Abdominal Pain Of Unknown Etiology Research Articles

Primary Omental Torsion in Children in the Laparoscopy Era: What Have we Learned so far?

Primary omental torsion is uncommon, mimicking appendicitis and other acute abdominal pathologies. It often escapes diagnosis on imaging investigation or conventional open laparotomy. This study aimed to evaluate the effect of laparoscopy on the various parameters of this entity, including incidence, diagnosis, and treatment. A systematic review was performed, including PubMed and Scopus databases, without a time limit, following the PRISMA principles. A total of 16 articles from January 2000 to December 2023, corresponding to 56 children with primary omental torsion, complied with the research criteria. Primary omental torsion was associated with obesity. Symptoms were right abdomen oriented, often compared to those of acute appendicitis. Preoperative ultrasound displayed low diagnostic accuracy, whereas computerized tomography diagnosed only two thirds of cases. In all patients, the vermiform appendix was normal. Laparoscopy affected both diagnosis and treatment of primary omental torsion in children. Easy peritoneal cavity access rendered possible the diagnosis of cases previously discharged as abdominal pain of unknown etiology. Combined with the increased pediatric obesity, it also affected primary omental torsion incidence. The recent pathogenetic theories may be better supported today, as laparoscopy provides a detailed view in situ, and facilitates harvesting of fat tissue from the omentum for molecular investigation. The diagnostic efficiency of laparoscopy is superior to ultrasonography and computerized tomography. Finally, the removal of the ischemic omentum is technically easier compared to the open laparotomy alternative with all the technical difficulties of traction of a vulnerable hemorrhagic tissue through a small incision.

Осведомленность врачей в Узбекистане о целиакии: исследование на основе анкетирования

Objective. To assess the level of awareness of celiac disease, its timely diagnosis and effective treatment among primary care and hospital physicians. Patients and methods. A total of 207 physicians from the Republic of Uzbekistan participated in the study. The questionnaire included 17 questions about clinical manifestations, diagnosis, identification of risk groups and treatment of celiac disease. Results. Only 31.9% of respondents were aware of the autoimmune mechanism of celiac disease. More than 71% of physicians, especially primary care, know well about the typical manifestations of celiac disease (diarrhea, underweight), but quite rarely consider constipation (25.1%), abdominal pain of unknown etiology (46.9%), common colds (24.6%) as a manifestation of celiac disease. Low awareness of the association of celiac disease with autoimmune thyroiditis (20.8%), type 1 diabetes (14.9%), and infertility (34.3%) was shown. Only 43.9% of physicians use to anti-tissue transglutaminase antibodies as serological markers of celiac disease, 30.9% continue to focus on anti-gliadin antibodies. Only 32.9% of patients with suspected celiac disease are referred to a gastroenterologist for evaluation. Conclusion. The results of the study demonstrate a rather low level of awareness of clinical manifestations, methods of diagnosis and treatment of celiac disease among physicians in the Republic of Uzbekistan. It is necessary to develop additional educational programs and introduce modern research methods, especially in remote regions of the country, for timely diagnosis and treatment of celiac disease. Key words: celiac disease, diagnosis, treatment, physicians, survey

Median arcuate ligament syndrome – Current state of management

Symptomatic celiac artery compression syndrome (CACS) or median arcuate ligament syndrome (MALS) is a controversial diagnosis that should be considered in patients with chronic abdominal pain of unknown etiology despite an extensive medical evaluation. Once suspected, patients should undergo mesenteric duplex ultrasound. Diagnosis is confirmed with elevated celiac artery velocities which normalize with deep inspiration followed by CT angiogram showing the typical “J-hook” conformation of the celiac artery. Patients should then undergo evaluation by a multi-disciplinary team to appropriately select and prepare patients for potential surgical treatment. Surgical options include release of the median arcuate ligament, with or without neurolysis of the celiac nerve plexus, and with or without concomitant revascularization procedures. Approaches can be open, laparoscopic, or robotic. Surgical treatment has an overall success rate of 70-80% with patients reporting improved abdominal pain and quality of life. Post-operatively, patients can have persistent or recurrent abdominal pain and should undergo re-evaluation for possible need for a revascularization procedure for stenosis of the celiac artery or celiac plexus block if the celiac artery flow is normalized. Additionally, some patients will have persistent pain consistent with functional gastrointestinal disorder (FGID) that will then require medical management. Psychiatric comorbidities have been identified as a predisposing factor that may predict poorer outcomes, and there are preliminary findings suggesting that patients with dysautonomia diagnoses may have worse outcomes as well.

