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FIGURE1-Coronal computed tomography of the neck clearly showing the fish impacted in cervical esophagus FIGURE 2-Esophagotomy and removal of the intact fish DISCUSSION The greater part of foreign bodies (80%) pass through the gastrointestinal tract without difficulties, but 20% can obstruct the lumen, requiring endoscopic or surgical removal (1% of cases). As the esophagus is a narrow portion of the gastrointestinal tract, 28-68% objects are found in this region 5. The symptoms depend on the location. Dysphagia, odynophagia and salivation suggest esophageal foreign body 4. It can also present chest pain, cough, dyspnea, wheezing or stridor. In more severe cases, particularly in large or sharp foreign bodies, there may be intense pain, vomiting, refusal to eat, saliva ink with blood or shock 1. A medical review of database present several accidents involving foreign bodies ingestion, including food-bolus impactions, coins, fish bones, dental prostheses, chicken bones, iron slices, lighters, little metallic foreign bodies, toothbrushes, needles, and spoons 5 , but no reports involving the ingestion of whole fish. Impaction events with fish bones includes 12.6% of the accidents, the third highest in incidence 5. As the majority of the bodies are radiopaque, the diagnosis can easily be done with plain radiography in posteroanterior and lateral projections. Endoscopy and contrasted study are needed in the case of radiotransparent objects. In all radiological exams it must be looked for signs of subcutaneous emphysema, which indicates drilling 3. The treatment of choice is the endoscopic removal of the foreign body, which is successful with little or no complications for the patient 2. The surgical treatment should be performed when endoscopic management is not possible to solve the problem, or if there is impairment of progression in the gastrointestinal tract or complications such as perforation, obstruction and bleeding 2,3 .
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FIGURE1 - Coronal computed tomography of the neck clearly
showing the sh impacted in cervical esophagus
FIGURE 2 - Esophagotomy and removal of the intact sh
DISCUSSION
The greater part of foreign bodies (80%) pass through
the gastrointestinal tract without difficulties, but 20% can
obstruct the lumen, requiring endoscopic or surgical removal
(1% of cases). As the esophagus is a narrow portion of the
gastrointestinal tract, 28-68% objects are found in this region5.
The symptoms depend on the location. Dysphagia, odynophagia
and salivation suggest esophageal foreign body4. It can also
present chest pain, cough, dyspnea, wheezing or stridor. In
more severe cases, particularly in large or sharp foreign bodies,
there may be intense pain, vomiting, refusal to eat, saliva ink
with blood or shock1.
A medical review of database present several accidents
involving foreign bodies ingestion, including food-bolus
impactions, coins, sh bones, dental prostheses, chicken bones,
iron slices, lighters, little metallic foreign bodies, toothbrushes,
needles, and spoons5, but no reports involving the ingestion of
whole sh. Impaction events with sh bones includes 12.6% of
the accidents, the third highest in incidence5. As the majority
of the bodies are radiopaque, the diagnosis can easily be
done with plain radiography in posteroanterior and lateral
projections. Endoscopy and contrasted study are needed in
the case of radiotransparent objects. In all radiological exams it
must be looked for signs of subcutaneous emphysema, which
indicates drilling3. The treatment of choice is the endoscopic
removal of the foreign body, which is successful with little or
no complications for the patient2. The surgical treatment should
be performed when endoscopic management is not possible to
solve the problem, or if there is impairment of progression in
the gastrointestinal tract or complications such as perforation,
obstruction and bleeding2,3.
REFERENCES
1. Arana A, Hauser B, Hachimi-Idrissi S, Vandenplas Y. Management of
ingested foreign bodies in childhood and review of the literature. Eur
J Pediatr. 2001;160(8):468.
2. Brady PG. Esophageal foreign bodies. Gastroenterol Clin North Am
1991;20(4):691-701
3. Eisen GM, Baron TH, Dominitz JA, et al. Guideline for the management
of ingested foreign bodies. Gastrointest Endosc 2002;55:802-6.
4. Hachimi-Idrissi S, Corne L, Vandenplas Y. Management of ingested
foreign bodies in childhood: our experience and review of the literature.
Eur J Emerg Med 1998;5:319-23.
