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#24 De: Alberto Canestri < acanestri@agora.com.ar >
Enviado: Viernes, 10 de Marzo de 2000 07:19 p.m.
Asunto: Caso clinico/Clinical case
Sponsored by: Pfizer
Pongo a consideracion de la lista surgery la siguiente consulta clinica de nuestra colega de Mendoza.
Invito a los miembros de la lista, a enviar su opinion sobre el caso:
Estimados colegas del pcvc:
pongo a criterio del foro, el caso de este paciente que me parece muy interesante para que compartamos diferentes criterios.
Paciente de sexo masculino, de 1.76 cm de estatura, 92 kg, de 76 años de edad, quien en la madrugada del 09 al10 de febrero proximo pasado, presenta dolor en zona infraumbilical en forma brusca, de tipo intenso que lo obliga a permanecer caminando y de a ratos se recuesta con cierto grado de angustia que acompaña a esta sintomatologia .Deciden llamar a un servicio de emergencias médicas domiciliario y el colega que lo atiende diagnostica colico hepatico y es medicado con antiespasmodicos, persistiendo el dolor a pesar de la medicacion. A las 02 hs llama nuevamente a su servicio de emergencias médicas (es otro el colega que lo controla), le colocan otro antiespasmodico, con el cual levemente calma la sintomatología.
No se acompaño de diaforesis, nauseas, hipotensión, no irradiaba a otras zonas. El 10/02 concurre a mi consultorio, donde me refiere lo antedicho y en mi exámen encuentro un abdomen francamente distedido, con incremento de ruidos hidroaereos, doliente a la palpacion profunda de toda la zona abdorminal, con signo de Murphy negativo, auscultando lo que me parecio ser un soplo leve, que nunca antes habia escuchado y sin maniobras positivas para aneurisma.
Solicito ecografia abdominal de urgencia, analitica y reposo domiciliario del paciente por no encontrarse en mal estado general y sin el dolor referido anteriormente. El examen cardiologico es dificultoso por su patologia respiratoria, ruido hipofoneticos no, soplos, choque de la punta es debil y en el 6 espacio medioclavicular y a nivel pulmonar espiracion prolongada, no estertores humedos.
Otros antecedentes : patron restrictivo-obstructivo pulmonar por tabaquismo cronico si bien hacen 12 años que no fuma, obeso, dislipidemia mixta: CT 213 - HDLc 39.2 -LDLc 100 - Tg 107, uricemia 10.36, PCR 20 , vsg 20 MM, FAL 377, GOT 135, GPT 182, Bilirrubina D: 0.30, GR 5.300.000, Hb 15.8, GB 6200, resto de la formula normal.
Rx Torax: hiperinsuflacion con aumento del espacio claro retroesternal y retrocardiaco, arco ventricular prominente, minimo estasis vascular pulmonar. Eco Doppler cardiaco: normal, fibrosis valvular aortica sin estenosis hemodinamica significativa, moderada dilatacion ventricular derecha:36 mm, resto de indices conservados.
Holter ecg: ritmo sinusal permanente, FC entre 43 y 79/min, ESPV frecuente y EVmonofocal aislada. .. Ecogr. abdomen: vesicula biliar levemente aumentada de tamaño, engrosamiento difuso de sus paredes con multiples calculos pequenios en su interior, moderada ptosis renal derecha y DILATACION ANEURISMATICA DE LA ARTERIA AORTA DISTAL DE 5.4 cm cefalocaudal x 3.9 cm x 3.8 cm, parede arteriales tortuosas con imagen de trombo parcial de 1.7 cm. TAC abdomen: idem con diám. anterop: 4 cm a nivel de aorta abdominal porcion distal, renales e iliacas libres. ECO DOPPLER COLOR: dilatacion aneurismatica de 6.41 x 3.38 x 3.64 con presencia de coagulo parietal, ilicas y renales libres. Talio 201: necrosis o fibrosis apical e inferoapical sin evidencia de isquemia.
