Clinical case
Synchronous acute cholecystolithiasis and perforated acute appendicitis. Case report
Colecistitis litiásica crónica agudizada y apendicitis aguda perforada sincrónicas. Reporte de caso
Guillermo Padrón-Arredondo
, Manuel de Atocha Rosado-Montero
Corresponding author
gpadronarredondo@hotmail.com
Corresponding author at: Cda, Corales 138 Residencial Playa del Sol, Playa del Carmen, C.P. 77724, Solidaridad, Quintana Roo, Mexico. Tel.: +52 (984) 1100 707.
Corresponding author at: Cda, Corales 138 Residencial Playa del Sol, Playa del Carmen, C.P. 77724, Solidaridad, Quintana Roo, Mexico. Tel.: +52 (984) 1100 707.
Departamento de Cirugía, Hospital General de Playa del Carmen, Solidaridad, Quintana Roo, Mexico
Read
4662
Timeswas read the article
1131
Total PDF
3531
Total HTML
Share statistics
array:25 [ "pii" => "S2444050715001473" "issn" => "24440507" "doi" => "10.1016/j.circen.2015.12.002" "estado" => "S300" "fechaPublicacion" => "2016-01-01" "aid" => "99" "copyright" => "Academia Mexicana de Cirugía A.C." "copyrightAnyo" => "2015" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Cir Cir. 2016;84:50-3" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1889 "formatos" => array:3 [ "EPUB" => 40 "HTML" => 1396 "PDF" => 453 ] ] "Traduccion" => array:1 [ "es" => array:20 [ "pii" => "S000974111500136X" "issn" => "00097411" "doi" => "10.1016/j.circir.2015.06.008" "estado" => "S300" "fechaPublicacion" => "2016-01-01" "aid" => "99" "copyright" => "Academia Mexicana de Cirugía A.C." "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Cir Cir. 2016;84:50-3" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 7645 "formatos" => array:3 [ "EPUB" => 59 "HTML" => 6084 "PDF" => 1502 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Caso clínico</span>" "titulo" => "Colecistitis litiásica crónica agudizada y apendicitis aguda perforada sincrónicas. Reporte de caso" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "50" "paginaFinal" => "53" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Synchronous acute cholecystolithiasis and perforated acute appendicitis. Case report" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 928 "Ancho" => 1650 "Tamanyo" => 274923 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Vesícula con litos y apéndice con fecalito.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Guillermo Padrón-Arredondo, Manuel de Atocha Rosado-Montero" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Guillermo" "apellidos" => "Padrón-Arredondo" ] 1 => array:2 [ "nombre" => "Manuel" "apellidos" => "de Atocha Rosado-Montero" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2444050715001473" "doi" => "10.1016/j.circen.2015.12.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444050715001473?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S000974111500136X?idApp=UINPBA00004N" "url" => "/00097411/0000008400000001/v1_201602250050/S000974111500136X/v1_201602250050/es/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S2444050715001497" "issn" => "24440507" "doi" => "10.1016/j.circen.2015.12.004" "estado" => "S300" "fechaPublicacion" => "2016-01-01" "aid" => "103" "copyright" => "Academia Mexicana de Cirugía A.C." "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Cir Cir. 2016;84:54-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1237 "formatos" => array:3 [ "EPUB" => 45 "HTML" => 795 "PDF" => 397 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Clinical case</span>" "titulo" => "Amyand's hernia and complicated appendicitis; case presentation and surgical treatment choice" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "54" "paginaFinal" => "57" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hernia de Amyand y apendicitis complicada; presentación de un caso y elección de tratamiento quirúrgico" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 896 "Ancho" => 989 "Tamanyo" => 156130 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Perforation of the caecal appendix (perforation, right arrow; hernia sac, left arrow).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Eugenio García-Cano, José Martínez-Gasperin, César Rosales-Pelaez, Valeria Hernández-Zamora, José Álvaro Montiel-Jarquín, Fernando Franco-Cravioto" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Eugenio" "apellidos" => "García-Cano" ] 1 => array:2 [ "nombre" => "José" "apellidos" => "Martínez-Gasperin" ] 2 => array:2 [ "nombre" => "César" "apellidos" => "Rosales-Pelaez" ] 3 => array:2 [ "nombre" => "Valeria" "apellidos" => "Hernández-Zamora" ] 4 => array:2 [ "nombre" => "José Álvaro" "apellidos" => "Montiel-Jarquín" ] 5 => array:2 [ "nombre" => "Fernando" "apellidos" => "Franco-Cravioto" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0009741115001401" "doi" => "10.1016/j.circir.2015.06.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0009741115001401?