Damage control surgical management of combined small and large bowel injuries in penetrating trauma: Are ostomies still pertinent?

Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%.

El trauma de las vísceras huecas representa una gran proporción de las lesiones asociadas al trauma penetrante. Actualmente, las lesiones aisladas de intestino delgado o colon se manejan a través de anastomosis primaria en pacientes sometidos a laparotomía definitiva o anastomosis diferida en pacientes que requieran cirugía de control de daños. El dogma quirúrgico tradicional de la ostomía se ha probado que es innecesario y en muchos casos puede aumentar la morbilidad. El objetivo de este artículo es describir la experiencia obtenida en el manejo de lesiones combinadas de vísceras huecas de pacientes con trauma penetrante. Se determinó que el manejo primario o diferido del intestino a través de anastomosis es el abordaje quirúrgico preferido en pacientes que presentan lesiones penetrantes combinadas de intestino delgado y colon. Se ha reportado que el 90% de lesiones combinadas penetrantes intestinales pueden ser manejadas a través de anastomosis primaria o diferida incluso en los casos más severos requieren la aplicación de los principios de control de daños. Aplicando esta estrategia, la tasa general para ostomía (primaria o diferida) puede ser reducida a menos del 10%.

Diagnosis and management of small intestinal injury due to percutaneous renal access.

PURPOSE: Define factors for proper diagnosis and treatment of small intestinal injury during procedures with percutaneous renal access, thus optimizing favorable outcomes and avoiding complications and death during conservative or surgical approaches. MATERIALS AND METHODS: Bibliographic review of case reports available in the literature and presentation of data from an additional case have been carried out. RESULTS: Percutaneous nephrolithotripsy was the procedure that most frequently caused injury of the small intestine. Time for diagnosis of the lesion took up to 5 days after the intraoperative phase. When occurring in the intraoperative phase, perforation was identified by direct endoscopic visualization; a catheter was then placed inside the intestinal lumen and a conservative approach to the derived fistula was adopted, which led to successful outcomes in all cases. Abdominal pain was the most common symptom in cases diagnosed during the postoperative phase (75%). In the presence of signs of peritonitis, surgical intervention was performed, with favorable evolution in all cases. CONCLUSIONS: Conservative management of small intestine injuries is possible when there is no peritoneal contamination. Its success factors include intraoperative diagnosis and non-transfixing lesions, which is more common in duodenal involvement. Laparotomy to clean the cavity associated with a corrective approach (enterorrhaphy or enterectomy with primary anastomosis) was successfully indicated in cases of late diagnosis with signs of peritonitis, a situation that is most commonly found in transfixing lesions of ileum and jejunum.

Small bowel perforation and death caused by anaplastic thyroid carcinoma metastasis in a patient with concomitant colonic and bilateral breast carcinoma

Undifferentiated or anaplastic thyroid carcinoma (ATC) is rare and one of the most aggressive human malignancies. The tumor is usually voluminous and fast-growing and mostly affects older women. The most common sites of distant metastases are the lungs, brain, and bones. Herein, we describe the case of a 66-year-old woman with a history of bilateral breast carcinoma and ATC, who presented with an acute abdomen and subsequently died. At autopsy, an isolated metastasis of ATC in the small intestine leading to bowel perforation was found. Moreover, there was adenocarcinoma in the descending colon. The review of extra-abdominal malignancies metastasizing to bowel and coincidence of breast and thyroid carcinoma is included.

Evisceración del intestino delgado estrangulado en una anciana con douglascele / Evisceration of the impacted small bowel in an elderly with douglascele

Se presenta el caso clínico de una anciana de 86 años de edad con evisceración del intestino delgado a través del periné. Se efectuó la exploración quirúrgica urgente del abdomen y se observó la perforación del fondo del saco de Douglas y la salida de 50 cm de intestino delgado estrangulado, de manera que se realizó la resección intestinal de todo el segmento afectado y anastomosis termino-terminal. Luego se reparó el defecto del fondo del saco de Douglas con una plastia perineal, para lo cual se utilizó una malla de polipropileno. Este proceder es una buena alternativa para el tratamiento quirúrgico en quienes presentan hernias perineales, pues permite un cierre mejor, disecar el saco herniario y reducirlo adecuadamente.

