specific presentation and rarity they are often misdiagnosed like hemorrhoids. BACKGROUND: Anal melanomas are rare tumors that constitute less than 1% of the malignant colorectal tumors and represent both a diagnostic and therapeutic challenge to physicians. They are generally pigmented but could be amelanotic in 29% of the cases and they are associated with poor prognosis, regardless of the surgical procedure used. Melanomas are often misdiagnosed by a lot of anorectal conditions and diagnosis must be suspected in patients with an anal mass. CASE REPORT: We present two anorectal cases of malignant melanoma treated by wide local excision, the principal complain in both patients was the presence of an anal mass and bleeding. Both patients were treated by local excision since survival rates are comparable to those of patients treated by abdomino perineal resections (with a high morbility and mortality rates) and a better quality of life is achieved with control of the symptoms. CONCLUSIONS: Anal melanoma is a rare entity with a poor prognosis. The overall treatment goal should be to optimize the quality of life.

[Anterior rectal duplication in adult patient: a case report]. / Duplicación rectal anterioren paciente adulto: informe de un caso.

OBJECTIVE: To report a case of rectal duplication in the adult and make a literature review. BACKGROUND: The intestinal duplications are injuries of congenital origin that can exist from the base of the tongue to the anal verge, being the most frequent site at level of terminal ileum (22%) and at the rectal level in 5% To date approximately exist 80 reports in world-wide Literature generally in the pediatric population being little frequent in the adult age. Its presentation could be tubular or cystic. The recommended treatment is the surgical resection generally in block with coloanal anastomosis. METHOD: A case review of rectal duplication in the adult and the conducted treatment. RESULT: The case of a patient appears with diagnose of rectal duplication with tubular type,whose main symptom was constipation and fecal impactation. In the exploration was detect double rectal lumen (anterior and posterior) that it above initiates by of the anorectal ring with fibrous ulcer of fibrinoid aspect of 3 approx cm of length x 1 cm wide, at level of the septum that separates both rectal lumina. CONCLUSIONS: The rectal duplication is a rare pathology in the adult nevertheless is due to suspect before the existence of alterations in the mechanics of the defecation, rectal prolapse and rectal bleeding,the election treatment is a protectomy with colonic pouch in "J" and coloanal anastomosis.

Colonic perforation as a complication of ventriculoperitoneal shunt: a case report.

Late perforation after ventriculoperitoneal (VP) shunting is extremely rare. Colonic perforation is uncommon and represents 0.1%-0.7% of abdominal complications. Colonic perforation can challenge diagnostic and therapeutic decisions, and there are no clear guidelines on the management of this problem. We present a 34-year-old woman who was admitted for a 1-week history of sensation of a foreign body through the anus at the time of bowel movements. She had previously undergone a VP derivation for hydrocephalus secondary to neurocysticercosis. Plain abdominal radiographs demonstrated the shunt within the colonic lumen and through the descendening and sigmoid colon. The shunt was exteriorized in the cervical area and a laparotomy was performed with a primary two-layer colonic close. The patient received antibiotic therapy for 2 weeks with good outcome. Percutaneous and endoscopic approaches have been reported in patients with no abdominal signs. Prompt recognition of this complication is critical to avoid high mortality rates.

Appendix adenocarcinoma associated with ulcerative colitis: a case report and literature review.

Ulcerative colitis (UC) represents a risk factor for colorectal cancer, but the association between UC and appendix cancer is uncommon. A 60-year-old woman with a 5-year history of UC initially received medical treatment with mesalazine and prednisone with no satisfactory response; therefore surgery was indicated. The procedure was a total intersphincteric proctocolectomy with ileostomy. Histopathological analysis indicated adenocarcinoma from the cecal appendix, and chronic-active ulcerative colitis of the colon. In conclusion, surgeons and pathologists should examine every surgical specimen from patients with UC because of the possibility, although remote, of a neoplasic pathology. The appendix adenocarcinoma and ulcerative colitis may or may not be associated, same as colon cancer in patients with UC.

Mucinous adenocarcinoma associated with fistula in ano: report of a case.