5. Zhao-Shen Li, MD, Zhen-Xing Sun, MD, Duo-Wu Zou, MD, Guo-Ming
Xu, MD, Ren-Pei Wu, MD,Zhuan Liao, MD. Endoscopic management
of foreign bodies in the upper-GI tract: xperience with 1088 cases
in China. Volume 64, No. 4: 2006 GASTROINTESTINAL ENDOSCOPY
ABCD Arq Bras Cir Dig Letter to the Editor
2016;29(1):67
DOI: /10.1590/0102-6720201600010019
NEISSERIA MENINGITIDIS
PERITONITIS SEROTYPE C:
CASE REPORT
Peritonite por Neisseria meningitidis sorotipo C: relato de caso
João Kleber de Almeida GENTILE1, Maurice Youssef
FRANCISS1,2, Hamilton Ribeiro BRASIL1,2
From the 1Departamento de Cirurgia Geral da Irmandade da Santa Casa de
Misericórdia de São Paulo, São Paulo, SP e 2Hospital Geral de Guarulhos
(1Department of General Surgery of the Irmandade da Santa Casa de
Misericórdia de São Paulo, São Paulo, SP and 2Guarulhos General Hospital,
Guarulhos, SP), Brazil
Correspondence:
João Kleber de Almeida Gentile
E-mail: joaokleberg@gmail.com
Financial source: none
Conicts of interest: none
Received for publication: 04/02/2015
Accepted for publication: 15/12/2015
ABCDDV/1173
INTRODUCTION
The meningococcal disease manifestation as acute
abdomen with meningococcal peritonitis is rare.
Is reported primary peritonitis and bacteremia by
Neisseria meningitidis serotype C occurring in conjunction with
the obstructive acute abdomen.
67
ABCD Arq Bras Cir Dig 2016;29(1):65-69
LETTER TO THE EDITOR
CASE REPORT
Man with 27 year old was admitted with diffuse abdominal
pain accompanied by stop in eliminating flatus and feces for
three days and fever 38,3º C for 24 h. As history, had passed
prior laparotomy seven years ago for acute appendicitis. He
denied other symptoms, recent travel or infectious diseases.
There was no recent use of medications or hospitalization.
Denied alcohol or illicit drugs.
On examination, he was confused, agitated, dehydrated
with clinical signs of sepsis. Was febrile (38,3º C), with
tachycardia (112 beats per minute), tachypnea (20 breaths
per minute) and hypotension (90x50 mmHg). The abdomen
had prior infraumbilical laparotomy scar, very distended,
painful diffusely, hypertimpanic and positive to sudden
decompression. There was no evidence or clinical signs of
liver disease or ascites. Rectal touch was normal without
bleeding or mucus in the stool.
Initial investigation showed leukocytosis (18,600
leukocytes with 11% rod cells), metabolic acidosis signals, high
C-reactive protein (38.6 mg/l) and abdominal radiography
with air-fluid levels without pneumoperitoneum. Abdominal
CT scan showed only distension and small amount of free
fluid in the abdominal cavity; urinalysis and electrolytes
unchanged. Differential diagnoses were acute inflammatory
abdomen with diffuse peritonitis and acute obstructive
abdomen.
Patient received treatment with appropriate volume
expansion 20 ml/kg and antibiotic therapy with ciprofloxacin
400 mg 12/12 h and metronidazole 500 mg 8/8 h. It was
referred to explorative laparotomy as urgency after 24 h
after admission.
The intraoperative findings were only distension of the
small bowel with the presence of thick flanges and thick
purulent fluid in the abdominal cavity and pelvis. In the
inventory of the cavity was not observed organized abscess
and visceral perforation with no identifiable cause for the
origin of pus. It was held lysis of adhesions and collection
of purulent fluid to culture. The result of the culture was
positive for Neisseria meningitidis group C, confirmed by
polymerase chain reaction. The antibiogram was sensitive
to ceftriaxone, meropenem and rifampicin.
Evolved on the 2nd day after surgery with worsening
of confusion and positive meningeal signs besides diffuse
petechiae and thrombocytopenia (88,000 platelets/mm3).
Spinal liquor resulted also be positive for Neisseria meningitidis
group C (diplococci gram negative) with 33,000 cells/mm3 (up
to 5 cells/mm3) 79% of neutrophils, 6 red blood cells (to 0/
mm3), total protein 172 mg/dl (up to 40 mg/dl) glucose and
1 mg/dl (40-80 mg/dl). It was referred to ICU with diagnosis
of meningitis with meningococcemia; began treatment
with ceftriaxone 1 g 12/12 h, resulting in improvement of
neurological and abdominal symptoms after 72 h.
DISCUSSION
Neisseria meningitidis, Gram-negative diplococcus,
was described in 1887 as major cause of meningitis and
meningococcal bacteremia in all ages. The dissemination
occurs through the nasopharynx with hematogenous spread
to the meninges or other organs. It is not part of the normal
gastrointestinal ora and isolated only in rectal secretions
in combination with sexual transmission. Meningococcal
spontaneous peritonitis have been reported in patients with
preexisting ascites, but still little understood in patients
without liver disease.
The rst case was described in 1917 by Moeltoen4 and
the second with characteristics with appendiceal abscesses,
was reported in 1938 by Turchetti5. In all cases, the peritonitis
is associated with meningococcal disease in other distant sites.