The case report of a 86 years elderly is presented with evisceration of the small bowel through the perineum. The urgent surgical exploration of the abdomen was carried out and it was observed the perforation of the Douglas pouch and the 50 cm prominence of impacted small bowel, so that the bowel resection of the whole affected segment and end to end anastomosis was carried out. Then the Douglas pouch defect was repaired with a perineal plasty, for which a polypropylene mesh was used. This procedure is a good alternative for the surgical treatment in those who present perineal hernias, because it allows a better closing, to dissect the hernial sack and to reduce it appropriately.

The role of ischemic preconditioning in the expression of apoptosis-related genes in a rat model of intestinal ischemia-reperfusion injury

Purpose: To analyze the effects of ischemic preconditioning (IPC) in the expression of apoptosis-related genes in rat small intestine subjected to ischemia and reperfusion.Methods: Thirty anesthetized rats underwent laparotomy and were drive into five groups: control (CG); ischemia (IG); ischemia and reperfusion (IRG); IPC and ischemia (IG+IPC); IPC and ischemia and reperfusion (I/RG+IPC). Intestinal ischemia was performed by clamping the superior mesenteric artery for 60 minutes, whereas reperfusion lasted for 120 minutes. IPC was carried out by one cycle of 5 minutes of ischemia followed by 10 minutes of reperfusion prior to the prolonged 60-minutes-ischemia and 120-minutes-reperfusion. Thereafter, the rats were euthanized and samples of small intestine were processed for histology and gene expression. Results: Histology of myenteric plexus showed a higher presence of neurons presenting pyknotic nuclei and condensed chromatin in the IG and IRG. IG+IPC and I/RG+IPC groups exhibited neurons with preserved volume and nuclei, along with significant up-regulation of the anti-apoptotic protein Bcl2l1 and down-regulation of pro-apoptotic genes. Moreover, Bax/Bcl2 ratio was lower in the groups subjected to IPC, indicating a protective effect of IPC against apoptosis. Conclusion: Ischemic preconditioning protect rat small intestine against ischemia/reperfusion injury, reducing morphologic lesions and apoptosis.(AU)

Spontaneous perforation of small intestine followed by rupture of the cystic artery: the natural history of Vascular Ehlers-Danlos Syndrome

Vascular Ehlers-Danlos Syndrome (VEDS) is a rare autosomal dominant disorder caused by mutations in the COL3A1 or COL1A1 genes. Its mortality is secondary to sudden and spontaneous rupture of arteries or hollow organs. The genotype influences the distribution of arterial pathology with aneurysms of intra-abdominal visceral arteries being relatively uncommon. We describe the case of a young man with probable VEDS who died of a spontaneous rupture and dissection of the cystic artery. The patient initially presented with abdominal pain due to an unrecognized spontaneous perforation of the small intestine complicated by sepsis. We postulate that inflammatory mediators may have triggered the arterial rupture due to remodeling and weakening of vessel walls. The phenotype of the patient's vascular damage included bilateral spontaneous carotid-cavernous sinus fistulae and dissection with pseudoaneurysm formation of large- and medium-sized arteries, predominantly the abdominal aorta and its branches. The autopsy uncovered a long history of vascular events that may have been asymptomatic. These findings along with a positive family history supported the VEDS diagnosis. Loeys-Dietz, Marfan, and familial thoracic aortic aneurysm and dissection syndromes were ruled out based on the absence of arterial tortuosity, eye abnormalities, bone overgrowth, and the distribution of vascular damage among other features. Interestingly, microscopic examination of the hippocampus revealed a focus of neuronal heterotopia, commonly associated with epilepsy; however, the patient had no history of seizures. The natural course of VEDS involves the rupture and dissection of arteries that, if unrecognized, can lead to a rapid death after bleeding into free spaces.

Abdominal trauma: experience of 4961 cases in Western Mexico.