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444050715001497?idApp=UINPBA00004N" "url" => "/24440507/0000008400000001/v1_201603020024/S2444050715001497/v1_201603020024/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2444050715001461" "issn" => "24440507" "doi" => "10.1016/j.circen.2015.12.001" "estado" => "S300" "fechaPublicacion" => "2016-01-01" "aid" => "98" "copyright" => "Academia Mexicana de Cirugía A.C." "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Cir Cir. 2016;84:45-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1054 "formatos" => array:3 [ "EPUB" => 54 "HTML" => 732 "PDF" => 268 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Clinical case</span>" "titulo" => "Minimally invasive treatment for traumatic chylopericardium. Paediatric case report" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "45" "paginaFinal" => "49" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento por mínima invasión del quilopericardio traumático. Reporte de un caso pediátrico" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 742 "Ancho" => 990 "Tamanyo" => 118651 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Ultrasound with radiolucent image, compatible with a pericardial effusion of approximately 500<span class="elsevierStyleHsp" style=""></span>ml.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Carlos García-Hernández, Lourdes Carvajal-Figueroa, Adriana Calderón-Urrieta, Araceli Lechuga-Tosqui, Sergio Landa-Juárez" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Carlos" "apellidos" => "García-Hernández" ] 1 => array:2 [ "nombre" => "Lourdes" "apellidos" => "Carvajal-Figueroa" ] 2 => array:2 [ "nombre" => "Adriana" "apellidos" => "Calderón-Urrieta" ] 3 => array:2 [ "nombre" => "Araceli" "apellidos" => "Lechuga-Tosqui" ] 4 => array:2 [ "nombre" => "Sergio" "apellidos" => "Landa-Juárez" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0009741115001358" "doi" => "10.1016/j.circir.2015.06.007" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0009741115001358?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444050715001461?idApp=UINPBA00004N" "url" => "/24440507/0000008400000001/v1_201603020024/S2444050715001461/v1_201603020024/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Clinical case</span>" "titulo" => "Synchronous acute cholecystolithiasis and perforated acute appendicitis. Case report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "50" "paginaFinal" => "53" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Guillermo Padrón-Arredondo, Manuel de Atocha Rosado-Montero" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Guillermo" "apellidos" => "Padrón-Arredondo" "email" => array:1 [ 0 => "gpadronarredondo@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Manuel" "apellidos" => "de Atocha Rosado-Montero" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Cirugía, Hospital General de Playa del Carmen, Solidaridad, Quintana Roo, Mexico" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author at: Cda, Corales 138 Residencial Playa del Sol, Playa del Carmen, C.P. 77724, Solidaridad, Quintana Roo, Mexico. Tel.: +52 (984) 1100 707." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Colecistitis litiásica crónica agudizada y apendicitis aguda perforada sincrónicas. Reporte de caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 557 "Ancho" => 990 "Tamanyo" => 124164 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Gallbladder with lithiasis and appendix with fecalith.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Synchronous appendicitis and cholecystitis have rarely been reported, most have been described as cholecystolithiasis and appendicitis in the early stages, and in pregnant patients (within the same gestation period), in other words, not absolutely synchronous. The few reported cases are from Eastern Europe, and one case from Argentina.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1–4</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Clinical case</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 43-year old woman attending General Surgery with pain in the right hypochondrium. The patient had intermittent, irradiated, right-sided girdling pain, positive Murphy's sign, vital signs: blood pressure 120/70<span class="elsevierStyleHsp" style=""></span>mmHg, heart rate 100/min, respiratory frequency 20/min, temperature 38.5<span class="elsevierStyleHsp" style=""></span>°C. Laboratory report: hemoglobin 10.7<span class="elsevierStyleHsp" style=""></span>g/dl, leukocytes 16,200/mm,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> segmented neutrophils 82%, prothrombin time 14.9<span class="elsevierStyleHsp" style=""></span>s, partial thromboplastin time 40.9<span class="elsevierStyleHsp" style=""></span>s, glucose 345<span class="elsevierStyleHsp" style=""></span>mg/dl; liver function tests: direct bilirubin 1.82<span class="elsevierStyleHsp" style=""></span>mg/dl, indirect bilirubin 0.50<span class="elsevierStyleHsp" style=""></span>mg/dl, total bilirubin 2.32<span class="elsevierStyleHsp" style=""></span>mg/dl, albumin 2.77<span class="elsevierStyleHsp" style=""></span>g/dl, albumin to globulin ratio 0.62<span class="elsevierStyleHsp" style=""></span>IU/l, gamma-glutamyl transferase 404<span class="elsevierStyleHsp" style=""></span>U/l, rest normal. Ultrasound reported acute cholecystolithiasis, and therefore a diagnosis of cholecystolithiasis was integrated.