Median Arcuate Ligament Syndrome Clinical Presentation, Pathophysiology, and Management: Description of Four Cases

Median arcuate ligament syndrome (MALS), otherwise called celiac artery compression syndrome (CACS), is an uncommon disorder that results from an anatomical compression of the celiac axis and/or celiac ganglion by the MAL. Patients typically present with abdominal pain of unknown etiology exacerbated by eating along with nausea, vomiting, and weight loss. MALS is a diagnosis of exclusion that should be considered in patients with severe upper abdominal pain, which does not correlate with the objective findings. The cardinal feature which is elicited in the diagnosis of MALS relies on imaging studies of the celiac artery, demonstrating narrowing during expiration. The definitive treatment is the median arcuate ligament’s surgical release to achieve surgical decompression of the celiac plexus by division of the MAL. This article describes our experience with this entity, focusing on symptom presentation, diagnostic challenges, and management, including long-term follow-up in four cases.

MON-067 A Perplexing Case of Hyponatremia and Abdominal Pain

Previously healthy 20-year-old female presented with diffuse lower abdominal pain, cramping in nature, multiple episodes of emesis as well as urinary frequency. On day 2 of symptoms, she was treated for a urinary tract infection with antibiotics, as well as NSAIDs and opiates for pain relief. Her serum sodium was 133 mmol/L at this time. On day 3 of symptoms, a CT scan of the abdomen was performed however did not reveal pathology. Her serum sodium was 129 mmol/L at this time. She presented to our ED, on day 5 of symptoms, where serum sodium was down to 122 mmol/L. Despite IV fluids, her sodium continued to decrease to a nadir of 117 mmol/L. Further testing, including a serum osmolality of 242 mOsm/kg, urine osmolality of 540 mOsm/kg, and urine sodium of 207 mmol/L, was consistent with a diagnosis of SIADH. Given persistence of abdominal symptoms along with SIADH further imaging studies, including US abdomen, CT brain and Chest XR, were ordered and returned unremarkable. The constellation of SIADH along with persistent abdominal pain, with negative imaging, lead to consideration of acute intermittent porphyria as a diagnosis. Random urine porphobilinogen was found to be elevated to 147.2 mcmol/L (≤ 2.4) leading to the presumptive diagnosis of acute intermittent porphyria presenting as a neurovisceral attack. Biochemical and genetic testing is being pursued to confirm her diagnosis.Acute intermittent porphyria is an autosomal dominant hematologic disorder characterized by deficiency in porphobilinogen deaminase, an enzyme in the heme synthesis cascade. Acute attacks are caused by accumulation of porphyrin resulting in autonomic and peripheral neuropathy which can present as abdominal pain, urinary retention, polyneuropathy, dark urine and psychiatric disturbance. Hyponatremia is present in 25–60% of cases which is caused by SIADH or sometimes renal and gastrointestinal sodium loss. Triggers for acute attacks include medications, starvation, infections, hormonal changes and alcohol. Treatment includes avoidance of triggers, IV dextrose and high carbohydrate diet. In severe attacks, IV hemin is used.Our patient’s urinary tract infection likely triggered her acute symptoms, which was further exacerbated by treatment with NSAIDS and opiates. She developed SIADH which improved with hypertonic saline and fluid restriction.This case illustrates the need to consider acute intermittent porphyria in the differential diagnosis of SIADH presenting with abdominal pain of unknown etiology.

