Abdominal Complaints Research Articles

Quality assurance for non-contrast CT of the abdomen and pelvis during a period of supply chain disruption leading to iodinated contrast shortage in the emergency department setting.

Iodinated contrast media (ICM) shortage crisis due to COVID-19 lockdowns led to a need for alternate imaging protocols consisting of non-contrast computed tomography (CT) for abdominal complaints and related trauma indications in emergency department (ED) settings. This quality assurance study aims to evaluate clinical outcomes of protocol modifications during ICM shortage and identify potential imaging misdiagnosis of acute abdominal complaints and related trauma. The study included 424 ED patients with abdominal pain, falls, or motor vehicle collision (MVC)-related trauma who had non-contrast CT of the abdomen and pelvis in May 2022. We accessed the initial complaint, order indication, non-contrast CT results, any acute or incidental findings, and any follow-up imaging of the same body region with their results. We evaluated their association utilizing Chi-squared tests. We assessed sensitivity, specificity, and positive/negative predictive values using follow-up scan confirmation. Across initial complaint categories, 72.9% of cases were abdominal pain, and 37.3% received positive findings. Only 22.6% of patients had follow-up imaging. Most confirmed original reports were for abdominal pain. We also found three reports of missed findings. There were significant associations between complaint categories and initial non-contrast CT report results (P < 0.001), as well as initial complaint categories and whether the patient received follow-up imaging or not (P < 0.004). No significant associations were found between follow-up imaging results and initial report confirmation. Non-contrast CT had 94% sensitivity and 100% specificity, with positive and negative predictive values 100% and 94%, respectively. Rate of missed acute diagnoses using non-contrast CT for patients presenting to the ED with acute abdominal complaints or related trauma has been low during the recent shortage, but further investigation would be needed to verify and quantify the implications of not routinely giving oral or intravenous contrast in the ED.

Blood lead level evaluation in children presenting with chronic constipation in Tehran-Iran: a cross-sectional study

Constipation is a common reason for children seeking medical care worldwide. Abdominal complaints and constipation are also common in lead-poisoned children. This study evaluates the prevalence of abnormal blood lead levels (BLL) among pediatric and adolescent patients and examines the association of constipation with elevated BLL. This was a prospective data collection of patients younger than 18 years old with the chief complaint of constipation seen in the Mofid Children’s Hospital gastroenterology clinic and Loghman Hakim pediatric and pediatric gastroenterology clinics were eligible for enrollment in this study. Constipation was defined as infrequent or difficult defecation according to ROME IV criteria lasting 2 months or more. BLL was measured with a fresh capillary whole blood capillary sample. The LeadCare II device assays BLL using an electrochemical technique (anodic stripping voltammetry). A total of 237 patients were enrolled in the study. 122 (51.48%) were female and 115 (48.52%) were male. About one fifth of patients (49; 20.67%) had BLL ≥ 5 µg/dL. The mean BLL in the sample was 3.51 µg/dL. Abdominal pain was the most common symptom accompanying constipation (134; 56%). Multivariate analysis found endoscopic evaluation (P values 0.024, OR 3.646, 95% CI 1.189–11.178), muscle pain (P values 0.020, OR 24.74, 95% CI 1.67–365.83), and maternal education (P values 0.02, OR 4.45, 95% CI 1.27–15.57) with significant differences in groups of patients with normal and elevated BLL. Elevated BLL necessitates an assessment and plans to reduce childhood lead exposure. BLL screening in childhood constipation with refractory chronic abdominal pain may also eradicate the need for invasive procedures like endoscopic evaluation.

Gastric dysmotility and gastrointestinal symptoms in myalgic encephalomyelitis/chronic fatigue syndrome