INTRODUCTION: Trauma is a leading cause of morbimortality in the world. Intraabdominal compartment is the third most affected anatomical region and bleeding from this origin is difficult to identify, therefore the importance to predict possible lesions to the abdominal cavity. OBJECTIVE: To describe and analyze the sociodemographic profile and injuries found in patients with abdominal trauma in a western hospital in Mexico. METHOD: Consecutive patients included in the local registry GDL-SHOT were analyzed. RESULTS: From 4961 patients, 91.4% were men, with a mean age of 28.7 years. Regarding the mechanism of trauma, 39.7% were stab wounds, 33% blunt abdominal trauma and 27.3% gunshots. The most affected organs were: small bowel (20.9%), liver (18.2%), and colon (14.2%). The mean hospital stay was 6.95 days with a mortality of 6.74%. CONCLUSION: In Mexico, abdominal trauma represents an important cause of morbidity and mortality, especially in young patients. We found an important amount of penetrating trauma.

INTRODUCCIÓN: El trauma es una de las principales causas de morbimortalidad en el mundo. El abdomen es, en frecuencia, la tercera región anatómica más afectada, y el compartimento intraabdominal es un sitio de hemorragia difícil de identificar, por lo que cobra importancia el conocimiento de las posibles lesiones tras un traumatismo. OBJETIVOS: Describir y analizar el perfil sociodemográfico y las lesiones encontradas en pacientes con trauma abdominal en un hospital de referencia del occidente de México. MÉTODO: Se seleccionaron para su análisis los pacientes incluidos en el registro hospitalario local GDL-SHOT. RESULTADOS: De 4961 pacientes, el 91.4% fueron hombres, con un promedio de edad de 28.7 años. Respecto al mecanismo, el 39.7% correspondió a arma blanca, el 33% a trauma cerrado y el 27.3% a arma de fuego. Los órganos más afectados fueron el intestino delgado (20.9%), el hígado (18.2%) y el colon (14.2%). La estancia hospitalaria promedio fue de 6.95 días, con una mortalidad del 6.74%. CONCLUSIONES: En México, el trauma abdominal representa una causa importante de morbimortalidad, en especial en pacientes jóvenes, y predomina el mecanismo penetrante; el manejo más común es no conservador. La frecuencia de lesiones encontradas es discordante con la literatura de otros países y predominan las de vísceras huecas, probablemente por la diferencia en los mecanismos implicados.

Factores de riesgo de dehiscencia de anastomosis de intestino delgado realizadas por reparo de lesiones de origen traumático penetrante en el Hospital Nacional Rosales / Risk factors for small bowel anastomosis dehiscence performed for repair of penetrating traumatic injuries at the Rosales National Hospital

En el manejo de las lesiones de intestino delgado se puede necesitar la utilización de líneas de sutura, hasta la resección de un segmento y anastomosis reconstructiva. Estos procedimientos pueden presentar complicaciones agudas y tardías entre las que destaca la dehiscencia de anastomosis. El objetivo del presente estudio fue el de investigar los factores relacionados a la dehiscencia de la anastomosis intestinal en contexto de trauma abdominal penetrante. Se utilizó un estudio observacional analítico de casos y controles no apareados, en pacientes que acudieron a la unidad de emergencia del Hospital Nacional Rosales que presentaron (casos) o no (controles) dehiscencia de anastomosis intestinales posterior a resección de un segmento por trauma penetrante por arma de fuego o arma blanca, en un periodo especifico del tiempo. Se obtuvo una tasa de dehiscencia de anastomosis de 19.14%, siendo el género masculino el más afectado, el mecanismo de lesión más frecuente fueron las heridas por arma de fuego, y el sitio más frecuentemente dañado fue el yeyuno. Los factores de riesgo que presentaron significancia estadística para dehiscencia fueron: el nivel de la lesión (p=0.009), centímetros resecados (p=0.000), número total de lesiones (p=0.001). Hipotensión perioperatoria (p=0.038) y las lesiones concomitantes (p=0-003). El control de daños se comportó como un factor protector para evitar las dehiscencias de anastomosis. En nuestro estudio, lesión en el yeyuno o ambos, centímetros resecados, número total de lesiones, hipotensión perioperatoria y tener lesiones concomitantes fueron factores de riesgo de dehiscencia de anastomosis

Retención de cápsula endoscópica como complicación de enteritis actínica: reporte de un caso / Retention of capsule endoscopy as a complication of radiation enteritis: a case report