Kelly in 2004 reported a case of peritonitis by N.
meningitidis diagnosed after laparotomy3 similar to acute
peritonitis. The theory that can explain the pathophysiological
mechanism for this condition is the spread of bacteria
through the blood; however, patients with ascites and liver
bacterial translocation can justify the isolation of bacteria
in peritoneum1,2,3,6.
REFERENCES
1. Bannatyne RM, Lakdawalla N and Ein S. Primary meningococcal
peritonitis. Can Med Assoc J. 1977;117(5):436.
2. Bar-Meir S, Chojkier M, Groszmann RJ, Atterbury CE and Conn HO.
Spontaneous meningococcal peritonitis. The American Journal of
Digestive Diseases. 1978;23(2):119-122.
3. Kelly SJ and Robertson RW. Neisseria meningitidis peritonitis. ANZ Journal
of Surgery. 2004;74:182-183. doi: 10.1046/j.1445-1433.2003.02850.x.
4. Moeltoen MH. Meningokokkenperitonitis. Zentralbi Chir. 1917;44: 94.
5. Turchetta A. Considerazioni cliniche su un caso di peritonite meningococcica
circoscritta in adulto apparentemente idiopatica. Minerva Med.
1938;(2):570.
6. Wendlandt D, King B, Zielbell C and Milling T. Atypical presentation
of fatal meningococcemia: peritonitis and paradoxical centrifugal
purpura fulminans of late onset. The American Journal of Emergency
Medicine. 2011;29(8):960.
ABCD Arq Bras Cir Dig Letter to the Editor
2016;29(1):68
DOI: /10.1590/0102-6720201600010020
WILKIE’S SYNDROME: A
RARE CAUSE OF INTESTINAL
OBSTRUCTION
Síndrome de Wilkie: causa rara de obstrução intestinal
Ayşe KEFELI, Adem AKTÜRK, Bora AKTAŞ, Kerim ÇALAR
From the Kecioren Training Hospital, Gastroenterology Deparment,
Pınarbası St. Sanatoryum Av. No:25 Kecioren and Siirt State Hospital,
Radiology Department Abdullah Özgür Yeniova Gaziosmanpaşa University,
Gastroenterology Department, Ankara,Turkey
Correspondence:
Ayşe Kefeli
aysekefeli@hotmail.com
Financial source: none
Conicts of interest: none
Received for publication: 09/12/2014
Accepted for publication: 19/11/2015
ABCDDV/1174
INTRODUCTION
Superior mesenteric artery (SMA) syndrome or Wilkie’s
syndrome is a rare but potentially life threatening
gastrointestinal condition. This syndrome is a clinical
phenomenon believed to be caused by compression of the
third part of the duodenum between the SMA and the aorta,
leading to obstruction. Patients may present symptoms of
gastrointestinal obstruction, such as with recurrent episodes
68 ABCD Arq Bras Cir Dig 2016;29(1):65-69
LETTER TO THE EDITOR
ResearchGate has not been able to resolve any citations for this publication.
Article
Two patients with spontaneous bacterial peritonitis caused byNeisseria meningitidis are described. In both cases immediate diagnosis was possible by examination of the ascitic fluid. Meningococcal peritonitis supports the hypothesis that the hematogenous spread of bacteria into the ascitic fluid may be one of the mechanisms of spontaneous bacterial peritonitis.
Article
Here we report an atypical case of meningococcemia presenting as peritonitis and later developing a centrifugal rash. The patient was a previously healthy 21-year-old Hispanic man who presented to the emergency department (ED) with a low-grade fever, right lower quadrant pain, and right lower extremity myalgia. Physical examination was suggestive for appendicitis, and the patient was showing signs of septic shock: hypotension, tachypnea, tachycardia, and a mottled appearance shortly after admission. Exploratory surgeries of the abdominal cavity and right lower extremity were unable to identify the nidus of infection. Eight hours after admission, the patient was noted to have a petechial rash, which rapidly progressed to purpura fulminans (PF) within the first hour of its initial appearance. Paradoxically, however, the petechiae and confluent ecchymosis were initially far more prominent proximally in this patient-largely sparing the distal extremities early in its course. Purpura fulminans always manifests distally and rarely affects the face. By contrast, the rash in our patient first developed proximally, being especially prominent on his trunk and back, and was also associated with a large degree of facial involvement. Blood cultures and fluid sampled from the peritoneal cavity grew Neisseria meningitidis.
Article
Two patients with spontaneous bacterial peritonitis caused by Neisseria meningitidis are described. In both cases immediate diagnosis was possible by examination of the ascitic fluid. Meningococcal peritonitis supports the hypothesis that the hematogenous spread of bacteria into the ascitic fluid may be one of the mechanisms of spontaneous bacterial peritonitis.