Dignostico: Aneurisma de aorta abdominal porcion distal
Tratamiento cronico: Teofilina de liberacion prolongada
Colelitiasis cronica con probable agudizacion
Budesonide 1200 ug /dia
EPOC con patron restrictivo
enalapril 5mg/24 hs
obesidad
aspirina 100 mg/24 hs
dislipidemia mixta atorvastatina 10 mg/24 hs
hiperuricemia allopurinol 300 mg/24 hs
dieta - quinesio respiratoria
Discusion: - 1 - seguimiento con eco abdominal cada 3 meses de su aneurisma y si se encuentra en 4.5 de diametro anteropost. decidir
cirugia o ante clinica evidente de diseccion .Control de factores de riesgo, el paciente es normo a hipotenso arterial.
-2 . colelitiasis: evidentemente es quirugica, y no por via endoscopica debido a la obesidad abdominal del paciente, esperar aque baje mas de peso si es posible.
Pero ¿podria incrementar el riesgo de diseccion de su aneurisma una cirugia de urgencia, o una colecistectomia clasica programada?.

I present to the surgery list for their consideration, the following clinical consult by our colleague from Mendoza.
I invite the members of the list to send their opinion about the case:
Dear colleagues from the fvcc:
I present to the forum the following case of this patient that it seems very interesting to me, so that we can share different criteria. Male patient, height 1.76m, 92kg, 76 years old, who at daybreak, on last February 9th to 10th, suffered intense pain in infraumbilical area abruptly, that forced him to remain walking, and from time to time he lied down with some degree of the anguish that accompanies this symptomatology. They decided to call a medical emergencies service and the colleague that treated him diagnosed hepatic colic, and he was medicated with antispasmodics, but the pain persisted in spite of the medication. At 02hs he called again to his medical emergencies service (another colleague controlled him), he was administered another antispasmodic, with which symptomatology was mildly calmed.
It was not accompanied by diaphoresis, nausea, hypotension, it did not irradiated to other areas. On February 10th he came to my office, where he told me all that was previously stated, and in my examination I found abdomen quite distended, with increase of hydro-aerial noise, painful to deep palpation in all abdominal area, with negative Murphy sign, auscultating what I believed to be a mild murmur, that I had never heard before, and without positive maneuvers for aneurysm. I asked an urgent abdominal, analytical echo, and rest at the patient's home because he was not in a general bad state, and without the pain previously mentioned. The cardiac examination was hard due to respiratory pathology, non hypo-phonetic noises, murmurs, weak shock of tip, and in the 6th medium clavicle line space and at pulmonary level extended expiration, non humid stertors.
History: restrictive-obtrusive pulmonary pattern due to chronic smoking, although he has not smoked for 12 years, obese, mixed dyslipidemia: TC 213 - HDLc39.2 -LDLc100 - TG 107, uricemia 10.36, reactive C protein 20, globular sedimentation value 20mm, ALP 377, GOT 135, GPT 182, Bilirubin D:0.30, RC 5,300,000, Hb 15.8, WC 6200, the rest of the formula is normal.
Thorax XR: hyperinsufflation with increase of clear retrosternal and retrocardiac space, prominent ventricular arch, minimal pulmonary vascular stasis. Cardiac Echo Doppler: normal, aortic valvular fibrosis without significant hemodynamic stenosis, mild right ventricular dilatation: 36mm, the rest of the indexes remain the same.
Holter ECG: permanent sinus rhythm, HR between 43 and 79/min, frequent supraventricular extrasystole, and isolated monofocal VE.
Abdominal echo: gallbladder mildly enlarged, diffuse thickening of its walls with multiple small calculus inside of it, mild right renal ptosis and ANEURYSMAL DILATATION OF DISTAL AORTIC ARTERY OF 5.4cm cephalo-caudal x 3.9cm x 3.8cm, twisted arterial walls with image of partial thrombus of 1.7cm. Abdominal TAC: idem with antero-posterior diameter: 4cm at level of distal portion of abdominal aorta, renal and iliac arteries free. COLOR ECHO DOPPLER: aneurysmal dilatation of 6.41 x 3.38 x 3.64 with presence of parietal clot, renal and iliac arteries free. Thallium 201: apical and inferoapical necrosis or fibrosis without evidence of ischemia.