La cápsula endoscópica es un método, que ha modificado el enfoque diagnóstico de numerosos procesos patológicos en el intestino delgado, sin embargo presenta complicaciones como la retención de la misma. Se estima en la literatura mundial que esta suele ocurrir en menos del 2% de los casos. Femenino de 40 años de edad, con antecedente de cáncer de cuello uterino (2011) en tratamiento con quimioterapia, radioterapia convencional y braquiterapia, que presenta cuadro clínico caracterizado por dolor urente en mesogastrio, y emesis de aspecto biliosos. Ruidos hidroaéreos presentes, dolor a la palpación de mesogastrio sin irritación peritoneal. Radiografía de abdomen y ecosonograma abdominal normales. TAC abdomino pélvica con contraste oral con adecuada progresión de contraste hasta el recto. Se practica gastroscopia y colonoscopia sin evidencia de alteraciones. En vista de persistencia de sintomatología se indica realización de cápsula endoscópica observando en íleon distal, a los 246 minutos del paso duodenal, área muy congestiva, con una úlcera circunferencial friable, que no permite el avance de la misma. Se indica tratamiento médico con laxantes por 72 horas, el cual es infructuoso, por lo cual es llevada a mesa operatoria por presentar signos francos de obstrucción intestinal. Los hallazgos fueron: adherencias en flanco y fosa ilíaca derecha, las cuales fueron liberadas, y segmento de íleon a 10 cm de la válvula ileocecal con inflamación franca, practicándose resección y anastomosis termino-lateral. El estudio histopatológico reportó enteritis crónica activa exulcerada, necrosis fibrinoide de pequeños vasos, y fibrosis en la submucosa. Paciente con post-operatorio exitoso decidiéndose el egreso de la institución. Excelente correlación entre los hallazgos de la cápsula endoscópica y la intervención quirúrgica. Los hallazgos de la cirugía se encuentran relacionados al uso de radioterapia convencional, por lo cual recomendamos la realización de pexia...

Capsule endoscopy is a method that has changed the diagnostic approach to many pathological processes in the small intestine, but it has complications such as retention of the same, is estimated in the literature that this usually occurs in less than 2% cases. Women 40 years of age, with a history of cervical cancer (2011) undergoing chemotherapy, conventional radiation therapy, and brachytherapy, presenting clinical picture characterized by burning pain in midgut, and bilious emesis aspect. Present bowel sounds, tenderness of mesogastrium without peritoneal irritation. Abdominal radiography and abdominal ultrasonography normal. Pelvic CT with oral contrast Abdomino with progression adequate contrast to the rectum. Gastroscopy and colonoscopy was performed without evidence of tampering. In view of the persistence of symptoms embodiment shown in watching endoscopic capsule distal ileum, to 246 minutes of step duodenal study, very congestive area with a circumferential friable ulcer which does not allow the advance thereof. Indicated medical treatment with laxatives for 72 hours being fruitless, operating table being carried by presenting overt signs of intestinal obstruction. The findings were: adhesions flank and right lower quadrant, which were released and ileal segment 10 cm from the ileocecal valve with frank inflammation resection and end-side anastomosis. Histopathological study reported chronic active enteritis exulcerada, fibrinoid necrosis of small vessels, and fibrosis in the submucosa. Postoperative patient deciding successful graduation from the institution. Excellent correlation between the findings of capsule endoscopy and surgery. The findings at surgery are related to the use of conventional radiotherapy, so we recommend an pexia of the organs that are in the radiation field, prior to it, and intestinal transit before indicating capsule endoscopy

Unusual small intestine inflammatory lesions in a dog with visceral leishmaniasis

The aim of this study is to describe a case of an asymptomatic dog naturally infected with L. infantum chagasi with a surprising number of parasites in the duodenum. A mixed breed dog of unknown age was referred to the Center for Zoonoses Control of the Municipality of Ribeirão das Neves, Belo Horizonte Metropolitan area, Minas Gerais State, Brazil. The dog was diagnosed for Leishmania using an enzyme-linked immunosorbent assay (ELISA), direct parasitological examination of bone marrow aspiration, and immunohistochemistry of ear biopsy. After euthanasia samples of spleen, liver, lung, kidney, heart, cervical and mesenteric lymph nodes; ear, snout, abdominal skin and GIT segments (esophagus, stomach, duodenum, jejunum, ileum, cecum, colon, and rectum) were evaluated histologically and immunohistochemically for the presence of parasite amastigotes. Gross and microscopic examination of necropsy samples showed no severe alterations of the mucosa in any gastrointestinal segment. A conspicuous parasite load was observed in the lamina propria of the duodenum, jejunum, ileum, cecum, colon, and rectum. Parasite distribution in the small intestine was diffuse through the lamina propria, whereas in the large intestine it was concentrated close to the muscularis mucosa and distant from the intestinal lumen. The parasite load in the duodenum, mainly in the subepithelial region, was higher...

