RESUMO
Complications related to cholecystectomy occur in <3% of patients. Endoclip migration after laparoscopic cholecystectomy with hepatolithiasis is an extremely rare complication. We report a case of hepatolithiasis secondary to endoclip migration after laparoscopic cholecystectomy treated successfully via right hepatectomy. A 35-year-old female presented with upper abdominal pain, fever and vomiting 9 years after laparoscopic cholecystectomy for chronic calculus cholecystitis. Laboratory investigation revealed gamma-glutamyl transpeptidase of 550 U/L and alkaline phosphatase of 350 U/L. Magnetic resonance cholangiopancreatography revealed a dilated intrahepatic bile duct in segment 6 filled with stones. After preoperative evaluation, a right hepatectomy was performed using the intermittent Pringle maneuver. The postoperative recovery was uneventful and the patient was well after 4 months of follow-up. Although rare, endoclip migration should be considered in patients presenting with intrahepatic lithiasis even many years after laparoscopic cholecystectomy. Liver resection may be necessary in cases of failure of endoscopic extraction.
RESUMO
We describe four pregnant patients with distal renal tubular acidosis (type I) (DRTA) whose initial presentation was rhabdomyolysis (RML) secondary to severe hypokalemia. We draw attention to the unusual presentation of DRTA during pregnancy, the low frequency of DRTA in adult patients and RML as initial manifestation. In one case the DRTA was secondary to Sjögren Syndrome and the etiology was unknown in the rest of the cases. We discuss the potential pathogenic mechanisms to explain hypokalemic RML and the various causes of DRTA in adult patients.
Assuntos
Acidose Tubular Renal/diagnóstico , Túbulos Renais Distais/fisiopatologia , Complicações na Gravidez/diagnóstico , Rabdomiólise/etiologia , Acidose Tubular Renal/sangue , Acidose Tubular Renal/classificação , Acidose Tubular Renal/complicações , Adulto , Doenças Autoimunes/complicações , Bacteriemia/complicações , Bacteriemia/microbiologia , Feminino , Humanos , Hipopotassemia/etiologia , Hipotireoidismo/complicações , Recém-Nascido , Transporte de Íons , Túbulos Renais Distais/metabolismo , Infecções por Klebsiella/complicações , Klebsiella pneumoniae/isolamento & purificação , Gravidez , Resultado da Gravidez , Quadriplegia/etiologia , Rabdomiólise/sangue , Síndrome de Sjogren/complicações , Vômito/etiologiaRESUMO
Patients that develop rhabdomyolysis of different causes are at high risk of acute renal failure. Efforts to minimize this risk include volume repletion, treatment with mannitol, and urinary alkalinization as soon as possible after muscle injury. This is a retrospective analysis (from January 1, 1992, to December 31, 1995) of therapeutic response to prophylactic treatment in patients with rhabdomyolysis admitted to an intensive care unit (ICU). The diagnosis of rhabdomyolysis was based on creatinine kinase (CK) level (> 500 Ui/L) and the criteria for prophylaxis were: time elapsed between muscle injury to ICU admission < 48 h and serum creatinine < 3 mg/dL. Fifteen patients were treated with the association of saline, mannitol, and sodium bicarbonate (S + M + B group) and 9 patients received only saline (S group). Serum creatinine at admission was similar in both groups: 1.6 +/- 0.6 mg/dL in the S + M + B group and 1.5 +/- 0.6 mg/dL in the S group (p > 0.05). Maximum serum CK measured was 3351 +/- 1693 IU/L in the S + M + B group and 1747 +/- 2345 IU/L in the S group (p < 0.05). However the measurement of CK was earlier in S + M + B patients (1.7 vs 2.7 days after rhabdomyolysis). APACHE II scores were 16.9 +/- 7.4 and 13.4 +/- 4.9 in the S + M + MB and S groups, respectively (p > 0.05). Despite the treatment protocol the serum levels of creatinine had similar behavior and reached normal levels in all patients in 2 or 3 days. The saline infusion during the first 60 h on the ICU was 206 mL/h in the S group and 204 mL/h in S + M + B (p > 0.05). Mannitol dose was 56 g/day, and bicarbonate 225 mEq/day during 4.7 days. Our data show that progression to established renal failure can be totally avoided with prophylactic treatment, and that once appropriate saline expansion is provided, the association of mannitol and bicarbonate seems to be unnecessary.
Assuntos
Injúria Renal Aguda/prevenção & controle , Diuréticos Osmóticos/uso terapêutico , Manitol/uso terapêutico , Rabdomiólise/complicações , Bicarbonato de Sódio/uso terapêutico , Injúria Renal Aguda/etiologia , Análise de Variância , Humanos , Testes de Função Renal , Estudos Retrospectivos , Cloreto de Sódio/uso terapêutico , Resultado do TratamentoRESUMO
It is possible to evaluate ICU performance using severity-of-illness systems, but are these systems objective enough to draw comparison between different units? A software was developed to allow data collection and calculation of the score APACHE II [1] and administrative hospital indicators. To provide homogeneity, all data were collected following the same protocol and verified by one author.
Assuntos
APACHE , Unidades de Terapia Intensiva/normas , Qualidade da Assistência à Saúde , Software , Idoso , Brasil , Coleta de Dados , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/organização & administração , Sistemas de Informação Administrativa , Pessoa de Meia-IdadeRESUMO
PURPOSE: To evaluate cardiac alterations secondary to exogenous intoxication by paraquat. METHODS: We performed analysis of clinical and laboratory data of 25 patients with acute paraquat poisoning admitted in our ICU from November 1983 to January 1991. RESULTS: There were purposeful overdoses in 24 cases (96%). The mortality rate was 56%. The lung involvement was 96%, renal was 92%, gastrointestinal tract was 72%, hepatic was 56%, and cardiac involvement was 40%. CONCLUSION: Cardiac involvement due to paraquat is frequent (40%). The clinical picture of this involvement has a wide spectrum, ranging from minimal changes in the ECG to acute and extensive myocardial necrosis.
Assuntos
Cardiopatias/induzido quimicamente , Paraquat/intoxicação , Adolescente , Adulto , Brasil/epidemiologia , Eletrocardiografia/efeitos dos fármacos , Feminino , Cardiopatias/diagnóstico , Cardiopatias/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Intoxicação/diagnóstico , Intoxicação/mortalidade , Tentativa de Suicídio/estatística & dados numéricosRESUMO
PURPOSE: Electrocardiographic alterations were evaluated in a group of accidental hypothermia patients, and correlated with values of core temperature, pH and plasmatic concentrations of Na+, K+ and Cl-. METHODS: Conventional 12-lead surface electrocardiograms were obtained in a group of 32 patients with accidental hypothermia after involuntary cold exposure. Cardiac arrhythmias, QRS configuration, ST-T segment and T wave alterations were analyzed. pH, Na+, K+ and Cl- serum concentrations were simultaneously measured. Electrocardiogram and electrolyte abnormalities were then correlated with the core temperature. RESULTS: Twenty-eight patients had abnormal electrocardiogram (90.6%). Sinus bradycardia and idioventricular rhythm were observed in 11 and 3 patients respectively. QT interval enlargement was found in 24 patients and Osborn wave in 28 cases. Altered T waves expressing an abnormal repolarization were observed in 23 cases. A significant negative correlation was obtained when J wave amplitude was correlated with core temperature levels. CONCLUSION: Hypothermia produces electrocardiographic abnormalities characterized by Osborn waves. Other minor findings include sinus bradycardia, idioventricular rhythm and long QT intervals.