Background Gastrointestinal symptoms are common in ME/CFS, but there is a knowledge gap in the literature concerning gastrointestinal motility features and detailed symptom description. Objective In this study, we aimed to characterize gastric motility and gastric symptoms in response to a liquid meal. Methods We included 20 patients with ME/CFS with abdominal complaints who were recruited to a double-blind randomized placebo-controlled trial of Rituximab. The patients of this sub study were examined with an ultrasound drink test, and gastrointestinal symptoms were evaluated using the Rome III questionnaire and Irritable Bowel Syndrome Symptom Severity Scale (IBS-SSS) questionnaire. Results We found that patients commonly reported fullness/bloating (75%), abdominal pain (45%) and nausea (35%). Ultrasound measurements revealed lower proximal measurements of the stomach after a meal (p < 0.01) and larger fasting antral area (p = 0.019) compared to healthy controls. The patients had a stronger symptomatic response to the liquid meal compared to healthy controls regarding epigastric pain, discomfort and nausea (p < 0.05). Ninety percent of the patients reported bowel movement frequencies within the normal range but scored high on bowel habit dissatisfaction and life disruption. Conclusion The patients presented with fullness/bloating, nausea and epigastric pain, showed signs of impaired gastric accommodation and visceral hypersensitivity, showing that the gastrointestinal symptoms of ME/CFS patients are similar to functional dyspepsia. Key summary Gastrointestinal symptoms are common in ME/CFS, but there is a knowledge gap in the literature concerning gastrointestinal motility features and detailed symptom description. • In this study, patients with ME/CFS had signs of impaired gastric accommodation after a liquid meal. • Out of 20 patients, 15 patients reported fullness/bloating, 9 reported abdominal pain, and 7 reported nausea. The patients showed signs of visceral hypersensitivity on a drink test. • Our findings suggest that patients with ME/CFS share many similarities with patients with Functional Dyspepsia. The findings were not typical for Irritable Bowel Syndrome.

Abdominal examination: Invaluable clinical findings and their interpretations

A thorough history, which may continue till the end of the consultation, helps the clinician understand the possible disease condition, its severity, and the overall physical &amp; mental status of the patient. Physical examination, which practically starts as soon as the doctor meets the patient, builds upon these observations. After completing the general examinations attention should be directed to the examination of all the systems with special emphasis on the system related to his complaints i.e., an abdominal examination in case the patient has abdominal complaints. Assimilation of the clinical observations will enable one to arrive at a probable diagnosis.

17-Years-Old Teenager with Anencephaly

Background: Anencephaly is the most common type of Neural Tube Defect (NTD). Babies born with anencephaly usually die within hours or a few days after birth. The prevalence of anencephaly cases reaches 5.1 per 10,000 births in the world. There is no therapy for patients with anencephaly, but this condition can be detected early by ultrasonography. Case: 17-year-old girl with abdominal complaints that are getting bigger. She has pregnant and the fetus had suspected anencephaly. The patient’s vital signs were good and laboratory examination showed a slight increase in leukocytes, proteinuria, and leukocyturia. The ultrasound examination results gestational age was 29/30 weeks, and the radiological examination by a radiologist expert had similar results. The baby girl was born with a weight of 1,568 grams and an Apgar score of 2-3. On examination, prominent brain tissue was visible. The baby was treated for three days at Trenggalek General Hospital and survived for four days. Conclusion: The aetiology and pathophysiology of anencephaly are still unclear, but risk factors such as environmental, genetic, maternal and fetal conditions encourage this condition. Detection of NTDs can be done early in pregnancy using ultrasound. Early prevention must be carried out, such as regular consumption of folic acid to prevent the occurrence of NTDs. In this case, the occurrence of NTDs is thought to be due to the condition of the mother who is too young, socioeconomic factors, low consumption of folic acid and lack of knowledge and information about the importance of prevention in NTD cases.

Non-Alcoholic Fatty Liver and Fatty Pancreas Diseases Associate with Acute Pancreatitis

Objective: Fat accumulation in the liver and pancreas are clinical manifestations of metabolic syndrome and associated with inflammation. It was aimed to investigate the effects of the computed tomography (CT) estimated non-alcoholic fatty liver disease (NAFLD) and non-alcoholic fatty pancreas disease (NAFPD) on the development of acute pancreatitis in this study.&#x0D; Patients and methods: This retrospective and cross sectional study was consisted of 194 participants who admitted to the hospital with an abdominal pain complaint and undergone an abdominal CT scan during the investigation of the differential diagnosis. Medical database records of patients were investigated. Groups were consisted of according to the presence of acute pancreatitis as study and control. Attenuation measurements of liver and pancreas were determined according to abdominal CT.&#x0D; Results: A statistical significance was observed for the development of acute pancreatitis when patients with normoglycemia were compared to both patients with prediabetes and diabetes. Percentages of NAFLD and NAFPD according to the median of CT attenuation difference between pancreas and spleen values were elevated in the study group. A logistic regression model was revealed that prediabetes, type 2 diabetes, NAFLD and NAFPD according to median value were risk factors for the acute pancreatitis (p

