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The metabolic response to sepsis is characterized by increased proteolysis and gluconeogenesis, reduced protein synthesis, and negative nitrogen balance. The effects of a solution with a high proportion of branched-chain amino acids (BCAA) on the nutritional state of septic patients were evaluated. Eighty patients with peritonitis were divided into two groups of 40 patients; group 1 was administered a solution with 22.5% BCAA and group 2 with 45% BCAA. The following parameters were evaluated: anthropometrics, creatinine/height index, urinary 3-methylhistidine, nitrogen balance, stress index, albumin, prealbumin, transferrin, retinol binding protein, lymphocytes, delayed cutaneous sensitivity tests, studies of hepatic function, and plasma aminogram. In group 2 a more positive nitrogen balance, a greater drop in the stress index, a rise in plasma prealbumin and retinol binding protein levels, an increase in the creatinine/height index, and a more marked fall in the urinary excretion of 3-methylhistidine were found. When solutions with a high BCAA content were administered, there was an increase in the plasma concentrations of these amino acids in the BCAA/aromatic amino acid quotient and a decrease in the aromatic amino acids. Plasma concentrations of leucine and valine achieved very high, potentially toxic, levels at 15 days when solutions with high BCAA content were used. It is concluded that solutions with BCAA are advisable for use in the septic patient in the increased protein catabolic phase, where positive nitrogen balance, a reduction in muscle protein catabolism, and faster recovery of muscle and visceral protein were obtained.

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A 47-year-old man came to the hospital because acute abdominal pain and vomits. The patient had suffered from episodes of intestinal obstruction since adolescence, and has been studied by a gastroenterologist who found no abnormalities. These episodes have been solved spontaneously in nearly all occasions. However, he had come to the emergency room for the same reason twice last year. The exploration showed abdominal distension and tympanism in the epigastrium. There were neither laparotomic scars nor hernia defects in the abdominal wall. Abdominal X-rays showed air-fluid levels at the small bowel, and marked distension in the proximal and medium jejunum. Gastrointestinal X-ray series with gastrographin showed no abnormal findings. After 48-72 hours the patient persisted with the same complaints, and we decided to operate. During the operation we found a congenital malformation: an intestinal hernia of jejunum inside a peritoneal sac formed by a peritoneal flap of the left mesentery (Fig. 1), as well as an abnormal implantation of the mesentery above the rectum. We performed a resection of the peritoneal sac (Fig. 2) and the adherences inside it. The postoperative period was normal. DISCUSSIONParaduodenal hernias are rare congenital malformations, but they are the most frequent cause of internal hernias (50% of them). They are caused by a failure in the intestinal rotation, and by an asynchronism in the future development of adhesion of the mesocolon. In right paraduodenal hernias, the small bowel is placed totally or partially behind the ascending mesocolon; in left paraduodenal hernias or mesocolic hernias, which are more frequent than the right ones, the small bowel is placed behind the descending mesocolon (1). We present a rare case of a paraduodenal sac formed by a peritoneal

The presence of peritoneal tuberculosis has to be clinically suspected in all patients with abdominal pain of unknown etiology, particularly when it is accompanied by fever, ascites, and abdominal distension. Access to the abdominal cavity using routine laparoscopy provides essential information on the diagnosis, from both macroscopic images and biopsy sampling, which will later provide a pathological and microbiological confirmation. This helps discriminate between potential differential diagnoses that may include similar symptoms. Other laboratory tests have to be considered as diagnostic aids, as well as for the indication of laparoscopy, including ADA, and Gallium-67 or Ca-125 scans.