Diagnostic: aneurysm of abdominal aorta, distal portion
Chronic treatment: Theophylline of extended liberation
Chronic cholelithiasis with probable worsening
Budesonide 1200ug/dia
COPD with restrictive pattern
Enalapril 5mg/24hs
Obesity
Aspirin 100mg/24hs
Mixed dyslipidemia atorvastatin 10mg/24hs
Hyperuricemia allopurinol 300mg/24hs
Diet - kinesio-respiratory therapy
Discussion: - 1 - follow up with abdominal echo each 3 months of its aneurysm and if it is found in 4.5 of anteroposterior diameter.
Decide surgery or before evident clinical manifestations for dissection. Control of risk factors, the patient is normo to hypotensive.
-2 cholelithiasis: obviously surgical, and not by endoscopic via due to the patient's abdominal obesity, wait until he loses weight if possible.
But, could the risk of dissection for his aneurysm be increased by an urgency surgery, or a scheduled classic cholecystectomy?
Dra. Susana Ginestar
Alberto Canestri, M.D.
SubCommittee Cardiovascular Surgery
First Virtual Congress of Cardiology
Argentine Federation of Cardiology

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#25 De: Dr. Jorge Rodriguez Campos <jcampos@agora.com.ar>
Enviado: Lunes, 13 de Marzo de 2000 11:16
Asunto: Caso-Clinico/Clinical case
Sponsored by: Agilent Technologies
Dra Susana Ginestar:
Dr. Alberto Canestri:
Con respecto al caso clinico de referencia que presenta la Dra. Susana Ginestar tengo la siguiente opinion: 1)De los antecedentes reunidos y los estudios realizados los sintomas que presento parecererian debidos a su colelitiasis y no a su aneurisma de aorta abdominal distal.- 2) De los analisis clinicos se observa una hemoglobina normal, G.R. normales, que seria negativo para una probable fisura del aneurisma, esta tampoco se observa en los metodos de diagnostico por imagen utilizados, Eco, Eco doppler color y T.A.C. siendo que estos ultimos tienen una sensibilidad del 86% y del 95 % respectivamente.- Si bien el cuadro clinico me llama la atencion cuando el paciente refiere una sensacion de angustia y que deambula en lugar del permanecer en reposo.-Este cuadro si es mas tipico de la fisura del aneurisma de aorta con una hemorragia contenida en el espacio retroperitoneal y que comprime las terminaciones nerviosas vecinas incomodando al paciente en determinadas posiciones y llevandolo a incorporarse y cambiar de posicion en forma repetida.- Los metodos de diagnosticos son concluyentes sobre la clinica y me siento propenso a descartar su aneurisma de aorta como causa del episodio referido.- 3) Una uricemia elevada, una eritrosedimentacion levemente elevada, sin un aumento de globulos blancos, pero si una fosfatasa elevada, con una bilirrubina normal coinciden para inculpar del episodio a un episodio de obstruccion parcial de la via biliar por su litiasis cronica con una leve inflamacion de la misma (colangitis) concomitante.- 4)
Creo de lo anteriormente expuesto que el paciente deberia ser operado de su colelitiasis previo un condicionamiento clinico de su patron pulmonar restrictivo obstructivo, y de su arritmia cardiaca, asi como lo necesario del resto de su organismo.- 5) Si la cirugia transcurre sin alteraciones importantes de su Presion arterial ( hipo o hipertensiones agudas o prolongadas) creo que el riesgo de que el aneurisma se rompa o se trombose en el perioperatorio es bajo ( 0.5 %).- 6) En cuanto al tratamiento del aneurisma aortico abdominal coincido en tratar los factores de riesgo. El crecimiento de los mismos es normalmente el 10 % de su diametro transversal por anio, en este caso 4 mm por anio esperable; los ecos pueden realizarse cada 3 o seis meses de acuerdo a la progresion de su dilatacion. El paciente debe estar advertido de la posibilidad de ruptura de su aneurisma a pesar de ser pequenio y saber a donde recurrir en ese caso, como asi tambien los sintomas iniciales.- 7) El valor del diametro transversal para realizar la indicacion quirurgica es relativo: si es aneurisma es estable y sin sintomas propios, mi conducta es la siguiente: a) si tiene una progresion acelerada de dilatacion,( mas del 20% anual) prefiero la cirugia cuando llega a 4,5 cm .- b) si progresa lentamente (menos del 10 % anual), espero hasta los 5,5 cm de diametro transversal.- c) si la progresion es normal (10 % anual), espero hasta los 5 cm.- Siempre hablando de pacientes como el presente del caso clinico, que tienen edad avanzada y una serie de compromisos organicos, en pacientes mas jovenes uno puede ser mas invasivo y en pacientes mas aniosos mas contemplativos.-
Saludo a Uds. muy atentamente.

