Barotrauma con laceración rectal por aire comprimido / Barotrauma with rectal laceration due to compressed air

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[Recurrent ingestion of foreign bodies and abdominal self-injury as a form of attempted suicide]. / Ingestión reiterada de cuerpos extraños y autoagresiones abdominales como intento de suicidio.

Accidental ingestion of foreign bodies is fairly common in the general population. However, recurrent, deliberate ingestion of foreign bodies associated with continual abdominal self-mutilation with blunt objects is extremely unusual. We present the case of a young woman with an underlying psychiatric disorder who repeatedly presented to the emergency department of our hospital for attempted suicide. The most frequent reason for presenting to the emergency department was ingestion of multiple objects, usually sharp metal objects, frequently associated with abdominal self-mutilation using a sharp instrument. Treatment consisted of extraction of the foreign bodies through upper gastrointestinal endoscopy or abdominal surgery. The patient has survived all these attempts with minimal morbidity.

[Diaphragmatic hernia of Morgagni-Larrey in adults: analysis of 10 cases]. / Hernia diafragmática de Morgagni-Larrey en el adulto: análisis de 10 casos.

Congenital diaphragmatic hernia of Morgagni-Larrey is a rare entity that usually presents on the right side. These hernias, occurring in the anterior midline through the sternocostal hiatus of the diaphragm, are usually discovered incidentally when the patient has reached adulthood, or when they become symptomatic due to intestinal involvement (occlusive symptoms) or when respiratory dysfunction occurs. We present 10 patients (mean age: 69 years) with symptomatic sternocostal hernia and intestinal occlusion. In 7 patients, the hernia was located on the right (Morgagni's hernia) and in three it was located on the left (Larrey's hernia). Most of the patients presented important associated comorbidity, mainly cardiovascular and neoplastic. Surgical treatment consisted of reduction of the contents of the herniated sac and hernia repair through simple suture with or without mesh for reinforcement, mainly through the abdominal approach. Mortality in this series was nil. The infrequency of this entity and its diagnosis mainly in adults, with a high prevalence of circumstances favoring abdominal hernias, suggest that an embryological defect of the sternocostal foramina of Morgagni or Larrey are an essential element in the physiopathology of these processes.

[Gallstone Ileus: results of analysis of a series of 40 patients]. / Ileo biliar: resultados del análisis de una serie de 40 casos.

Gallstone ileus is an infrequent surgical emergency that nevertheless represents a not insignificant percentage of occlusions of the small intestine without strangulation. We present a retrospective study of 21 years (1980-2000) in 40 patients. Mean age was 76 years and most of the patients (85%) were women. Mean age and associated disease increased throughout the study period. Cases of gallstone ileus decreased in the second and third 5-year periods and clearly increased in the fourth (1996-2000). Localization of gallstones was ileum in 25 patients, jejunum in 9, duodenum in 3, colon in 1 and feces in 2. Only 12 patients (30%) received a correct preoperative diagnosis. Treatment was surgical in 38 patients with 7.5% mortality and 57.5% morbidity. Enterolithotomy was the technique of choice. A high degree of suspicion for gallstone ileus and early treatment may be the factors required to improve prognosis. The increase in life expectancy and associated comorbidity, which contraindicate elective surgery for cholelithiasis, may be contributing towards an increase in the population prone to developing gallstone ileus.

Perforaciones intestinales causadas por cuerpos extraños / Intestinal perforations caused by foreign bodies

El objetivo del trabajo es presentar 4 casos de perforaciones intestinales cuya causa es la ingestión de cuerpos extraños, que originan problemas intestinales, concretamente oclusión de intestino delgado o intestino grueso, perforación de víscera hueca y peritonitis. En todos los casos los pacientes no relacionaban sus síntomas con la ingestión de cuerpos extraños, ya que el período de evolución fue superior a las 2 semanas. La actitud quirúrgica y el tratamiento antibiótico son imprescindibles en la perforación intestinal. La demora en su diagnóstico ocasiona una cirugía tardía, con un aumento de la morbimortalidad, por lo que creemos que el adecuado conocimiento de esta afección quirúrgica es importante, aunque su frecuencia es inferior al 1 por ciento del total de las perforaciones del tracto digestivo (AU)