Unusual small intestine inflammatory lesions in a dog with visceral leishmaniasis

The aim of this study is to describe a case of an asymptomatic dog naturally infected with L. infantum chagasi with a surprising number of parasites in the duodenum. A mixed breed dog of unknown age was referred to the Center for Zoonoses Control of the Municipality of Ribeirão das Neves, Belo Horizonte Metropolitan area, Minas Gerais State, Brazil. The dog was diagnosed for Leishmania using an enzyme-linked immunosorbent assay (ELISA), direct parasitological examination of bone marrow aspiration, and immunohistochemistry of ear biopsy. After euthanasia samples of spleen, liver, lung, kidney, heart, cervical and mesenteric lymph nodes; ear, snout, abdominal skin and GIT segments (esophagus, stomach, duodenum, jejunum, ileum, cecum, colon, and rectum) were evaluated histologically and immunohistochemically for the presence of parasite amastigotes. Gross and microscopic examination of necropsy samples showed no severe alterations of the mucosa in any gastrointestinal segment. A conspicuous parasite load was observed in the lamina propria of the duodenum, jejunum, ileum, cecum, colon, and rectum. Parasite distribution in the small intestine was diffuse through the lamina propria, whereas in the large intestine it was concentrated close to the muscularis mucosa and distant from the intestinal lumen. The parasite load in the duodenum, mainly in the subepithelial region, was higher...(AU)

Tumor neuroendocrino de Íleon: a propósito de un caso / Ileum's neuroendocrine tumor: report of a case

Los tumores neuroendocrinos (TNE) del aparato gastrointestinal representan menos del 5% de las neoplasias del aparato gastrointestinal siendo el intestino delgado, en especial el íleon, donde se presentan mayor frecuencia (30%). Se originan del sistema endocrino difuso gastrointestinal y tienen capacidad de secretar péptidos y aminas bioactivas, principalmente la 5-hidroxitriptamina (5-HT) o serotonina. La Organización mundial de la salud (OMS) los clasifica de acuerdo al grado de diferenciación y conducta biológica en 5 grados. Las manifestaciones clínicas pueden estar ausentes o ser inespecíficas, su hallazgo, como en el caso de nuestra paciente, puede ser casual. Se reporta el caso de paciente femenino de 56 años la cual consultó por distensión abdominal y dolor anorrectal, realizándose colonoscopia con ileoscopia encontrando tumor subepitelial en íleon terminal con inmunohistoquímica que reportó: Tumor neuroendocrino bien diferenciado. El tratamiento de los TNE varía desde la resección quirúrgica en los estadíos menos avanzados hasta tratamiento quirúrgico asociado a quimioterapia y radioterapia en los más avanzados con una tasa de supervivencia a los 5 y 10 años de 73 y 65% para tumores bien diferenciado. De allí la importancia del diagnóstico precoz. Asimismo resaltar la canulación de retiro de la válvula ileocecal durante la colonoscopia de pesquisa.

The gastrointestinal neuroendocrine tumors (NET) represent less than 5% of the gastrointestinal tract neoplasms, being the small bowel, specially ileum, the most frequent location (30%). They originate from the diffuse endocrine gastrointestinal system and are able to secrete peptides and bioactive amines, mainly the 5-hidroxitryptamine (5-HT) or serotonine. The World Health Organization (WHO) classifies them according to its differentiation grade and biological behavior in 5 grades. The clinical manifestations could be absent or non specifics. Its finding, as in our patient case, can be casual. We report a case of a 56 years old female patient who complained of abdominal distention and anorectal pain. A colonoscopy with ileoscopy was performed finding a subepithelial tumor in the terminal ileum which inmunohistochemestry reported: Well differentiated neuroendocrine tumor. The treatment of NET varies from surgical resection alone in the less advanced stages, to surgical treatment associated to chemotherapy and radiotherapy in the most advanced stages, with a survival rate of 73 and 65% in the 5 and 10 years for the well differentiated tumors, being very important its early diagnosis. Equally must be highlighted the canulation of ileum cecal valve during a screening colonoscopy.