2692 Dunbar Syndrome: A Rare Cause of Abdominal Pain

INTRODUCTION: Dunbar Syndrome, also known as median arcuate ligament syndrome (MALS), is a rare condition with a reported incidence of 2 per 100,000. It is characterized by an extrinsic compression of the celiac trunk, and should be considered when evaluating patients with abdominal pain of unknown etiology. CASE DESCRIPTION/METHODS: A 78 year old female presented with a complaint of epigastric discomfort that was post-prandial in nature, with associated weakness and early satiety. Her symptoms had been persistent for one year. Workup prior to her presentation included a normal nuclear medicine (NM) gastric emptying scan and normal NM hepatobiliary scan with CCK. A detailed history revealed that her pain was particularly worse after eating and was associated with early satiety. Laboratory results on admission were unremarkable. Contrast-enhanced CT scan of the abdomen and pelvis showed external compression and indentation of the superior aspect of the proximal celiac axis with post-stenotic dilation. Further diagnostic evaluation utilized end-inspiratory phase CT angiography of the abdomen, which showed an approximately 1 cm length segment of proximal celiac arterial narrowing, measuring 70% maximally at its origin. She was diagnosed with MALS after review of the CTA reconstructive images which showed moderate external compression of the celiac artery. DISCUSSION: MALS predominantly affects women between the ages of 30 and 50 and is marked by the hallmark feature of postprandial abdominal pain. Other signs and symptoms may include nausea, vomiting, and consequent weight loss from an inability to tolerate oral intake. Symptoms are thought to have both a vascular (mesenteric ischemia) as well as neurogenic component (somatic pain thought to originate from the splanchnic plexus). CT angiography and conventional angiography are considered to be gold standard imaging modalities for Dunbar syndrome. They demonstrate focal stenosis that has a characteristic hooked appearance due to the indentation of the celiac trunk on its superior surface. Imaging for an accurate diagnosis should ideally be performed during the end-inspiratory phase, as indentation of the celiac trunk may be seen normally during expiration. Additional imaging features may include post-stenotic dilation, prominent collateral vessels, and thickening of the median arcuate ligament. Treatment includes endovascular transluminal angioplasty and stent placement, as well as laparoscopic division of the arcuate ligament and resection of the celiac plexus.

A5023 - The utility of diagnostic laparoscopy in post-bariatric surgery patients with chronic abdominal pain of unknown etiology

A5023 - The utility of diagnostic laparoscopy in post-bariatric surgery patients with chronic abdominal pain of unknown etiology

Intermittent hydronephrosis in childhood

Intermittent pelviureteric junction obstruction, and its consequence,intermittent hydronephrosis is a difficult condition to identify. The renal collecting system is not dilated between the episodes of abdominal pain attacks and a prompt investigation is hard to carry out during the time of painful crisis. Therefore, most of the patients are initially misdiagnosed. The aim of the study was to assess the occurrence and the clinical characteristics of this phenomenon in children operated in the Department of Urological Surgery, Heim Pál Children Hospital, Budapest, Hungary. Medical records of children operated for hydronephrosis between 2008 and 2012 were reviewed. The occurrence rate and clinical features of intermittent hydronephrosis were analyzed. 76 children were operated for pelviureteric junction obstruction, of which 10 met the criteria of intermittent hydronephrosis. The average interval between the onset of symptoms and the final diagnosis was 2 years and 4 months. In 7 patients pyeloplasty, and in 3 patients nephrectomy were performed. Intermittent hydronephrosis represents a well-defined proportion among cases operated for hydronephrosis. The delay in diagnosis led to the loss of the kidney in one third of the patients, and this finding urges for the awareness of health professionals for this phenomenon. In case of recurrent abdominal pain of unknown etiology one must suspect a urological origin, even if a previous abdominal ultrasound showed normal kidneys.

Herniated mobile descending colon

Persistent descending mesocolon is a congenital anomaly that has been shown, in most cases, to be asymptomatic because of its short length. To the best of our literature review and knowledge, no case of internal herniation of the mobile descending colon into either gastrocolic or splenocolic recesses have been reported. We therefore wish to report a case of herniated mobile descending colon in a middle-aged woman. HA was a 54-year-old female with a 2-year history of recurrent episodes of left upper quadrant pain of the abdomen. The pain, which was initially dull aching, suddenly became sharp in nature and so severe that it precluded her from doing her domestic activities. She had undergone clinical evaluation and work up previously but no etiology for her pain was found. After resuscitation, she consented to exploratory laparatomy for an acute on-chronic abdominal pain of unknown etiology. The intraoperative findings were a portion of the wall of the left colon seen to have herniated into a small band of tissue on the left posterior wall. The whole descending colon was unattached to the posterior peritoneum. The trapped portion (4 cm in length) of the wall of the colon was released and a warm pack was applied to the segment of large bowel so released. Following this maneuver, the portion was found to be viable and so a left colopexy was performed and the adhesion band that was placed obliquely from the spleen toward the midline was excised. Postoperative period was uneventful and since then the patient's abdominal pain has been abated over the past 1 year. The morbidity of a mobile descending colon includes internal herniation. Therefore, early detection and colopexy is necessary.