Clostridium Symbiosum Sepsis Diagnosed Using Next-Generation Sequencing in a 2 Year Old Child: A Case Report

Background: Sepsis is a severe illness that can affect preterm, term, and young infants, and is often associated with negative cultures.Case report: A 2-year-old boy, with a previous partial colectomy after birth, presented with abdominal complaints and clinical sepsis. We empirically treated with meropenem and linezolid. Blood cultures were sterile, and fecal cultures demonstrated no pathogenes. Metagenomic next-generation sequencing identified Clostridium symbiosum from blood sample. The result supported the continued use of the antibiotic regimen. After 1 week, CRP and PCT returned to normal and subsequent de-escalation therapy (cefotaxime sodium sulbactam and metronidazole) was used for anaerobic bacteria. Conclusions: mNGS identified an anaerobic agent responsible for sepsis. From the published sensitivities, the organism was sensitive to the original empiric antibiotic therapy.

A Reduced Tryptophan Diet in Patients with Diarrhoea-Predominant Irritable Bowel Syndrome Improves Their Abdominal Symptoms and Their Quality of Life through Reduction of Serotonin Levels and Its Urinary Metabolites.

(1). An essential component of any treatment for patients with irritable bowel syndrome (IBS) is an adequate diet. Currently, a low FODMAP diet is recommended as a first-line therapy, but it does not relieve abdominal discomfort in all patients, and alternative nutritional treatment is required. The purpose of this study was to evaluate the effect of a tryptophan-lowering diet (TRP) on abdominal and mental symptoms in patients with irritable bowel syndrome with predominant diarrhea (IBS-D). (2). The study included 40 patients with IBS-D, and 40 healthy subjects served as a baseline for IBS-D patients, after excluding comorbidities. The TRP intake was calculated using the nutritional calculator. The severity of abdominal symptoms was assessed using the gastrointestinal symptom rating scale (GSRS-IBS). Mental state was assessed using the Hamilton anxiety rating scale (HAM-A), the Hamilton depression rating scale (HAM-D), and the insomnia severity index (ISI). The serum levels of serotonin and melatonin and the urinary excretion of their metabolites 5-hydroxyindoleacetic acid (5-HIAA) and 6-sulfatoxymelatonin (aMT6) were determined by the ELISA method. The severity of symptoms and laboratory data were analyzed before and after a 12 week diet with tryptophan restricted to a daily dose 10 mg per kilogram body weight. (3). Compared to the control group, patients with IBS-D had a higher serum level of serotonin (198.2 ± 38.1 vs. 142.3 ± 36.4 ng/mL; p < 0.001) but a similar level of melatonin (8.6 ± 1.1 vs. 9.4 ± 3.0 pg/mL; p > 0.05). The urinary excretion of 5-HIAA was also higher in patients with IBS-D patients (7.7 ± 1.5 vs. 6.0 ± 1.7 mg/24 h; p < 0.001). After nutritional treatment, both the serum serotonin level and the urinary 5-HIAA excretion significantly decreased (p < 0.001). The severity of the abdominal symptoms and anxiety also decreased, while the HAM-D score and the ISI score remained unchanged (4). Lowering the dietary intake of tryptophan may reduce abdominal complaints and does not alter the mental state of IBS-D patients.

Pachydermoperiostosis with Chronic Diarrhoea: A Case Report

Pachydermoperiostosis (PDP) is a rare autosomal disorder characterized by periostosis, clubbing, thickening of the skin (pachyderma) of the face and scalp, seborrhea and hyperhydrosis. It is the primary form of hypertrophic osteoarthropathy (HOA), the other name of which is Touraine- Solente-Golé syndrome. PDP has various organ involvements and there are some rare associations of PDP with other disorders. Here we describe a 16-year-old boy who presented with skin and skeletal manifestations typical of PDP who also had chronic diarrhea, abdominal pain and weight loss. After giving treatment with risedronate sodium and mesalazine he got significant improvement in his skeletal and abdominal complaints.&#x0D; Bangladesh Med J. 2021 Sept; 50(3): 52-55

Trocar site hernia after laparoscopy: Early recognition prevents catastrophic sequelae