Radioprotection of sensitive rat tissues by oligoelements Se, Zn, Mn plus Lachesis muta venom.

In this study we first evaluated the general radioprotective efficacy of Se, Zn and Mn (4 µg/ml each) plus Lachesis muta venom (4 ng/ml) combination (O-LM) by determining survival on rats irradiated with lethal doses of gamma-rays. The aim of the second part of the study was to investigate the O-LM ability to prevent ionizing radiation-induced damage on small intestine, bone marrow and submandibular glands. Hence, histological characteristics and functional studies, together with proliferation and apoptotic marker levels on whole body irradiated rats with a 5 Gy dose were evaluated. Results show that all animals of the untreated group died after whole body irradiation with 8 and 10 Gy while 60 day-survival was more than 80% and 40% in O-LM-treated animals, respectively. Histopathological examinations revealed a high degree of small intestine and submandibular gland radioprotection 3 days post-irradiation. O-LM inhibited histological damage on small intestine, restoring the radiation-induced reduction in villous height and crypt number. O-LM prevented radiation-induced loss of salivary gland function and morphological alterations. These effects were associated to a complete inhibition of radiation-induced apoptosis. Furthermore, studies performed 30 days post-irradiation revealed that O-LM significantly improved bone marrow repopulation, increasing all medullar progenies to the extent of the non-irradiated animals, and completely prevented permanent submandibular gland alterations. Based on the present results and taking into account that O-LM is being safely administered in phase I clinical trial as an immunomodulator, we conclude that O-LM is a non-toxic promising approach to achieve radioprotection for patients undergoing radiotherapy.

Videoenteroscopia de balón único con prototipo Olympus: experiencia preliminar / Single-balloon videoenteroscopy olympus prototype: preliminary experience

Introducción: La enteroscopia de balón único es una técnica segura con alto alcance diagnóstico y terapéutico. Sin embargo, existe la dificultad para el manejo de accesorios mientras mayor es la profundidad de inserción. Objetivo: Mostrar ventajas en el diagnóstico y tratamiento de patología del intestino delgado utilizando un prototipo Olympus con canal 3,2 mm. Pacientes y métodos: 18 procedimientos en 13 pacientes. Diciembre 2009-Abril 2010. Se utilizó el prototipo Olympus X SIF 180 JY, con canal 3.2 mm y canal externo de irrigación. Se usaron accesorios endoscópicos de tecnología convencional para colonoscopia. Se registraron datos demográficos, indicaciones, vía de acceso, tiempo del procedimiento, profundidad de inserción, hallazgos y terapéutica. Resultados: 13 pacientes: 9 femenino, 4 masculino, edad promedio: 47,61 años. Indicaciones principales: sangrado digestivo oscuro (4), Diarrea crónica (4), síndrome de poliposis (3). Procedimientos. Vía anterógrada 13, retrógrada 4, combinado 1. Tiempo promedio: 40,46 minutos anterógrada, 36,35 minutos retrógrada. Profundidad de inserción: 201,53 cm anterógrada, 95 cm retrograda. Estudio normal: 46,15 % de los pacientes, hallazgos positivos: 53,84%. Terapéutica: 5 (27,7%): clips (2), inyección con adrenalina+argón (1), polipectomía (1), dilatación de estenosis (1). No hubo complicaciones. Conclusión: el prototipo Olympus X SIF 180 JY cuenta con canal terapéutico que permite la utilización de accesorios endoscópicos de tecnología convencional con menor dificultad de deslizamiento a mayor profundidad de inserción y canal de irrigación externo que mejora la visibilidad del campo. Ambas características favorecerían la realización de procedimientos terapéuticos.

