Hemorragia masiva tras fístula arterio-esofágica por una arteria subclavia aberrante desconocida / Massive hemorrhage after arterioesophageal fistula from an unknown aberrant subclavian artery

La arteria subclavia derecha aberrante tiene una incidencia de un 0,5-1% en la población, con una localización generalmente retroesofágica. Puede llevar a la formación de una fístula arterio-esofágica en pacientes con factores de riesgo predisponentes por dispositivos colocados en posición esofágica o traqueal, al ser particularmente susceptible a la compresión extrínseca y a la necrosis por presión.Presentamos el caso de un paciente con una fístula traqueo-esofágica posquirúrgica, que desarrolló un sangrado masivo por una fístula arterio-esofágica secundaria a una arteria subclavia derecha aberrante desconocida. Para el manejo hemostático se realizaron maniobras alternativas, como la colocación de una sonda urinaria tipo Foley en el punto de sangrado y la posterior colocación de un balón de Sengstaken-Blakemore en posición craneal.Dada la gravedad del cuadro y el posible retraso diagnóstico, parece adecuado considerar la realización de un angio-TC preoperatorio en pacientes con factores de riesgo sometidos a estos procedimientos.(AU)

The aberrant right subclavian artery has an incidence of 0.5-1% in the population, generally with retroesophageal location. It can lead to the formation of an arterio-esophageal fistula in patients with predisposing risk factors due to devices placed in esophageal or tracheal position, as it is particularly susceptible to extrinsic compression and pressure necrosis.We present the case of a patient with a postsurgical tracheoesophageal fistula, who developed massive bleeding due to an arterioesophageal fistula secondary to an unknown aberrant right subclavian artery. For hemostatic management, alternative maneuvers were performed, such as the placement of a Foley-type urinary catheter at the point of bleeding and the subsequent placement of a Sengstaken-Blakemore balloon in cranial position.Given the severity of the condition and the possible diagnostic delay, it seems appropriate to consider performing a preoperative CT angiography in patients with risk factors who undergo these procedures.(AU)

Massive hemorrhage after arterioesophageal fistula from an unknown aberrant subclavian artery.

The aberrant right subclavian artery has an incidence of 0.5%-1% in the population, generally with retroesophageal location. It can lead to the formation of an arterio-esophageal fistula in patients with predisposing risk factors due to devices placed in esophageal or tracheal position, as it is particularly susceptible to extrinsic compression and pressure necrosis. We present the case of a patient with a postsurgical tracheoesophageal fistula, who developed massive bleeding due to an arterioesophageal fistula secondary to an unknown aberrant right subclavian artery. For hemostatic management, alternative maneuvers were performed, such as the placement of a Foley-type urinary catheter at the point of bleeding and the subsequent placement of a Sengstaken-Blakemore balloon in cranial position. Given the severity of the condition and the possible diagnostic delay, it seems appropriate to consider performing a preoperative CT angiography in patients with risk factors who undergo these procedures.

Elevación del lactato en el postoperatorio como marcador de isquemia mesentérica aguda. Descripción de dos casos / Postoperative lactate elevation as a marker of underlying acute mesenteric ischemia. Description of two cases

El lactato sérico es un marcador inespecífico de hipoperfusión tisular. El diagnóstico diferencial de su elevación incluye la isquemia intestinal aguda. A pesar de ser controvertido para este uso, el lactato se sigue empleando, por su elevada sensibilidad y a falta de otros marcadores validados. Presentamos los casos de 2 pacientes que desarrollaron como complicación posquirúrgica una isquemia mesentérica aguda, que cursó con dolor abdominal moderado —un síntoma inespecífico en el contexto postoperatorio— y unos niveles de lactato sérico en aumento progresivo, lo que facilitó la sospecha y la posterior confirmación diagnóstica mediante una prueba de imagen. Se destaca la importancia fisiopatológica de la elevación del lactato en el contexto perioperatorio, que debe llevar a realizar un diagnóstico diferencial de sus posibles causas, incluyendo entre las mismas la isquemia mesentérica; pues aunque en el primer caso el desenlace fue negativo, la sospecha precoz permitió en el segundo, realizar un diagnóstico y tratamiento efectivos.(AU)

Serum lactate is a non-specific marker of tissue hypoperfusion. Elevated serum lactate is used in the differential diagnosis of acute intestinal ischemia. Although this practice is controversial, in the absence of other validated markers lactate is still used because of its high sensitivity. We present the cases of two patients who developed acute mesenteric ischemia as a post-surgical complication. The patients reported moderate abdominal pain —a non-specific symptom in the postoperative context— and tests showed progressively increasing serum lactate levels, which facilitated suspicion and subsequent diagnostic confirmation through an imaging test. These cases highlight the physiopathological importance of lactate elevation in the perioperative context and of performing a differential diagnosis of its possible causes, including mesenteric ischemia. Although the outcome was negative in the first case, early suspicion allowed us to make an effective diagnosis and administer appropriate treatment in the second patient.(AU)

Postoperative lactate elevation as a marker of underlying acute mesenteric ischemia. Description of two cases.

Serum lactate is a non-specific marker of tissue hypoperfusion. Elevated serum lactate is used in the differential diagnosis of acute intestinal ischemia. Although this practice is controversial, in the absence of other validated markers lactate is still used because of its high sensitivity. We present the cases of two patients who developed acute mesenteric ischemia as a post-surgical complication. The patients reported moderate abdominal pain -a non-specific symptom in the postoperative context- and tests showed progressively increasing serum lactate levels, which facilitated suspicion and subsequent diagnostic confirmation through an imaging test. These cases highlight the physiopathological importance of lactate elevation in the perioperative context and of performing a differential diagnosis of its possible causes, including mesenteric ischemia. Although the outcome was negative in the first case, early suspicion allowed us to make an effective diagnosis and administer appropriate treatment in the second patient.

Postoperative lactate elevation as a marker of underlying acute mesenteric ischemia. Description of two cases. / Elevación del lactato en el postoperatorio como marcador de isquemia mesentérica aguda. Descripción de dos casos.

Serum lactate is a non-specific marker of tissue hypoperfusion. Elevated serum lactate is used in the differential diagnosis of acute intestinal ischemia. Although this practice is controversial, in the absence of other validated markers lactate is still used because of its high sensitivity. We present the cases of two patients who developed acute mesenteric ischemia as a post-surgical complication. The patients reported moderate abdominal pain -a non-specific symptom in the postoperative context- and tests showed progressively increasing serum lactate levels, which facilitated suspicion and subsequent diagnostic confirmation through an imaging test. These cases highlight the physiopathological importance of lactate elevation in the perioperative context and of performing a differential diagnosis of its possible causes, including mesenteric ischemia. Although the outcome was negative in the first case, early suspicion allowed us to make an effective diagnosis and administer appropriate treatment in the second patient.

Antimicrobial susceptibility and molecular typing of toxigenic clinical isolates of Clostridium difficile causing infections in the south of Spain.

Antimicrobial susceptibility to 6 antimicrobial agents, PCR-ribotyping and molecular genetics of fluoroquinolone resistance was assessed in 70 toxigenic clinical isolates of C. difficile recovered from patients attended in a hospital in southern Spain with suspected Clostridium difficile infection. Moxifloxacin was the least active drug, mainly driven by the aminoacid substitution Thr82Ile in GyrA, while PCR-ribotype 078 was the most prevalent lineage identified and grouped several of the fluoroquinolone resistant isolates.