Cuerpos extraños en el rectosigma / Foreign bodies in the rectum and sigmoid colon

Se presentan 6 casos de cuerpos extraños en el rectosigma, siendo la vía de entrada la introducción endoanal. Por causa de sus potenciales complicaciones, los cuerpos extraños en el recto y el sigma deben ser considerados como una patología relevante y deben ser tratados de forma expeditiva. A pesar de su poca frecuencia es una posibilidad a tener en cuenta ante un dolor pélvico o anal en un paciente que no admite libremente la introducción del objeto transanal (AU)

Gangrena de Fournier / Fournier's gangrene

Introducción. La gangrena de Fournier es una infección necrosante subcutánea de origen urogenital o anorrectal, que afecta a la zona genital, perineo y pared anterior del abdomen en la que están implicados gérmenes aerobios y anaerobios. Es una enfermedad poco frecuente, pero potencialmente letal. Pacientes y métodos. Estudiamos de forma retrospectiva 10 casos de gangrena de Fournier, desde 1994 hasta 1999. En la recogida de datos figuran: filiación, edad y sexo, antecedentes patológicos, factores predisponentes, causas, clínica, analítica, tratamiento médico y quirúrgico, gérmenes, antibioterapia, estancia, ingreso en UCI y resultados. Resultados. Todos los pacientes eran varones, con una edad media de 65 años. Todos tenían importante patología orgánica de base y presentaban factores predisponentes, destacando la diabetes mellitus (6 casos) seguida del consumo crónico de alcohol (5 casos). La etiología fue: absceso perianal (3 casos), instrumentación urológica o rectal (2 casos), enfermedades genitourinarias (2 casos), idiopática (2 casos) y traumatismo (un caso). La clínica fue similar, con una zona de celulitis inicial, con dolor local en el escroto y posterior diseminación perineal, con crepitación y cuadro febril. Todos presentaban leucocitosis franca. En todos los pacientes se instauró antibioterapia y se realizó desbridamiento en una o varias sesiones, así como medidas de soporte metabólico y nutricional. En 3 casos se realizó íleo-colostomía derivativa y en 2 casos cistostomía suprapúbica. El germen más aislado fue E. coli, seguido de Bacteroides. En la antibioterapia destaca el uso de piperacilina/tazobactam. La estancia media fue d 27 días. Cinco pacientes requirieron su ingreso en la UCI. Fallecieron 4 pacientes (40 por ciento), con un denominador común de sepsis; de ellos dos llevaban estoma (colostomía).Conclusiones. La gangrena de Fournier es una enfermedad de alta morbimortalidad, especialmente en pacientes mayores, con factores predisponentes como diabetes y alcoholismo y cuya causa desencadenante es una enfermedad perirrectal o urogenital, que no ha sido tratada correctamente. El pronóstico es incierto, llegando nuestra serie a una mortalidad del 40 por ciento, por lo que el diagnóstico precoz y la terapéutica temprana y agresiva son esenciales (desbridamiento quirúrgico, antibióticos de amplio espectro y cuidados intensivos) (AU)

Hernia de Richter como causa de obstrucción del intestino delgado / Richter's hernia presenting as small bowel obstruction

El objetivo del trabajo es presentar 4 casos de hernia de Richter que ocasionan problemas mecánicos intestinales, concretamente oclusión del intestino delgado. En todos los casos hubo un grave deterioro del estado general y una deshidratación importante, siendo el cuadro clínico lentamente progresivo con una sintomatología en varios casos de distensión abdominal y en otro caso de diarrea persistente. La demora en su diagnóstico ocasiona una cirugía tardía, con un aumento de la morbimortalidad, por lo que creemos que el adecuado conocimiento de esta rara enfermedad quirúrgica es importante (AU)

Thoracic esophageal perforations: surgical management with mechanical bipolar exclusion.