Introduction: The single balloon enteroscopy is a safe technique with high diagnostic and therapeutic yield. However, there is the difficulty to manage attachments while the greater the depth of insertion. Objective: To show benefits in the diagnosis and treatment of diseases of the small bowel using a prototype Olympus with 3.2 mm channel. Patients and Methods: 18 procedures in 13 patients. December 2009-April 2010. We used the prototype Olympus SIF 180 JY X, with 3.2 mm channel and external canal irrigation. Standard endoscopic accessories were used for colonoscopy. Recorded demographic data, indications, route of access, procedure time, insertion depth, and therapeutic findings. Results: 13 patients: 9 women, 4 men, mean age: 47.61 years. Main indications: obscure gastrointestinal bleeding (4), chronic diarrhea (4), polyposis syndrome (3). Procedures. 13 antegrade, 4 retrograde, combined 1. Average Time: 40.46 minutes antegrade, retrograde 36.35 minutes. Depth of insertion: 201.53 cm antegrade, retrograde 95 cm. Study normal: 46.15% of patients, positive findings: 53.84%, with active bleeding lymphangioma (1), Dieulafoy lesion (1), celiac disease (1), Crohn's (1), polyposis (3). Therapeutics 5 (27.7%) clips (2), adrenaline injection + argon (1), polypectomy (1), dilatation of stenosis (1). There were no complications. Conclusion: The prototype Olympus SIF 180 JY X has therapeutic channel allows the use of standard endoscopic accessories more easily slip deeper insertion and external irrigation canal which enhances the visibility of the field. Both features favor the therapeutic procedures.

Adenocarcinoma primário multicêntrico com 12 focos: relato de caso e revisão da literatura / Multicenter primary adenocarcinoma with 12 foci: case report and literature review

Relata-se caso raro de adenocarcinoma primário multicêntrico sincrônico em intestino delgado, apêndice cecal e intestino grosso, em homem de 82 anos, com quadro de abdome agudo inflamatório. Foi submetido à laparotomia exploradora, observando-se lesão intestinal estenosante e infiltrativa no ângulo hepático e múltiplas aderências entre as alças do intestino delgado. Foi realizada hemicolectomia direita. O estudo anatomopatológico mostrou 12 focos de adenocarcinomas primários comprometendo intestino delgado (oito focos), válvula ileocecal, apêndice cecal e intestino grosso (cólon ascendente e transverso).

A rare case of synchronous multicenter primary adenocarcinoma in the small intestine, cecal appendix and large intestine, in an 82-year-old man with a condition of acute abdominal inflammation, is reported. He underwent exploratory laparotomy, and a stenosing and infiltrative intestinal lesion was seen in the hepatic angle, along with multiple adherences between the loops of the small intestine. Right hemicolectomy was performed. The anatomopathological evaluation showed 12 foci of primary adenocarcinomas affecting the small intestine (eight foci), ileocecal valve, cecal appendix and large intestine (ascending and transverse colon).

PI3Kγ controls leukocyte recruitment, tissue injury, and lethality in a model of graft-versus-host disease in mice.

PI(3)Kγ is thought to mediate leukocyte migration to injured tissues and may be important in the pathogenesis of various T-lymphocyte-dependent pathologies, including autoimmune and inflammatory diseases. The present study evaluated the relevance of PI(3)Kγ in donor cells for the pathogenesis of acute GVHD using a model of adoptive transfer of splenocytes from WT or PI(3)Kγ(-/-) C57BL/6J mice to B6D2F1 mice, and mice that received PI(3)Kγ(-/-) cells showed reduced clinical signs of disease, bacterial translocation, tissue injury, and lethality rates. This was associated with reduced production of proinflammatory cytokines and chemokines (TNF-α, IFN-γ, CCL2, CCL3, and CCL5) and reduced infiltration of CD8(+), CD4(+), and CD11c(+) cells in the small intestine. Mechanistically, in addition to decreasing production of proinflammatory mediators, absence or pharmacological blockade of PI(3)Kγ was associated with decreased rolling and adhesion of leukocytes to the mesenteric microcirculation, as assessed by intravital microscopy. Despite decreased GVHD, there was maintained GVL activity when PI(3)Kγ(-/-) leukocytes were transferred into WT mice. In conclusion, PI(3)Kγ plays a critical role in GVHD by mediating leukocyte influx and activation in tissues. PI(3)Kγ inhibitors may be useful in the treatment of GVHD in patients undergoing BMT.