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A Masson incision was made with the following findings: gallbladder under tension (empyema) with thickened walls, on exploration adherences were released, and a subhepatic abscess was opened of approximately 300<span class="elsevierStyleHsp" style=""></span>ml, greenish yellow in color and fetid (anaerobes), a subtotal anterograde cholecystectomy was performed at the level of the gallbladder neck opening same and extracting stones, the largest was 2<span class="elsevierStyleHsp" style=""></span>cm and round and 2 more which were faceted. When evacuation of the abscess, and the simple cholecystectomy were completed the right iliac fossa was reviewed, finding a plastron and sub-serous retrocaecal appendix perforated in its middle third with free fecalith of 2<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>cm (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) with an abscess in the pelvic cavity and right groove, an antegrade appendicectomy was performed. The patient made satisfactory progress and was discharged on the 5th day of her hospital stay as her condition had improved and she was tolerating an oral diet, with return of normal elimination.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">An important principle of medical diagnosis is the acute onset of symptoms, and the constellation of signs which should provide a better diagnosis. However, in this patient with a history of recurring gallbladder pain, with acute disseminated abdominal pain and no signs of peritoneal irritation, the clinical suspicion was acute cholecystitis with probable empyema of the gallbladder, without considering symptoms of appendicitis. Our case was similar to other reported cases in that 2 possible synchronous conditions were not considered.</p><p id="par0025" class="elsevierStylePara elsevierViewall">DeMuro<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a> reported a synchronous case of acute cholecystitis and acute early-stage appendicitis operated laparoscopically, both being pathological processes which had been diagnosed preoperatively. On reviewing the medical literature we only found 3 cases of acute appendicitis simultaneous with acute cholecystitis: (1) one case of concomitance of acute appendicitis and acute cholecystitis<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a>; (2) another case of a pregnant women with gallbladder perforation coexisting with appendicitis<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a>; (3) and finally, an apparent concomitance of acute appendicitis with acalculuous cholecystitis.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a> Acute appendicitis and symptomatic gallstones are the most common indications for non-obstetric surgical procedures during pregnancy. However, the combination of these 2 clinical presentations in the same gestation period is anecdotal. Neither DeMuro's case<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a> nor those presented in their references were similar to ours in their form of presentation. Başaran et al.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">9</span></a> reported the case of a 30-year old female patient with a twin pregnancy complicated by acute appendicitis followed by cholecystitis with poor fetal outcomes, in whom despite appropriate care when the 2 conditions occurred in the same gestational period, one after the other (not synchronous), complications can become inevitable. Recently, Martínez et al.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">10</span></a> reported a case of appendicectomy due to acute appendicitis followed on the 4th day by acute acalculous cholecystitis in a girl of 11; the aetiopathogenesis of this condition in the immediate postoperative period has been associated with a high concentration of bile in the gallbladder, followed by rapid and intense contractions to empty the biliary sludge after starting an oral diet, in this case there was no absolute synchrony either. And another case of Shpizel et al.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> referring to the co-existence of destructive cholecystitis and appendicitis in a child. Poliakov et al.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">12</span></a> also reported this association as acute destructive phlegmonous appendicitis and cholecystitis. In our case, we could not specify which disorder predisposed to the other. Cholecystalgia, appendices and destructive gallbladders (phlegmonous and gangrenous, expressions of the inflammatory phases which end in necrosis and perforation) are terms which are little used in the West, but they also mean acute phases of these infectious processes which are very similar in physiopathology. These are terms which are widely used in Eastern Europe.