Spinal Subarachnoid Hemorrhage Mimicking an Acute Abdomen

A 39-year-old woman with a history of systemic lupus erythematosum developed an acute abdomen. An intestinal ischemia was suspected and an exploratory laparotomy was performed. No abnormalities were found during surgery and five days later the patient was transferred to our institution. On admission, the patient presented a distended abdomen and paraparesis. The spinal tap showed hemorrhagic CSF and the MRI a subacute subarachnoid hemorrhage (SAH) of the dorsal-lumbar spine. Two days later, the patient suffered an episode of sudden headache. The CT scan revealed an acute SAH at the posterior fossa and digital subtraction angiography a dissection of the right V4 segment. Spinal subarachnoid hemorrhage is a rare syndrome particularly when associated with dissecting aneurysms of the intracranial segment of the vertebral artery. SSAH should be considered early in the differential diagnosis of any case with sudden back or abdominal pain of unknown etiology, even in the absence of neurological deficits.

Py in a Florescent Red Sky

Purpose: This is a case of a patient who presented with abdominal pain of unknown etiology. Although his presentation was typical for many different diseases, an often unseen condition was the result of his illness. Although a rare disease, his eventual diagnosis should be considered in the differential of patients presenting with similar complaints. A 22-yearold African American male with past medical history significant only for prior gunshot wound was admitted with a 4 week complaint of intermittent abdominal pain, nausea, vomiting, and diarrhea accompanied with 10 pound weight loss. He had no history of food allergies or change in his diet. At two outside hospitals, the patient was diagnosed with gastroesophageal reflux and viral gastroenteritis. A trial of ranitidine did not improve his symptoms. Upon presentation to our hospital, his examination was remarkable for dehydration, abdominal distension and mild upper abdominal tenderness. Laboratory tests revealed WBC 12,100/mm3 with an eosinophil count of 57% (normal 0-4%). All other laboratory tests including liver function tests, routine stool studies, were normal. CT scan of the abdomen revealed distended lops of jejunum with wall thickening and reactive lymphadenopathy suggestive of infectious enteritis. EGD with push enteroscopy discovered patchy erythema from jejunum to antrum, with evidence of moderate esophagitis. Biopsies revealed moderate eosinophilic uptake >50 per high powered field and Helicobacter pylori. The patient was treated with triple therapy and steroid therapy and noted marked improvement on follow-up with a significant decrease in eosinophilic count and eradication of Helicobacter pylori. Eosinophilic associated gastrointestinal disorders (EGIDs) are a spectrum of increasingly recognized inflammatory diseases characterized by gastrointestinal symptoms and eosinophilic infiltration of the gastrointestinal tract, in the absence of other known causes of eosinophilia. Between 50-75% of EGIDs patients have coexisting allergic disease or positive allergen skin test, which our patient did not have. The association between Helicobacter pylori and EGID is not well studied but the belief is linked with histamine release and immunoglobulin E. The presentation of EGIDs is varied, but can often be mistaken for more common conditions. This must be considered in the differential diagnosis of abdominal complaints, especially in patients with a history of atopy or eosinophilia.