BackgroundTrocar site hernia is a rare but potentially serious complication of laparoscopic surgery that may lead to bowel incarceration and strangulation. Prompt diagnosis by emergency physicians facilitates timely intervention that prevents bowel necrosis. We report a case of trocar site hernia presenting to the emergency department (ED) with abdominal pain that was correctly diagnosed and promptly managed. Case ReportA 25-year-old woman, gravida 2, abortion 2, underwent outpatient surgery and laparoscopic removal of a ruptured right-sided tubal pregnancy without any intraoperative difficulties. However, 48 h later, she presented to the ED complaining of acute abdominal pain and nausea. Computed tomography revealed a loop of small bowel herniating through a 12-mm right lower quadrant trocar site defect in the fascia. She was taken back to the operating room, where the computed tomography findings were confirmed and the entrapped bowel was successfully reduced and the fascial defect repaired. The patient was discharged home feeling much improved. Why Should an Emergency Physician Be Aware of This?Trocar site hernia is a rare but potentially dangerous complication that can present with acute symptoms or be asymptomatic if late in onset. Intestinal necrosis begins as soon as 6 h after constriction of blood flow to entrapped bowel, so timely intervention is critically important. Therefore, trocar site hernias should be considered in patients presenting with abdominal complaints after laparoscopic surgery and included in the differential diagnosis of bowel obstruction.

Utilizing Point of Care Ultrasound to Evaluate for Small Bowel Obstruction in Emergency Department Patients

Small bowel obstruction (SBO) is a common diagnosis made in the Emergency Department (ED) representing about 15% of hospital admissions for acute abdominal complaints. We sought to investigate if bedside ultrasound as performed by ED physicians is a reliable test to diagnose and rule out SBO. This was a prospective cohort study of nonconsecutive patients who presented to an academic, suburban ED with a census of approximately 100,000 patients per year between November 2018 and May 2019. Patients with a history of prior abdominal surgeries who presented to the ED with nausea and/or vomiting and had a CT Abdomen and Pelvis with PO contrast ordered by their provider were consented for a bedside ultrasound. Interpretation was performed by the physician performing the study at bedside. The physician performing the study identified the largest loops of bowel in each of the four quadrants and measured the identified loops from bowel wall to bowel wall. A diameter of greater than 2.5 cm was considered positive for dilated bowel and probable obstruction. At the completion of the study the physician entered their interpretation of the result which was later reviewed by an ultrasound fellowship-trained physician. There were 101 patients included in the study. Study personnel were accurate in 92% of cases. Overall the sensitivity of point of care ultrasound (POCUS) for SBO was 90% (72.7 to 97.8) and specificity was 92% (82.7 to 96.9). The positive and negative likelihood ratios were 10.76 (4.95 to 23.38) and 0.11 (0.04 to 0.33). Given that our study demonstrated a low negative likelihood ratio, those with low probability of an SBO on history could have an ultrasound examination performed at the bedside which could be sufficient to rule out this disease without requiring patients to undergo further imaging.

S2496 Endoscopic Source Control of Gram-Negative Bacteremia Secondary to Foreign Body Ingestion - A Rare Case

Introduction: Foreign body (FB) ingestion is usually observed in the pediatric population; however, adult cases of FB ingestion are not uncommon. Usual FB culprits seen in adults include fish bones, chicken bones, and dentures. Possible complications include dysphagia, complete occlusion with risk of aspiration, and perforation. Such complications warrant retrieval of FB via endoscopic removal or surgical on case-to-case basis. We present a very rare case of FB ingestion resulting in bacteremia necessitating endoscopic removal leading to source control. Case Description/Methods: The patient is a 58-year-old male with a past medical history of diabetes mellitus, hypertension, and chronic venous stasis. He was initially admitted for sepsis secondary to cellulitis and had to be readmitted due to cultures from the initial admission being positive for slow-growing gram-negative anaerobic rods (GNAR). The most common sources of GNAR are recognized to be genitourinary and gastrointestinal in origin. The patient had no history of benign prostatic hyperplasia, and denied any urinary complaints, with negative urine cultures from the initial admission. The patient did not have any abdominal complaints either; however, cross-sectional abdominal imaging was obtained to assess for any intra- abdominal collections/abscess, which surprisingly showed a 5.3 cm tubular radiopaque focus in the cecum suggestive of a foreign body. Blood cultures from the second admission also grew GNAR, which speciated into capnocytophaga. Gastroenterology was consulted to assist with endoscopic evaluation of this finding with possible retrieval of the foreign body. Colonoscopy was attempted and a chicken bone was found in the cecum which was successfully removed with a snare. Possible inflammation of this bowel segment from cecal trauma could have resulted in transient translocation of the bacteria from the cecum with resultant bacteremia. Subsequent blood cultures after FB removal were negative suggesting adequate source control. Discussion: GNAR bacteremia warrants workup for genitourinary and gastrointestinal sources. Our case highlights a rare clinical scenario where FB ingestion led to GNAR bacteremia. Though this is a very rare phenomenon, clinicians investigating the causes of GNAR bacteremia should have a broad differential in cases where the culprit is not obvious. Timely identification of the GNAR source and its control is very crucial in treating such population.