We present a case of the rare occurrence of a mucus-secreting adenocarcinoma originating in an anal gland. A 37-year-old diabetic man had an anal fistulotomy 16 years before. He had four ischiorectal abscesses in a 6-month period. A seton was inserted in a complex fistula tract in the left anterior lateral aspect. Due to delayed healing, a new surgical exploration was carried out; pathological analysis of the curetted mucinous tissue revealed a mucoid adenocarcinoma. Surgical resection is the first choice of curative treatment, and additional treatments include chemotherapy, radiotherapy and brachytherapy.

Endoanal sonography in assessment of fecal incontinence following obstetric trauma.

OBJECTIVES: Fecal incontinence is a common, incapacitating and largely unrecognized medical problem and can be caused by various factors. Obstetric trauma is the most common cause of fecal incontinence secondary to trauma. We aimed to analyze the role of endoanal ultrasound in assessment of this type of fecal incontinence, and report the functional results of surgical treatment. METHODS: We reviewed the records of all 22 patients with fecal incontinence secondary to obstetric trauma who were evaluated by endoanal ultrasound and underwent surgical management in our department from April to 1997 to April 2002. Pre- and postoperative evaluation of the degree of incontinence was done using the incontinence score of Jorge and Wexner. RESULTS: The patients had a median age of 43 (range, 29-68) years. All had vaginal deliveries, five of which (22.7%) were instrumental. Most of the patients had total fecal incontinence (solids) with preoperative incontinence score values of 15-20 (median, 18). Endoanal ultrasound confirmed structural defects in the anterior external anal sphincter alone in 16 (72.7%) patients, and both anterior external and internal sphincter defects in six (27.3%) patients. A thinned perineal body was present in all patients. All patients received surgical treatment with overlapping sphincteroplasty and there was improvement of continence in 19 (86.4%) patients with postoperative incontinence score values between 4 and 0 (median, 2). CONCLUSIONS: Endoanal sonography is an accurate method for assessing sphincter anatomy, delineating both internal and external anal sphincters. Surgical treatment of sphincter defects is associated with good outcome.

Experience in management of Fournier's gangrene.

We report our experience and results in the management of Fournier's gangrene. Fournier's gangrene is a synergistic infective necrotizing fasciitis, which involves perianal, perineal and genital regions, originated mostly from colorectal and genitourinary sources. Charts and records from 28 patients with Fournier's gangrene diagnosed between 1993 and 1997 were reviewed. The mean patients age was 57.8 years (range, 22-82 years); mean hospital stay was 19 days. Eighteen patients (64.3%) were diabetic. The most common source of gangrene was ischiorectal abscess in 22 patients (78.6%). Colostomy was performed on 14 patients (50%) and cystostomy on 7 patients (25%). Ten patients (35.7%) died because of sepsis. In conclusion, medical and surgical treatment should be aggressive. Colostomy should only be performed if sphincter complex is damaged. Multidisciplinary management is mandatory, because of high morbidity and mortality.

[Toxic megacolon secondary to pseudomembranous colitis]. / Megacolon tóxico secundario a colitis pseudomembranosa.

BACKGROUND: Toxic megacolon is a rare complication of pseudomembranous colitis. OBJECTIVE: The aim of this paper is to present a rare case of toxic megacolon secondary to pseudomembranous colitis. METHODS: The chart of a 75-year-old male, who developed a toxic megacolon secondary to pseudomembranous colitis no was reviewed. RESULTS: The clinical features and outcome of a 75-year-old male with pseudomembranous colitis are depicted. The main symptoms were no ever, abdominal distention, bloody and diarrhea; the man suddenly developed a toxic megacolon and taken was to surgery. Total colectomy with proximal rectal closure was performed. The patient died within 24 hours of the abdominal procedure. CONCLUSIONS: Toxic megacolon is a rare complication of pseudomembranous colitis. Its presence should be suspected when these patients develop no colonic dilatation with associated systemic toxicity. Aggressive surgical intervention is indicated.

[Synchronous neoplasias in colorectal cancer]. / Neoplasias sincrónicas en cáncer colorrectal.