Hemorragia digestiva média e outras indicações de exame com a capsula endoscópica: resultados em uma série consecutiva de 187 pacientes / Avarage gastrointestinal bleeding and other indications of capsule endoscopy examination with the: results in a consecutive series of 187 patients

Objetivo: verificar as indicações e os resultados do emprego da cápsula endoscópica em uma série consecutiva de pacientes, analisando-se, em especial, os casos de hemorragia de causa obscura e também a relação no momento em que o exame foi efetuado em relação à atividade de sangramento. Análises especiais ainda para os casos de exames inconclusivos, cápsulas retidas e lesões fora do delgado. Material e Métodos: 187 pacientes consecutivos submetidos ao exame do intestino delgado pela cápsula foram analisados. Utilizou-se a cápsula da empresa Given, específica para o delgado (versões M2A e PillCam SB), e as análises de imagens foram efetuadas no software específico deste método, versão 5.1. Resultados: 70,5% (132 casos) dos exames foram indicados por hemorragia de causa obscura (64 casos) ou anemia de causa obscura (68 casos). Diarreia, dor abdominal, suspeita de pólipos e outras menos frequentes foram as demais indicações. Dos 187 casos, em 124 deles observaram-se lesões, sendo 101 lesões em delgado e 23 lesões fora do delgado. Em 29,9% dos casos, a cápsula não observou lesões e, em 3,7% do total de casos, o exame foi inconclusivo. Em 5 casos (2,6%), a cápsula ficou retida. As lesões vasculares do intestino delgado representaram o diagnóstico mais frequente e, quando da análise dos casos de hemorragia em relação ao momento do sangramento, demonstrou-se um percentual de 69,5% de encontro de lesões no paciente com sangramento ativo, 77,7% no paciente com sangramento recente e 64,6% no paciente examinado fora do episódio hemorrágico. Conclusões: a hemorragia digestiva ou a anemia, de causa obscura, foi a indicação mais frequente (70,5%) do exame do delgado com a cápsula endoscópica. Na análise dos resultados em 66,3% dos exames efetuados, a cápsula demonstrou lesões, inclusive fora do delgado. As lesões vasculares foram as mais encontradas e, nos casos de hemorragia/anemia de causa obscura, a capacidade da cápsula em encontrar lesões foi maior nos pacientes que efetuaram o exame durante o episódio hemorrágico, ou logo após do mesmo, do que em pacientes nos quais o exame foi feito distante deste episódio, embora estes resultados não tivessem relevância estatística. Exames inconclusivos tiveram um percentual de 3,7% dos casos e, em 2,6% dos casos, a cápsula ficou retida em estenoses do delgado.

Objectives: to verify the indications and results of the use of endoscopy capsule in a consecutive series of patients, especially the cases of obscure bleeding cause with the moment when the examination was made (related to bleeding activity). Special analysis for the cases not conclusive yet, retained capsules and lesions out of small bowel. Materials and Methods: 187 consecutive patients underwent the small bowel examination by the capsule were analyzed. A capsule from the Given company was used, it is specific for small bowel (M2A e PillCam SB) and the analyses were made in this brand-specific software, version 5,1. Results: in the analysis it was observed that 70,5% of them (132 cases) were indicated by obscure bleeding cause (64 cases) or obscure anemia cause (68 cases). Diarrhea, abdominal pain, suspected polyps and others least often were the other indications. From the 187 cases, in 124 of them were observed lesions, 101 of them in the small bowel and 23 lesions out of it. In 29,9% of the cases the capsule did not observed lesions and in 3,7% of all cases the examination was inconclusive. In 5 cases (2,6%) the capsule was retained. Vascular lesions of the small bowel were the most frequent diagnosis, and the bleeding causes analysis, in relation to the bleeding moment, 69,5% of lesions in the patient with the active bleeding were showed, 77,7% in the patient with recent bleeding and 64,6% in the patient whose examination was out of the bleeding episode. Conclusion: gastrointestinal bleeding and/or obscure anemia cause were the most frequent indication (70,5%) of the small bowel examination with the endoscopy capsule. In the results analysis, in 66,3% of the examinations made, the capsule showed lesion(s), even out of the small bowel. Vascular lesions were the most found and in the obscure bleeding/anemia cause cases the capsules capacity to find lesions was higher in patients that did the examination during the bleeding episode or just after it, than in patients that the examination was done far from the episode. Inconclusive examinations had a percentage of 3,7 of cases and in 2,6% of cases the capsule was retained in small bowel stenosis.