S3493 Two Cases of Perforated Jejunal Diverticulum With Severe COVID-19

Introduction: Jejunoileal diverticulitis is very rare with a high mortality rate of 21-40%. The rates of small bowel diverticulitis with perforation associated with COVID are unknown. Here, we present cases of complicated jejunal diverticulitis with perforation in two patients with severe COVID infection. Case Description/Methods: The first patient is a 69-year-old man who presented to our Emergency Department with shortness of breath, cough, and diarrhea. He was diagnosed with severe COVID-19 despite being vaccinated. He was started on methylprednisolone and remdesivir. 13 days into admission, the patient developed pneumomediastinum. Computed Tomography Abdomen/Pelvis (CT A/P) for further evaluation showed pneumoperitoneum and perforated jejunal diverticulitis. Given the severity of COVID pneumonia requiring high-flow oxygen, continued use of corticosteroids (methylprednisolone 40mg BID), and risk of surgical complications with COVID, conservative management with antibiotics and bowel rest was pursued. The patient developed an abscess in the mesentery and pelvis for which a drain was placed percutaneously by Interventional Radiology. He unfortunately developed progression of the perforation and passed away from septic shock. The second patient is a 57-year-old male with hypertension, deep vein thrombosis who presented with worsening shortness of breath, cough, fever. He was diagnosed with severe COVID (unvaccinated) and started on baracitinib, remdesivir, methylprednisolone. Ten days into admission he developed severe abdominal pain, nausea, vomiting, and worsening leukocytosis. CT A/P showed new abscess involving the left upper quadrant with a contained jejunal perforation. The patient was initially managed with bowel rest, antibiotics and pain control. However, he developed worsening leukocytosis and pain with peritonitis on exam. He was taken emergently to the operating room and had proximal perforated jejunum resection and lysis of adhesions. He ultimately had small bowel re-anastomosis. He continued to improve clinically and was discharged home. (Figure) Discussion: It is unclear if the complication of perforated diverticulum in these cases is due to the underlying inflammatory response due to COVID, steroid-induced disruption of intestinal mucosal barrier or incidental diverticulitis with evolution to complicated perforation. However, each case reminds us how important it is to take abdominal complaints in COVID seriously as jejunoileal diverticulitis has a high mortality rate.Figure 1.: Left panel- Patient 1 CT Abdomen/Pelvis transverse view showing jejunal perforation with surrounding inflammation (arrow). Right panel- Patient 2 CT Abdomen/Pelvis transverse view showing thickened loops of jejunum with interloop abscess (arrow).

S2658 Symptomatic Sclerosing Mesenteritis: A Flank Problem

Introduction: Sclerosing mesenteritis is a rare diagnosis consisting of fatty inflammation and necrosis of the abdominal mesentery. Patients usually present asymptomatically or with vague, generalized systemic symptoms including abdominal pain, fever, and weight loss. Here, we present a case of a 72-year-old female with an unusual presentation of right flank pain in the diagnosis of sclerosing mesenteritis. Case Description/Methods: A 72 YO female was evaluated in the hospital for acute onset, intermittent right flank pain described as a spasm sensation. Her history was significant for multiple abdominopelvic surgeries, dating back almost 50 years and including appendectomy, herniorrhaphy, pelvic reconstruction and hysterectomy, and bladder sling placement. Her most recent surgery was the appendectomy 5 months prior to admission. There was no temporal or positional association of the pain. She had no associated fevers, malaise, changes in bowel habits, nausea, vomiting, melena, or hematochezia. Prior colonoscopy history was unknown. Physical exam showed a diffusely soft, n abdomen without any masses or organomegaly. Laboratory evaluation demonstrated leukocytosis and elevated ESR and CRP. The remaining laboratory work-up was within normal limits. CT abdomen and pelvis without contrast showed hazy attenuation of the mesenteric root with hypodense halos surrounding the mesenteric lymph nodes, suggestive of sclerosing mesenteritis. Surgical intervention was deferred given the patient's comorbid conditions. Given her presentation of flank pain, retroperitoneal ultrasonography was done which was negative for any acute pathologies. Discussion: The diagnosis of sclerosing mesenteritis is often an incidental finding on abdominal imaging, as seen in our patient case. Usually, such imaging studies are performed for evaluation of an abdominal mass seen in up to 35-50% of patients, however, in our case, it was performed for initial evaluation of her flank pain. In our patient case, the only risk factor for the development of sclerosing mesenteritis was her significant history of abdominal surgery. Studies have shown up to 30% of patients diagnosed with sclerosing mesenteritis have a history of prior abdominal surgery. A wide differential should be maintained in patients presenting without obvious abdominal complaints yet having a significant abdominal surgery history.