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">13,14</span></a> While the vast majority of patients with abdominal pain have one single diagnosis, surgeons need to be aware that multiple diagnoses can coexist. In such cases, a laparoscopic approach can be the ideal method, allowing surgical access to the entire abdomen, and is a procedure which is currently used almost all over the world. Patients with chronic recurring acute cholecystolithiasis, like our case, can present technical difficulties due to dense fibrosis, which hinders a clear identification of elements of Calot's triangle, which makes a subtotal cholecystectomy necessary.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">15–18</span></a> Finally, acute cholecystitis is not a known complication of acute appendicitis, and appendicitis is not a complication of acute cholecystitis, in other words, these are 2 different disorders which are present at the same time.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions</span><p id="par0030" class="elsevierStylePara elsevierViewall">The synchronous presentation of acute cholecystolithiasis and acute complicated (perforated) appendicitis has not been reported in medical literature, and this is the first case that we have observed in our hospital and treated successfully simultaneously, therefore symptoms of acute abdomen with a diagnosis of acute cholelithiasis could be masking appendicitis symptoms and, therefore, a complete review of the intra-abdominal organs is compulsory.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres611308" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Clinical case" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Discussion" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec625336" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres611307" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Caso clínico" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Discusión" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec625335" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-04-25" "fechaAceptado" => "2014-11-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec625336" "palabras" => array:5 [ 0 => "Cholecystitis" 1 => "Lithiasis" 2 => "Appendicitis" 3 => "Acute" 4 => "Synchronous" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec625335" "palabras" => array:5 [ 0 => "Colecistitis" 1 => "Litiasis" 2 => "Apendicitis" 3 => "Aguda" 4 => "Sincronía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Acute appendicitis and acute cholecystitis are among the most common diagnoses that general surgeons operate on. However, it is rarely described in its synchronous form.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Clinical case</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A 43 year-old woman attending the clinic for right upper quadrant pain of 11 days duration. The patient refers to intermittent radiating pain in the right side, with positive Murphy, tachycardia, and fever. The laboratory results showed white cells 16,200/mm<span class="elsevierStyleSup">3</span>, glucose 345<span class="elsevierStyleHsp" style=""></span>mg/dl, abnormal liver function tests. Acute cholecystitis was reported with ultrasound. A Masson-type incision was made, noting an enlarged pyogenic gallbladder with thickened walls, sub-hepatic abscess of approximately 300<span class="elsevierStyleHsp" style=""></span>ml, greenish-yellow color, and fetid. An anterograde subtotal cholecystectomy is performed due to difficulty in identifying elements of Calot triangle due to the inflammatory process, opening it and extracting stones. The right iliac fossa is reviewed, finding a plastron and a sub-serous retrocaecal appendix perforated in its middle third with free fecalith and an abscess in the pelvic cavity. An anterograde appendectomy was performed and the patient progressed satisfactorily, later being discharged due to improvement.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In this patient, with a history of recurrent episodes of gallbladder pain and disseminated acute abdominal pain without peritoneal irritation, clinical suspicion was exacerbated cholecystitis with probable empyema of the gallbladder. Open surgery approach for this patient allowed access to both the appendix and gallbladder in order to perform a complete exploration of the abdominal cavity.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The synchronous presentation of cholecystolithiasis and complicated appendicitis has not been reported in the literature.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Clinical case" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Discussion" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La apendicitis aguda y colecistitis aguda son los diagnósticos más comunes que los cirujanos generales operan. Sin embargo, rara vez se describe su presentación de forma sincrónica.