OBJECTIVE: The aim of this study was to show the incidence of synchronous lesions in colorectal cancer patients treated surgical at our service. SUMMARY BACKGROUND DATA: Many studies have shown different incidences of synchronous lesions in colorectal cancer, mainly due to variations in the accuracy of the diagnostic methods used and the intentional search for associated lesucosal. METHOD: Fifty-eight clinical records of patients operated on for colorectal cancer were retrospectively reviewed from August 1995 to March 1999. The synchronous lesions were classified as benign or malignant lesions based on its histological classification. Statistical analysis was carried out by the Spearman coefficient correlation. RESULTS: Fifteen patients (25.8%) had 28 synchronous lesions, nine were male (60%), and six females (20%). The average age was 63.2 years with a range of 26 to 83 years. The endoscopic diagnosis of synchronous lesions was performed preoperatively in 12 patients (80%). The most frequent localization's of primary tumor was the sigmoid colon in six patients (40%). The more frequent localization of synchronous lesions was the rectum (35.7%). Benign lesions were most commonly found in synchronous lesions (89.3%). CONCLUSIONS: The patient with colorectal cancer has an unstable epithelium and an uncommon predisposition to develop several mucosal alterations. This predisposition is prone to grow benign or malignant lesions. For this reason, we advise all that patient with colorectal cancer be fully studied endoscopically.

[Colonoscopy. Analysis of 2,000 procedures]. / La colonoscopia. Análisis de 2,000 procedimientos.

BACKGROUND: During the last 3 decades, colonoscopy has become the diagnostic study with greatest sensitivity and acuity in colonic pathology. AIMS: To know the most frequent diagnostic and colonoscopic disorders, and the pathology found, to establish certainty of the colonoscopic procedure. METHOD: Between 1987 and 1997, a descriptive, transversal, retrospective and observational study of the 2,000 colonoscopies that were carried out at on service was done, making a registry of the endoscopic search in colorectal pathology and their characteristics in on patients. RESULTS: Colonoscopies were done in 967 men (47.3%) and 1,053 women (52.6%) with a median age of 55.8 years (10 range (-) 93 years). In 1,780 of them (89.%), it was possible to arrive to cecum; 1,150 (57.5%) were pathologic. The most frequent finding was hemorrhage of the lower digestive tube in 525 (26.2%) patients; in addition cancer in 402 (20.1%), suspicion of intestinal inflammatory disease 292 (14.6%) and colorectal polyps 199 (10%) were found. The most frequent endoscopic diagnosis was colorectal polyps in 405 (35.7%) patients; in additions diverticular disease was found in 404 (35.1%) patients intestinal inflammatory disease in 185 (16%), colorectal cancer in 85 (7.4%), and vascular ectasias in 52 (4.5%) patients. There were four complicated cases (0.25%), three by resolved therapeutic colonoscopy and one diagnostically. CONCLUSION: The most frequent colonoscopic were findings hemorrhage of the lower digestive tube and the finding of cancer. The most frequent diagnoses were colorectal polyps and diverticular disease. Colonoscopy is a safe diagnostic and therapeutic procedure.

[Anorectal surgery in patients infected with human immunodeficiency virus]. / Cirugía anorrectal en pacientes infectados por el virus de la inmunodeficiencia humana.

OBJECTIVE: The aim of this study was to describe the clinical characteristics of the patients infected with the human immunodeficiency virus (HIV), who were submitted to anorectal surgery with emphasis on healing time and complications. METHODS: The patients were evaluated prospectively from July 1998 to July 1999; there was a total of 23 patients HIV (+) (Group 1). They were compared to a control group of randomly chosen HIV (-) patients (Group II) to establish the characteristics of each group, the morbidity, and the time of healing. The statistical analysis was performed with the student T test. RESULTS: In Group I, the diagnosis were fistula in the anus, anal fissure, anal abscess, condylomata acuminata, anal ulcer, and cutaneous flaps. Seven patients had a fistulotomy, a drainage of abscess in one, resection of different skin lesions in 12, electrofulguration of condylomata in two, fisturectomy in three and solely biopsy in three. The average healing time was 26.087 days for Group I and 23.21 days for Group II. A comparison between healing time and complications in these two groups was carried out to determine a whether significant difference exists in these parameters. There was no significant difference between these groups, but there were unequal rates of healing (26.087, DE +/- 10.778 days vs 23.21 DE +/- 6.259 days; p = not significant) and complications for the similar procedures. CONCLUSIONS: The healing in time HIV (+) patients submitted to anorectal surgery may not vary important when compared with HIV (-) patients.