S2029 Epiploic Appendagitis: A Red Herring?

Introduction: Epiploic appendagitis (EA) is a rare cause of acute abdominal pain that has a relatively benign course. The importance of identifying EA as a clinical mimicker is crucial to avoid unnecessary hospitalizations, antibiotic use, and surgery. Although no trigger has been established as a cause for EA, it is hypothesized that systemic inflammation can lead to an EA attack. Case Description/Methods: A 43-year-old White female with no significant GI history presented with 2 days of sudden onset, sharp, non-radiating, worsening left lower quadrant (LLQ) with nausea. Initial blood work was unremarkable. CT abdomen revealed a hyper-attenuating ring lesion along the anti-mesenteric margin adjacent to the distal descending colon, along with mesenteric lymph nodes consistent with epiploic appendagitis. She was managed conservatively with complete resolution of symptoms. A few years later, she presented again, with similar abdominal complaints. Repeat abdominal imaging showed recurrence of EA in the same location. Few shotty mesenteric lymph nodes were identified. She was treated conservatively for EA. A few more years passed, and she now had another episode of recurrent LLQ pain, CT abdomen showed findings consistent with EA along with a short segment of mural thickening and mild hyper-enhancement in the mid descending colon. Colonoscopy revealed a large circumferential mass in the sigmoid colon with an apple core lesion in the proximal sigmoid colon with luminal narrowing. Biopsy revealed an adenocarcinoma. No lymph node involvement was noted. As the TNM staging was pT3 N0 M0, she underwent a sigmoidectomy with left colon and rectal end-to-end anastomosis (Figure). Discussion: Epiploic appendages are fat-filled serosal outpouchings of the colonic surface. They are connected to the colon by a vascular stalk. Acute epiploic appendagitis is theorized to be caused by torsion, underlying inflammation, or venous occlusion of the appendage. CT scan is the gold standard for diagnosing EA and helps rule out other intra-abdominal pathologies. Recurrent and persistent EA is very rare and may mask an underlying occult abdominal pathology. There have not been any reported cases of CRC that are associated with and possibly trigger EA. In patients with recurrent EA, after common causes of acute abdominal pain are ruled out, evaluation for intestinal/intraluminal pathologies, especially colorectal malignancy should be considered as they are not readily apparent on CT scans.Figure 1.: A: Red arrow showing an inflamed epiploic appendage during initial presentations. B: Red arrow showing epiploic appendagitis. Green arrow with colonic wall thickening in the descending colon, with adjacent EA. 3: Colonoscopy showing the large friable mass in the sigmoid colon.

S2011 Disseminated Histoplasmosis Involving the Whole Colon: It's Ulcers All the Way Down