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Caso clínico</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Mujer de 43 años que acudió a la consulta por dolor en el hipocondrio derecho de 11 días de evolución, con dolor intermitente irradiado en el hemicinturón derecho, Murphy positivo, taquicardia y fiebre. Leucocitos 16,200/mm<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a>, glucosa 345<span class="elsevierStyleHsp" style=""></span>mg/dl, pruebas de funcionamiento hepático alteradas, el ultrasonido reportó colelitiasis agudizada. Se realizó incisión tipo Masson obteniendo vesícula a tensión (piocolecisto) con paredes engrosadas, absceso subhepático de aproximadamente 300<span class="elsevierStyleHsp" style=""></span>ml, color verdoso-amarillento, fétido. Se realizó colecistectomía anterógrada subtotal por dificultad para identificar elementos del triángulo de Calot debido al proceso inflamatorio, con apertura de la misma y extracción de litos; se revisó la fosa iliaca derecha encontrando plastrón y apéndice retrocecal subseroso perforado en su tercio medio, con fecalito libre y absceso en hueco pélvico por lo que se realiza una apendicectomía parcial anterógrada. La paciente evolucionó satisfactoriamente siendo dada de alta por mejoría.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discusión</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En esta paciente, con el antecedente de cuadros recurrentes de dolor vesicular y con dolor abdominal agudo diseminado, y sin datos de irritación peritoneal, la sospecha clínica fue colecistitis litiásica agudizada con probable piocolecisto. El abordaje abierto para esta paciente permitió el acceso tanto al apéndice como a la vesícula biliar, permitiendo realizar la exploración de la cavidad abdominal.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La presentación sincrónica de colecistolitiasis agudizada y apendicitis aguda complicada (perforada) no ha sido informada en la literatura médica.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Caso clínico" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Discusión" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Padrón-Arredondo G, de Atocha Rosado-Montero M. Colecistitis litiásica crónica agudizada y apendicitis aguda perforada sincrónicas. Reporte de caso. Cir Cir. 2016;84:50–53.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 557 "Ancho" => 990 "Tamanyo" => 124164 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Gallbladder with lithiasis and appendix with fecalith.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0100" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Symptom complex of appendicitis and cholecystitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Kędra" 1 => "J. Jodłowski" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Przegl Lek" "fecha" => "1955" "volumen" => "11" "paginaInicial" => "89" "paginaFinal" => "94" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14384958" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0105" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Simultaneous perforation of the gallbladder and of the appendix" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "B.K.H. Abasov" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Vestn Khir Im II Grek" "fecha" => "1958" "volumen" => "80" "paginaInicial" => "106" "paginaFinal" => "107" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0110" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A combination of acute cholecystitis and appendicitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R.P. Starikova" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Khirurgiia (Mosk)" "fecha" => "1960" "volumen" => "36" "paginaInicial" => "119" "paginaFinal" => "120" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0115" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Colecistitis aguda y peritonitis por apendicitis gangrenosa concomitante" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.E. Abella" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Prensa Med Argent" "fecha" => "1961" "volumen" => "48" "paginaInicial" => "3002" "paginaFinal" => "3005" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13858922" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0120" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Simultaneous acute cholecystitis and acute appendicitis treated by a single laparoscopic operation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.P. DeMuro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1155/2012/575930" "Revista" => array:5 [ "tituloSerie" => "Case Rep Surg" "fecha" => "2012" "volumen" => "2012" "paginaInicial" => "575930" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22830068" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0125" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Concomitance of acute appendicitis and acute cholecystitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.L. Reimann" 1 => "H.G. Reeves" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am Surg" "fecha" => "1955" "volumen" => "21" "paginaInicial" => "220" "paginaFinal" => "222" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14350215" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0130" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Synchronous