We report 12 cases of thoracic esophageal perforation diagnosed during the last seven years. Management was nonsurgical in 2 patients and the rest were treated surgically. Primary repair and drainage were performed in 2 patients, and 7 patients underwent suture of the perforation and bipolar exclusion using nonresorbable staples. The remaining patient was treated with proximal unipolar exclusion. The approach was always through a posterolateral thoracotomy. The result was optimal in 8 patients; the most important postsurgical complications were 2 esophageal fistulas that required surgery, and only one of the patients died of fulminating sepsis. Bipolar exclusion is a procedure that needs only one operation and provides excellent morbidity-mortality rates compared with other exclusion techniques with later reconstruction. We consider suturing with nonresorbable staples to be a simple and safe procedure, with spontaneous recanalization of the esophageal lumen in 2 weeks.

Seat belt-induced intestinal perforation.

OBJECTIVE: To determine whether a relationship exists between bowel perforation and seat belt use in patients presenting abdominal trauma after traffic accidents. EXPERIMENTAL DESIGN: We prospectively studied every patient admitted to the emergency room with abdominal trauma after a traffic accident. PATIENTS AND METHODS: We included every patient diagnosed (clinically, by ultrasound or computerized tomography or at laparotomy) as suffering intraabdominal injury. The degree of trauma was classified according to the Injury Severity Score, taking into account the number of abdominal injuries associated with mortality and seat belt use. RESULTS: A total of 146 patients were studied. The spleen was the most frequently injured organ (n = 56). The mean Injury Severity Score was 19. Head injuries were more common among patients not wearing the seat belt. Thirteen cases of bowel perforation in patients who had been using the seat belt (p < 0.0001) were observed. CONCLUSION: Seat belt use can decrease the mortality rate associated with traffic accidents. However, a significant increase exists in the incidence of bowel perforations among seat belt wearers, probably as a result of improper use.

[Low digestive hemorrhage caused by amebic colitis]. / Hemorragia digestiva baja por colitis amebiana.

Amebiasis is an infectious disease produced by Entamoeba histolytica, which has invasion capacity of the colon mucosa. It has different clinical forms, varying from the asymptomatic carrier state to severe, although not frequent, fulminant or necrotizing colitis, with an important necrosis of the colon mucosa. Perforation or intestinal bleeding are possible. We report one case of patient who had a history of recent travel to India. Was admitted with a clinical picture of abdominal pain, diarrhea and fever. Initially he received treatment with Metronidazole and steroids, because of doubts in the endoscopy diagnosis of Crohn's Disease versus Amebic Colitis. The patient developed a fulminant colitis, that required emergency surgery because of lower intestinal massive bleeding. During the operation perforations of the caecum and rectum were found. We performed a total colectomy with ileostomy and closing of the stump rectal. Six months later a second operation was made for the reconstruction of the intestinal continuity by an ileal pouch and rectal anastomosis.

[Retractile mesenteritis. Report of 3 cases]. / Mesenteritis retráctil. A propósito de tres casos.

Mesenteric panniculitis is an infrequent pathology; the diagnosis is made by the pathologist and it is characterized by inflammation, fibrosis and retraction of the mesenteric fat. We report three new cases of retractile mesenteritis or mesenteric panniculitis, two cases presented with intestinal obstruction and the other had an abdominal tumour. In all cases the pathological diagnosis was retractile mesenteritis.

[Synchronous colonic and rectal carcinomas]. / Carcinomas sincrónicos de colon y recto.

We present a retrospective study of 360 patients with surgically treated colorectal neoplasm between 1982 and 1990, in order to determine the incidence of synchronous colorectal carcinomas; and to analyze diagnosis procedures, detection time, pathology and treatment strategies. The incidence of synchronous carcinomas was 5.5% (20 cases). Only 30% of them were diagnosed preoperatively, and up to 40% were discovered in the pathological examination. In 2 patients 3 synchronous tumors were well found. All the synchronous neoplasms were differentiated, 65% of them were Dukes stage A. Synchronous colorectal polyps were found in 80% of patients. Complete exploration of the colon preoperatively by a routine pan-colonoscopy is recommended. In regard to the treatment of patients with synchronous colorectal carcinomas, partial colectomies are indicated as long as oncological criteria are followed, and the colon had been fully explored.