Introduction: Histoplasma capsulatum is a dimorphic fungus endemic to river valleys of Eastern and Central U.S. that is spread via inhalation of spores from soil contaminated by bird or bat droppings. Disseminated Histoplasmosis (DH) spreads through the reticuloendothelial system via parasitized macrophages and can cause severe infection in immunocompromised patients with AIDS, hematologic malignancies, transplant recipients, and those receiving tumor necrosis factor (TNF)-alpha inhibitors or chronic corticosteroids. Gastrointestinal involvement in DH is frequently seen, but it is not uncommon for patients to be asymptomatic. We present a case of DH with pan-colonic ulcerations in a renal transplant patient. Case Description/Methods: A 83-year-old male with deceased donor renal transplantation on immunosuppression therapies presented with profound weakness. He was restarted on hemodialysis one month prior for declining renal allograft function which had been stable for the past 2 decades. Initial workup showed pneumonia on imaging, elevated procalcitonin, alkaline phosphatase, and pancytopenia. He developed hematochezia with worsening anemia which prompted colonoscopy that revealed deep and innumerable ulcers measuring greater than one cm in the whole colon. One large ulcer with a visible vessel near the hepatic flexure was treated with epinephrine, electrocautery, and endoclip for hemostasis. Ulcer biopsy revealed granulomatous inflammation with fungal yeast forms morphologically compatible with Histoplasma by Grocott's Methenamine Silver (GMS) staining. Bone marrow pathology was suggestive of fungal infiltration, but marrow and blood cultures were negative. Family revealed he lives in an old mold infested home and has history of visiting caves. Treatment was initiated with liposomal Amphotericin B then transitioned to oral Itraconazole. He has continued to make a strong recovery and remains on dialysis (Figure). Discussion: For healthy individuals, exposures to Histoplasma generally occur as asymptomatic to self-limited pulmonary infection. Disseminated Histoplasmosis is often undiagnosed and carries high mortality if untreated. These patients usually had past exposures with dormant inoculation that is reactivated after immunosuppression. GI involvement is common but can be non-symptomatic or with only vague abdominal complaints from colonic fungal invasion. Suspicion of DH should be met with a low threshold for endoscopic evaluation and requires tissue biopsy for diagnosis.Figure 1.: (A) Large ulcer in the cecum which was biopsied. (B) Numerous ulcers seen diffusely throughout the colon. (C, D) H&E and Grocott’s Methenamine Silver (GMS) stain of colonic mucosa with patchy ulceration and granulomatous inflammation including fungal yeast forms, morphologically compatible with Histoplasma.

Ziekte van Crohn versus abdominale tuberculose: ‘when the bowels are not what they seem’

Abdominal tuberculosis mimicking Crohn’s disease: be aware of false-negative testing when stakes are high Differentiating between abdominal tuberculosis (TB) and Crohn’s disease (CD) can be very challenging. Both are chronic granulomatous diseases involving the gastro-intestinal tract, most typically the ileocecal region, with overlapping clinical, radiological, endoscopic and histological features. A correct differentiation is, however, crucial as the repercussions of a misdiagnosis can be serious. If CD is misdiagnosed as abdominal TB, unnecessary anti-tuberculous therapy poses a risk of toxicity and the appropriate CD treatment is delayed. In case of the reverse misdiagnosis, treatment with steroids or other immunosuppressants can result in disastrous dissemination of TB. The incidence rates of TB are generally low in Western Europe. Still, abdominal TB should be considered in the differential diagnosis of abdominal complaints, especially in patients with risk factors such as previous stays in endemic regions and HIV positive or immunocompromised patients. A high index of suspicion is important as no single test can reliably differentiate abdominal TB from CD in all patients. Concurrent immunosuppression may further reduce the sensitivity of the diagnostic tests. In this article, the case of a young man with severe ileocolitis is presented. He was diagnosed with CD and started on corticosteroids and later anti-TNF-alpha agents, only to develop an acute abdomen based on a disseminated TB infection. Retrospectively, abdominal TB was most probably the primary diagnosis, mimicking CD. This case illustrates the diagnostic challenges and limitations of the available diagnostic tests, as well as the clinical importance to exclude abdominal TB before diagnosing CD and starting immunosuppressive therapy.

REVIEW OF PROPHETIC FOOD: THE VITIS SPECIES

Vitis species or the grapes, possess various natural constituents that can be found in their seeds, leaves and skin extracts. The active chemicals consist of polyphenols, flavonoids, stilbenes, alkaloids and volatile oils. Each of them contributes to pharmacological effects. This study is to highlight the Vitis species that are widely known for their health benefits. The historical uses of this plant include treating stomach pain, injury, and abdominal complaints. In addition, this herb was used as an ointment in treating eye and skin diseases. The medicinal properties of the grapes were reported as anticancer, antioxidant, anti-inflammatory, antimicrobial, cardioprotective, hepatoprotective and neuroprotective. The objectives of this study are to perform a literature search (from 2000 - 2020) and review the shortlisted publications on the Vitis species. From the online articles, the phytochemistry and pharmacological activity of the grapes were mentioned. The review included the traditional uses of the grapes. It is expected that the understanding of the chemical and biological activity of Vitis species may contribute to the development of new drugs. Keywords: grape; medicine; prophetic; review; Vitis