Surgical pathology associated with Meckel's diverticulum in a tertiary hospital: 12 year review

We want to present our experience about surgical pathology of Meckel´s diverticulum by means of a retrospective study. We report a group of patients of our Department of General and Abdominal Surgery and Paediatric Surgery of our Hospital with Meckel´s diverticulum since January 1997 to January 2010. We report the clinical presentation, complementary test, interventions, and the postoperative follow up. 45 patients were operated in total, 33 of them in emergency surgery under the clinical form of acute abdominal pain; and the others 12 in programmed surgery, these cases came up more frequently like a clinical manifestations of latent abdominal pain, rectal bleeding and anemia. The complementary tests were so varied; abdominal ultrasounds were used in 63% of emergency cases and the 40% of programmed cases, in these patients,gammagraphy with Tc99 was the second test in frequency. Laparoscopy was used in 10 cases (22%). The main surgery technique used was diverticulectomy (82%). The presence of Meckel´s diverticulum has to be clinically suspected in all patients with abdominal pain of unknow naetiology. Access to the abdominal cavity using routine laparoscopy provides essential information on the diagnosis and for the treatment.

Serine proteases mediate inflammatory pain in acute pancreatitis

Acute pancreatitis is a life-threatening inflammatory disease characterized by abdominal pain of unknown etiology. Trypsin, a key mediator of pancreatitis, causes inflammation and pain by activating protease-activated receptor 2 (PAR(2)), but the isoforms of trypsin that cause pancreatitis and pancreatic pain are unknown. We hypothesized that human trypsin IV and rat P23, which activate PAR(2) and are resistant to pancreatic trypsin inhibitors, contribute to pancreatic inflammation and pain. Injections of a subinflammatory dose of exogenous trypsin increased c-Fos immunoreactivity, indicative of spinal nociceptive activation, but did not cause inflammation, as assessed by measuring serum amylase and myeloperoxidase activity and by histology. The same dose of trypsin IV and P23 increased some inflammatory end points and caused a more robust effect on nociception, which was blocked by melagatran, a trypsin inhibitor that also inhibits polypeptide-resistant trypsin isoforms. To determine the contribution of endogenous activation of trypsin and its minor isoforms, recombinant enterokinase (ENK), which activates trypsins in the duodenum, was administered into the pancreas. Intraductal ENK caused nociception and inflammation that were diminished by polypeptide inhibitors, including soybean trypsin inhibitor and a specific trypsin inhibitor (type I-P), and by melagatran. Finally, the secretagogue cerulein induced pancreatic nociceptive activation and nocifensive behavior that were reversed by melagatran. Thus trypsin and its minor isoforms mediate pancreatic pain and inflammation. In particular, the inhibitor-resistant isoforms trypsin IV and P23 may be important in mediating prolonged pancreatic inflammatory pain in pancreatitis. Our results suggest that inhibitors of these isoforms could be novel therapies for pancreatitis pain.

IgG4-related sclerosing disease – retroperitoneal fibrosis: a case report

<h3>Introduction</h3> IgG4-related sclerosing disease (IgG4-RSD) is a systemic disease in which IgG4-positive plasma cells and T-lymphocytes extensively infiltrate various organs.¹ A mass is formed in most cases of IgG4-RSD and a malignant tumour is frequently suspected on initial presentation.¹ <h3>Case report</h3> A 70-year-old lady was presented with a six-week history of worsening post-prandial epigastric abdominal pain of unknown aetiology. <h3>Radiology</h3> Computed tomography scans of the abdomen showed abnormal mesenteric and retroperitoneal soft tissue mass, which was encasing the abdominal aorta (65 mm). A laparotomy was performed for biopsy. <h3>Serology</h3> IgG and IgG4 levels were 16.30 g/L (6.45–13.90) and 1.7 g/L (0.04–0.86), respectively. <h3>Histology</h3> Showed an invasive pattern with destruction of adipo-cytes, dense sclerosis with patchy chronic inflammation, and focal obliterative phlebitis. IgG4 cell numbers were 128 per high power field (hpf) and IgG4/IgG ratio was 60% (threshold: 50 cells per hpf and ratio over 40%²). A diagnosis of IgG4-RSD was made and the patient was treated with dexamethasone 4mg per day. Follow-up radiological studies after 9 weeks showed size shrinkage to a 5 mm residual mass. <h3>Discussion/Conclusion</h3> Retroperitoneal fibrosis is characterised by the presence of chronic inflammation and marked fibrosis. In some cases, the fibrotic tissue can entrap abdominal organs, leading to obstructive symptoms or pain. Awareness about this condition and consideration of a differential diagnosis IgG4-RSD in any idiopathic fibrosclerosing lesion or inflammatory mass can spare patients from unnecessary major surgical interventions.

