Esophagopericardial fistula attributed to a barogenic rupture of the esophagus. Report of a case and review of the literature.

In this case we describe a fatal condition of esophagopericardial fistula secondary to barogenic rupture of the esophagus. The review of the literature disclosed only one fatal case (reported in 1968) of esophagopericardial fistula attributed to barogenic rupture of the esophagus. Early diagnosis and adequate treatment including pericardiocentesis along with intermittent drainage of the pericardium, full-course antibiotic therapy and a timely, well-planned surgical intervention will substantially improve the prognosis in this type of pathology. Patients similar to our case should be treated with either surgical bipolar esophageal exclusion (conservative disconnection) or esophagectomy combined with large drainage of the pericardial and mediastinal spaces. This case report reinforces the complexity of the diagnosis, and perhaps the need for clinical awareness and the inclusion of this entity in a differential diagnosis.

Colecistitis aguda acalculosa en el paciente con trauma grave / Acute acalculous cholecistitis in severe trauma patients

Antecedentes: La frecuencia informada de CAA en pacientes con lesiones traumáticas oscila entre 0.5 y 5 por ciento, con una mortalidad que varía entre 7 y 75 por ciento, valores determinados por reporte de casos o series retrospectivas. Objetivo: Determinar la frecuencia de colecistitis aguda acalculosa (CAA) en una población de pacientes con trauma contuso grave y las implicaciones clínicas que tiene, así como los factores de riesgo que puedan precipitar su aparición, evaluación de cambios morfológicos tempranos, tratamiento quirúrgico y morbi-mortalidad. Pacientes y métodos: Estudio prospectivo, observacional, longitudinal y descriptivo inferencial conducido entre ocubre de 1994 y junio de 1995. Se incluyeron 28 pacientes adultos consecutivos con trauma contuso al menos en dos regiones corporales. Se estimó la severidad de las lesiones con una escala fisiológica (Revised Trauma Score = RTS) y una anatómica (Injury Severity Score = ISS). Todos los pacientes se sometieron a ultrasonido de hígado y vías biliares a su ingreso y cada 5 a 7 días para la detección temprana de cambios sonográficos o concluyentes de CAA. Cada paciente recibió tratamiento conveniente de acuerdo a sus lesiones. La evaluación fue clínica, laboratorial y de los posibles factores de riesgo para el desarrollo de esta alteración. Mediciones: Prueba exacta de Fisher de dos colas para las variables cualitativas y prueba U de Mann-Withney para las cuantitativas. Resultados: Del total 21 correspondieron al sexo masculino (75 por ciento) y 7 al femenino (25 por ciento) con un promedio de edad de 45.5 años y un período de observación promedio de 22.5 días. Siete de los pacientes (25 por ciento) desarrollaron cambios sonográficos a partir del noveno día de manejo, 4 fueron concluyentes de CAA demostrados histológicamente, de los cuales tres se sometieron a colecistectornía abierta sin morbilidad y mortalidad y mejoría de sus condiciones clínicas. El otro caso falleció por hipovolemia sin ofrecerle tratamiento quirúrgico. Los factores de riesgo con significancia estadística fueron: Estancia prolongada, fiebre, dolor abdominal, evaluación de la fosfatasa alcalina, hipoalbuminemia, uso de nutrición parenteral total y casos complicados con neumonía intrahospitalaria (P = < 0.05). Hubo significancia marginal con el uso de analgesia-sedación. La mortalidad global fue del 18 por ciento. Conclusiones: La frecuencia es mayor a la informada previamente y no hubo mortalidad relacionada a la presencia de la CAA. El ultrasonido detecta fácilmente los cambios morfológicos vesiculares. No hubo morbilidad y mortalidad atribuida a la colecistectomía.

[Acute acalculous cholecystitis in patients with severe trauma]. / Colecistitis aguda acalculosa en el paciente con trauma grave.

BACKGROUND: The incidence of AAC on patients with traumatic lesions fluctuates between 0.5 to 5%, with mortality which varies between 7 and 75%. These values are determined by case reports or retrospective series. AIM: To determine the incidence of acute acalculous cholecystitis (AAC) in a number of patients with severe trauma and its clinical implications, as well as the risk factors that can favour the development of this pathology, evaluation of early morphological changes, surgical treatment and morbidity and mortality. PATIENTS AND METHODS: Prospective, observational, longitudinal and descriptive inferential study conducted from October 1994 to June 1995. Twenty eight consecutive adult patients with contusion severe trauma on at least two corporal regions were included. The severity of lesions was estimated with a physiologic scale (Revised Trauma Score = RTS) and an anatomic one (Injury Severity Score = ISS). All patients were submitted to ultrasound of the liver and biliary tract on their admittance and every 5 or 7 days for an early detection of sonographic changes or conclusive of AAC. Each patient was treated conveniently in accordance with his or her lesions. The patients were evaluated clinically, with laboratory exams, and for possible risk factors for the development of this pathology. MEASUREMENTS: Two Tailed Fisher's Exact Test for qualitative variables and Mann-Withney U Test for the quantitatives. RESULTS: Twenty one patients were male (75%) and 7 were female (25%), average age 45.5 years and an average observation period of 22.5 days. Seven of these patients (25%) developed sonographic changes starting the 9th day after admission, 4 were conclusive of AAC proved histologically, three of these underwent open cholecystectomy with no morbidity and mortality and improvement of their clinical conditions. The other patient died due to hypovolemia without having been offered surgical treatment. The risks factors with statistical significance were: Long in-hospital stay, fever, abdominal pain, elevation of alkaline phosphatase, hypoalbuminemia, use of parenteral nutritional support and nosocomial pneumonia (P = < 0.05). There was a marginal significance with the use of sedatives and analgesics. Global mortality was 18%. CONCLUSIONS: The incidence is more than the one previously informed and there was no mortality related the presence of AAC. The ultrasound easily detects the gallbladder morphological changes. There was no morbidity or mortality due to the cholecystectomy.