presentation of acute acalculous cholecystitis and appendicitis: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S.M. Sahebally" 1 => "J.P. Burke" 2 => "N. Nolan" 3 => "A. Latif" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1752-1947-5-551" "Revista" => array:4 [ "tituloSerie" => "J Med Case Reports" "fecha" => "2011" "volumen" => "5" "paginaInicial" => "551" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0135" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spontaneous perforation of the gallbladder from cholecystitis with acute appendicitis in pregnancy. A case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D.A. Grimes" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Reprod Med Obstet Gynecol" "fecha" => "1996" "volumen" => "41" "paginaInicial" => "450" "paginaFinal" => "452" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0140" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Twin pregnancy complicated with acute appendicitis and cholecystitis in the same gestational period" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Başaran" 1 => "G. Bozdağ" 2 => "A.T. Aksu" 3 => "O. Deren" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00404-007-0331-7" "Revista" => array:6 [ "tituloSerie" => "Arch Gynecol Obstet" "fecha" => "2007" "volumen" => "276" "paginaInicial" => "291" "paginaFinal" => "293" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17287980" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0145" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Colecistitis aguda alitiásica tras apendicectomía por apendicitis aguda en edad pediátrica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J. Martínez Ruiz" 1 => "P. Cascales Sánchez" 2 => "J.L. Rueda Martínez" 3 => "J.A. González Masía" 4 => "J.M. Moreno Resina" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Esp Enferm Dig" "fecha" => "2008" "volumen" => "100" "paginaInicial" => "185" "paginaFinal" => "186" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18416650" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0150" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Destructive cholecystitis and appendicitis in a child" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.S. Shpizel’" 1 => "L.R. Shpizel’" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Vestn Khir Im I I Grek" "fecha" => "1985" "volumen" => "134" "paginaInicial" => "90" "paginaFinal" => "91" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4049670" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0155" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Combination of acute phlegmonous appendicitis and destructive cholecystitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "N.G. Poliakov" 1 => "A.M. Galanzovski¿" 2 => "I.A. Babin" 3 => "V.A. Shuliarenko" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Klin Khir" "fecha" => "1986" "volumen" => "4" "paginaInicial" => "64" "paginaFinal" => "65" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25097984" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0160" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute destructive appendicitis associated with destructive cholecystitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "V.V. Pokh-Drobantsev" 1 => "I. Makarchenko" 2 => "G.V. Stetsenko" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Klin Khir" "fecha" => "1992" "volumen" => "11" "paginaInicial" => "72" "paginaFinal" => "73" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7658676" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0165" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Appendix and gallbladder disease, appendiceal cholecystalgia. A new theory" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.M. Kinawi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Egypt Med Assoc" "fecha" => "1953" "volumen" => "36" "paginaInicial" => "4" "paginaFinal" => "13" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13070293" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0170" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Some observations on the surgery of the gall-bladder and the bile-ducts" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "W.J. Mayo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Surg" "fecha" => "1899" "volumen" => "30" "paginaInicial" => "452" "paginaFinal" => "458" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17860759" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0175" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Subtotal cholecystectomy in acute cholecystitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "G.F. Madding" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Surg" "fecha" => "1955" "volumen" => "89" "paginaInicial" => "604" "paginaFinal" => "607" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13228819" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0180" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Subtotal cholecystectomy: for the difficult