Dr. Susana Ginestar:
Dr. Alberto Canestri:
In regard to the clinical case of reference that Dr. Susana Ginestar presented, I have the following opinion: 1) From the history gathered, and the studies performed, the symptoms that he presented seem to be caused by his cholelithiasis, and not to his aneurysm of abdominal distal aorta. 2) From the clinical analysis normal hemoglobin is observed, normal red cells, that would be negative for a probable fissure of the aneurysm, this is not observable either in the diagnostic methods by image employed, Echo, Echo doppler color, and computed axial tomography, since the latter have a sensitivity of an 86%, and a 95% respectively. However, I was surprised at the clinical manifestations when the patient mentions a feeling of anguish, and that he wanders around instead of remaining in rest. These clinical manifestations are more typical of the fissure of aneurysm of aorta with hemorrhage contained in the retroperitoneal space, that compresses neighboring nervous endings, making the patient uncomfortable in certain positions, and making him sit up and change positions repeatedly. The diagnostic methods are conclusive about clinic, and I feel prone to dismiss his aneurysm of aorta as a cause for the mentioned episode. 3) High uricemia, slightly increased erythrocyte sedimentation rate without increase of white cells, but with increased phosphatase, with normal bilirubin coincide to blame for the episode, an episode of partial obstruction of the biliary path due to his chronic lithiasis with a mild inflammation of the same concomitant
(cholangitis). 4) I think from what has been previously stated, that the patient should be operated for his cholelithiasis with a prior clinical conditioning for his restrictive obstructive pulmonary pattern, and his cardiac arrhythmia, just as everything necessary for the rest of his organism. 5) If surgery happens without important alterations of blood pressure (acute or extended hypo or hypertensions) I think that the risk of the aneurysm breaking or becoming thrombus in the peri-operative is low (0.5%) 6) About the treatment for abdominal aortic aneurysm, I agree in treating the risk factors. Their growth is normally a 10% of their transversal diameter per year, in this case 4mm by year is to be expected; the echos may be carried out each 3 to 6 months, according to the progress of the dilatation. The patient must be warned about the possibility of break in his aneurysm in spite of its being small, and he should know where to go in that case, just as the initial symptoms. 7) The value of the transversal diameter to make a surgical indication is relative: if it is aneurysm, it is stable, and without symptoms of its own, my management is the following: a) if it has an accelerated progression of dilatation (more than 20% per year) I prefer surgery when it reaches 4.5cm. b) if it progresses slowly (less than 10% per year), I wait until 5.5cm of transversal diameter c) if progression is normal (10% per year), I wait until 5cm. I am always speaking about patients like the present clinical case, that are of advanced years, and have a series of organic compromises, in younger patients one may be more invasive, and in older patients more contemplative.
Sincerely yours,
Dr. Jorge F. Rodriguez Campos
Cirujano Cardiovascular

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