Article
Foreign body ingestion is a common occurrence in children and in specific high-risk groups of adults such as those with underlying esophageal disease, prisoners, the mentally retarded, and those with psychiatric illnesses. Although most foreign bodies pass through the gastrointestinal tract without difficulty, sharp, pointed, and elongated foreign bodies are associated with a greater risk of perforation, vascular penetration, and other complications. Foreign body ingestion is usually diagnosed based on a history of ingestion given by the patient or an observer. However, children and impaired adults may be unable to give an accurate history, and a high index of suspicion must be maintained in these groups. Dysphagia and odynophagia are the usual symptoms of foreign body impaction in the esophagus. Respiratory symptoms due to compression of the adjacent trachea are also common in younger children and are occasionally the presenting symptom in adults. The preferred method of removal of esophageal foreign bodies is extraction with the flexible endoscope. This may be accomplished in both adults and children with the use of conscious sedation rather than general anesthesia. The availability of grasping instruments specifically designed for foreign body removal and snares greatly facilitates endoscopic extraction. An overtube conveys all of the advantages of the rigid esophagoscope to the flexible endoscope, enabling extraction of sharp and pointed foreign bodies while protecting the mucosa from injury. Adherence to the general principles of foreign body removal and proper preparation result in successful removal rates as high as 98%, with minimal or no complications. Nonendoscopic methods of removal are associated with increased risks of perforation and aspiration and generally should be avoided, with the exception of a trial of intravenous glucagon. Surgical removal is rarely indicated except in the event of perforation or other foreign body complications.
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The management of foreign bodies in the gastrointestinal tract is not standardized. Retrospectively, we analysed the management of 174 cases of accidental ingestion of foreign bodies in children. No child had ingested more than one foreign object. The ingested foreign bodies were: coins, toy parts, jewels, batteries, 'sharp' materials such as needles and pins, fish and chicken bone, and 'large' amounts of food. Of the patients 51% had transient symptoms at the moment of ingestion, such as retrosternal pain, cyanosis and dysphasia. Attempts to extract the foreign body either by a magnet tube, endoscopy or McGill forceps was performed in 83 patients. The majority of the extracted foreign bodies were batteries and sharp materials. The outcome of all the patients was excellent. No complications were observed.
Article
Unlabelled: The management of ingested foreign bodies in children is not standardised. During a 15-year period, we recorded 325 consecutive paediatric cases of accidental ingestion of foreign bodies or with symptoms suggesting oesophageal obstruction presented at the emergency department or the paediatric gastroenterology unit. The foreign bodies that had to be removed were, in decreasing order of frequency: coins, toy parts, jewels, batteries, sharp materials such as needles and pins, fish and chicken bones, and "large" amounts of food. Only 54% of the patients had transient symptoms at the moment of ingestion, such as retrosternal pain, cyanosis and dysphagia. A minority (28, 9%) of foreign bodies could be removed with a McGill forceps; 65 (20%) were removed with a magnet probe. Endoscopic removal was performed in 82 cases (25%). In the majority of cases (150, 46%) natural elimination occurred. The outcome of all patients was uneventful. Conclusion: Recommendations for management of children presenting with a history of suspected accidental ingestion of a foreign body for the community paediatrician are proposed.
Article
This is one of a series of statements discussing the utilization of gastrointestinal endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.
Article
Reports on endoscopic management of ingested foreign bodies of the upper-GI tract in China are scarce. To report our experience and outcome in the management of ingestion of foreign bodies in Chinese patients. Between January 1980 and January 2005, a total of 1088 patients (685 men and 403 women; age range, 1 day to 96 years old) with suspected foreign bodies were admitted to our endoscopy center. All patients underwent endoscopic procedure after admission. Demographic and endoscopic data, including age, sex, and referral sources of patients, types, number and location of foreign bodies, associated upper-GI diseases, endoscopic methods, and accessory devices for removal of foreign bodies were collected and analyzed. A total of 1090 foreign bodies were found in 988 (90.8%) patients. The types of foreign bodies varied greatly: mainly food boluses, coins, fish bones, dental prostheses, or chicken bones. The foreign bodies were located in the pharynx (n = 12), the esophagus (n = 577), the stomach (n = 441), the duodenum (n = 50), and the surgical anastomosis (n = 10). The associated GI diseases (n = 88) included esophageal carcinoma (33.0%), stricture (23.9%), diverticulum (15.9%), postgastrectomy (11.4%), hiatal hernia (10.2%), and achalasia (5.7%). A rat-tooth forceps and a snare were the most frequently used accessory devices. The success rate for foreign-body removal was 94.1% (930/988). Ingestion of foreign bodies is a common clinic problem in China. Endoscopy procedures are frequently performed, and a high proportion of patients with foreign bodies require endoscopic intervention.