Differential diagnosis and long-term outcomes of non-atrophic duodenal changes in children

Objectives and studyGastrointestinal endoscopy is often performed when investigating abdominal complaints in children. While atrophic changes of the duodenal mucosa are usually caused by celiac disease, the prevalence and clinical significance of non-atrophic duodenal changes are less clear. We studied these issues in a large pediatric endoscopic cohort.MethodsComprehensive data on clinical features, diagnostic findings and long-term outcomes of children who had undergone upper gastrointestinal endoscopy with systematic duodenal sampling were collected. Study variables were compared between children with non-atrophic changes and normal histology, and between those with non-atrophic changes who did and did not receive a diagnosis.ResultsThe study comprised 1,170 consecutive children, of whom 51 (4.4%) had non-atrophic and 315 (26.9%) atrophic duodenal changes and 804 (68.7%) normal histology. The most common non-atrophic findings were non-specific inflammation (n = 19) and intraepithelial lymphocytosis (n = 14). Patients with non-atrophic changes presented more often with blood in stools (23.5 vs. 11.3%; p = 0.009), anemia (43.2 vs. 36.5%; p = 0.028) and positive celiac serology (34.3 vs. 12.9%; p < 0.001) than those with a normal duodenum. Twenty-four (44%) of those with non-atrophic changes received an initial diagnosis, the most common of which were inflammatory bowel disease (IBD) (n = 8), Helicobacter pylori infection (n = 3) and food allergy (n = 3). The prevalence of the diagnoses did not differ from those with a normal duodenum. Those who received a diagnosis had more often blood in stools (37.5 vs. 11.1%; p = 0.027), anemia (70.6 vs. 20.0%; p = 0.002) and negative celiac serology (50.0 vs. 7.7%; p = 0.013) than those without diagnosis. During a follow-up of 6.1–13.3 years, five of the 12 initially undiagnosed seropositive patients developed celiac disease, and one patient also developed ulcerative colitis.ConclusionNon-atrophic duodenal changes are relatively common and associated with anemia, blood in stools, and positive celiac disease serology. Excluding potential celiac disease, those without an initial diagnosis have a favorable long-term prognosis.

Assessment of Outcome of and Factors Associated with Gangrenous Small Bowel Obstruction

1.1. Background: small bowel obstructions account for 15% of hospital admissions for acute abdominal complaints and up to 30% of these patients will require operative intervention. Ethiopia is one of the countries where intestinal obstruction is a major cause of morbidity and mortality. 1.2. Objectives: To assess outcomeand factors associated with gangrenous small bowel obstruction among patients admitted to surgical ward of Hiwot Fana Specialized University Hospital from January 1, 2016-December 31, 2020. 1.3. Methods: A retrospective cross-sectional study was conducted on all patients with gangrenous small bowel obstruction admitted to surgical ward of Hiwot Fana Specialized University Hospital from January1, 2016-December 31,2020. For this study, a customized data abstraction form was developed for data capturing from medical records of the patients. The captured data was coded, entered to EpiINFo and exported to statistical package for social sciences software, version 22.0. for analysis. To summarize demographic and clinical characteristics of the patients considered for this study, descriptive statistics such as percent and frequency was employed. All variables with P-value &lt; 0.3, during bi-variable analyses were considered for multivariable logistic regression analyses. Odds ratio along with 95% Confidence interval were estimated to measure the strength of the association. Level of statistical significance was declared at p value less or equal to 0.05. 1.4. Results: A total of 91patiens were included and finally analyzed in this study. From these 52 (57.1%) patients have un favorable surgical outcomes of gangrenous Small bowel obstruction. Of the 52 patients with unfavorable outcome, the most common postoperative complication occurred was anastomotic leak (29.5) followed by surgical site infection (25.5%) and pneumonia (23.6%) . A total of 15 postoperative deaths were also documented as unfavorable surgical management outcomes of gangrenous Small bowel obstruction. Three factors including duration of illness before surgery, length of hospital stay after surgery and shock at presentation were significantly associated withthe surgical management outcome of gangrenous Small Bowel Obstruction. 1.5. Conclusion: In this study, the majority of patients had unfavorable surgical management outcomes of gangrenous Small Bowel Obstruction, however the proportion of patients with favorable outcomes was considerable. Thus, designing a strategy that address the factors associated with unfavorable outcomes could be helpful to further increase the likelihood of favorable surgical management outcomes of gangrenous Small Bowel Obstruction.