gallbladder in portal hypertension and cholecystitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P.C. Bornman" 1 => "J. Terblanche" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Surgery" "fecha" => "1985" "volumen" => "98" "paginaInicial" => "1" "paginaFinal" => "6" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3892743" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0185" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Colecistectomía laparoscópica subtotal" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "T. Singhai" 1 => "S. Balakrishnan" 2 => "A. Hussain" 3 => "J. Nicholls" 4 => "S. Grandy-Smith" 5 => "S. El-Hasani" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Surgeon" "fecha" => "2009" "volumen" => "7" "paginaInicial" => "263" "paginaFinal" => "268" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19848058" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0190" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute acalculous cholecystitis: a review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.L. Huffman" 1 => "S. Schenker" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.cgh.2009.08.034" "Revista" => array:6 [ "tituloSerie" => "Clin Gastroenterol Hepatol" "fecha" => "2010" "volumen" => "8" "paginaInicial" => "15" "paginaFinal" => "22" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19747982" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/24440507/0000008400000001/v1_201603020024/S2444050715001473/v1_201603020024/en/main.assets" "Apartado" => array:4 [ "identificador" => "44602" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Clinical Cases" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/24440507/0000008400000001/v1_201603020024/S2444050715001473/v1_201603020024/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444050715001473?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 0 | 9 |
| 2024 October | 28 | 2 | 30 |
| 2024 September | 41 | 4 | 45 |
| 2024 August | 40 | 3 | 43 |
| 2024 July | 32 | 8 | 40 |
| 2024 June | 29 | 107 | 136 |
| 2024 May | 23 | 8 | 31 |
| 2024 April | 30 | 7 | 37 |
| 2024 March | 44 | 10 | 54 |
| 2024 February | 38 | 3 | 41 |
| 2024 January | 61 | 9 | 70 |
| 2023 December | 60 | 11 | 71 |
| 2023 November | 61 | 13 | 74 |
| 2023 October | 93 | 10 | 103 |
| 2023 September | 46 | 10 | 56 |
| 2023 August | 41 | 6 | 47 |
| 2023 July | 27 | 7 | 34 |
| 2023 June | 54 | 4 | 58 |
| 2023 May | 69 | 6 | 75 |
| 2023 April | 60 | 3 | 63 |
| 2023 March | 49 | 6 | 55 |
| 2023 February | 28 | 3 | 31 |
| 2023 January | 24 | 5 | 29 |
| 2022 December | 33 | 6 | 39 |
| 2022 November | 26 | 9 | 35 |
| 2022 October | 27 | 16 | 43 |
| 2022 September | 18 | 20 | 38 |
| 2022 August | 22 | 11 | 33 |
| 2022 July | 28 | 14 | 42 |
| 2022 June | 32 | 8 | 40 |
| 2022 May | 29 | 7 | 36 |
| 2022 April | 44 | 10 | 54 |
| 2022 March | 44 | 6 | 50 |
| 2022 February | 57 | 8 | 65 |
| 2022 January | 55 | 6 | 61 |
| 2021 December | 45 | 12 | 57 |
| 2021 November | 56 | 6 | 62 |
| 2021 October | 44 | 10 | 54 |
| 2021 September | 26 | 14 | 40 |
| 2021 August | 26 | 7 | 33 |
| 2021 July | 20 | 13 | 33 |
| 2021 June | 21 | 12 | 33 |
| 2021 May | 24 | 16 | 40 |
| 2021 April | 62 | 30 | 92 |
| 2021 March | 43 | 19 | 62 |
| 2021 February | 29 | 28 | 57 |
| 2021 January | 24 | 13 | 37 |
| 2020 December | 28 | 10 | 38 |
| 2020 November | 36 | 4 | 40 |
| 2020 October | 23 | 16 | 39 |
| 2020 September | 34 | 30 | 64 |
| 2020 August | 48 | 31 | 79 |
| 2020 July | 41 | 8 | 49 |
| 2020 June | 15 | 9 | 24 |
| 2020 May | 26 | 12 | 38 |
| 2020 April | 22 | 1 | 23 |
| 2020 March | 32 | 8 | 40 |
| 2020 February | 21 | 10 | 31 |
| 2020 January | 21 | 8 | 29 |
| 2019 December | 33 | 9 | 42 |
| 2019 November | 30 | 8 | 38 |
| 2019 October | 32 | 8 | 40 |
| 2019 September | 40 | 3 | 43 |
| 2019 August | 46 | 3 | 49 |
| 2019 July | 47 | 14 | 61 |
| 2019 June | 88 | 12 | 100 |
| 2019 May | 218 | 29 | 247 |
| 2019 April | 95 | 9 | 104 |
| 2019 March | 28 | 4 | 32 |
| 2019 February | 25 | 5 | 30 |
| 2019 January | 20 | 5 | 25 |
| 2018 December | 12 | 2 | 14 |
| 2018 November | 22 | 10 | 32 |
| 2018 October | 23 | 8 | 31 |
| 2018 September | 27 | 4 | 31 |
| 2018 August | 6 | 16 | 22 |
| 2018 July | 14 | 3 | 17 |
| 2018 June | 9 | 1 | 10 |
| 2018 May | 10 | 10 | 20 |
| 2018 April | 11 | 3 | 14 |
| 2018 March | 22 | 3 | 25 |
| 2018 February | 6 | 0 | 6 |
| 2018 January | 16 | 2 | 18 |
| 2017 December | 9 | 0 | 9 |
| 2017 November | 18 | 2 | 20 |
| 2017 October | 26 | 7 | 33 |
| 2017 September | 14 | 13 | 27 |
| 2017 August | 6 | 7 | 13 |
| 2017 July | 15 | 3 | 18 |
| 2017 June | 21 | 7 | 28 |
| 2017 May | 23 | 10 | 33 |
| 2017 April | 15 | 2 | 17 |
| 2017 March | 18 | 93 | 111 |
| 2017 February | 30 | 7 | 37 |
| 2017 January | 15 | 4 | 19 |
| 2016 December | 29 | 5 | 34 |
| 2016 November | 11 | 6 | 17 |
| 2016 October | 30 | 12 | 42 |
| 2016 September | 33 | 12 | 45 |
| 2016 August | 16 | 5 | 21 |
| 2016 July | 17 | 2 | 19 |
| 2016 June | 25 | 9 | 34 |
| 2016 May | 34 | 26 | 60 |
| 2016 April | 21 | 13 | 34 |
| 2016 March | 56 | 22 | 78 |
Show all