The association of mast cells and serotonin in children with chronic abdominal pain of unknown etiology

BackgroundAbdominal pain of unknown origin affects up to 20% of school-aged children. Evaluation of children is symptom-based without clear guidelines to investigate molecular mechanisms of abdominal pain. Aberrant molecular mechanisms may increase intestinal permeability leading to interactions between the immune and nervous systems, subclinical inflammation, and visceral pain. This study evaluated the association between interleukin-6 (IL-6), mast cell infiltrates, and serotonin (5-HT) levels in gastrointestinal (GI) biopsies, with perceived abdominal pain in a pediatric cohort.MethodsClinical data and biopsy samples from pediatric patients (n = 48) with chronic abdominal pain, with and without inflammation were included. Formalin-fixed paraffin-embedded GI biopsies were sectioned and immunohistochemistry performed for IL-6 and 5-HT; mast cells were identified with toluidine blue stain. Histological findings were compared to self-reported abdominal pain between groups.ResultsThere was significantly greater IL-6 immunoreactivity in biopsies with confirmed histologic inflammation (p = 0.004). There was a greater number of mast cells per HPF in non-inflammatory biopsies (3.5 ± 2.9) compared to the inflammatory biopsies (2.6 ± 1.8) p = 0.049. The non-inflammatory biopsy group was significantly less likely to respond to standard treatment as evidenced by higher pain reports (p = .018). Mast cells (p = .022) and 5-HT (p = .02) were significantly related to abdominal pain scores.ConclusionsA potential association between self-reported abdominal pain, number of mast cells, and 5-HT levels, which may contribute to perceived GI pain in pediatric patients may exist.

Symptomatic calcified splenic artery aneurysm: Case report

Although the third most common aneurysm within the abdomen, after aneurysms of the aorta and iliac arteries, splenic artery aneurysms are rare, but not exceptionally. Owing to new imaging techniques, they have been discovered with increasing frequency. Authors present a 47-year-old woman, multipara, who presented with left upper abdominal pain in whom X-ray showed a calcified ring in the area of distal pancreas. Selective angiography confirmed a splenic artery aneurysm of its proximal part. During an open surgery the aneurysm was excised (aneurismectomy) without immediate, early or late complications. The patient became symptom-free. In patients, particularly women, the multiparas who present with epigastric or left upper abdominal pain of unknown aetiology, splenic artery aneurysm has to be taken into account. Further diagnostic procedures such as plain X-ray and selective angiography in suspected cases should be performed. Surgery or other treatment modalities are to be seriously considered in all patients, particularly in those with increased risk of rupture.

Transomental defects as a cause of chronic abdominal pain, the role of diagnostic laparoscopy: a case series

IntroductionTransomental herniation is a rare but recognised clinical condition, which usually presents as an emergency with bowel obstruction. It accounts for 1-4% of intra-abdominal herniations. We reviewed 3 patients found to have a transomental defect during elective diagnostic laparoscopy performed for chronic abdominal pain. To our knowledge, there is no case series reported in the literature on transomental defect in the non-emergency situation.Case presentationA retrospective case note analysis of 3 patients, found to have transomental defect during elective diagnostic laparoscopy, was undertaken. Data were gathered with respect to clinical presentation, investigations performed, transomental defect size and outcome of surgery. All patients were followed up for 6 months post-operatively. Three females (age range 18-35 years) were referred with a 3-10 year history of chronic intermittent abdominal pain, often postprandial. Blood tests, radiological investigations (ultrasound, magnetic resonance imaging/computed tomography, small bowel studies) and endoscopy were all normal. In each case, diagnostic laparoscopy revealed the presence of a peripheral defect in the greater omentum, but no actual small bowel herniation. No other pathology was found. These defects were resected, which subsequently led to complete resolution of the patients’ symptoms.ConclusionChronic abdominal pain of unknown aetiology with normal radiological findings may be caused by intermittent obstruction due to small bowel herniation through a transomental defect. This should be considered during elective diagnostic laparoscopy, in the absence of any other obvious pathology. The omentum should be thoroughly inspected as a discrete entity and any such defects should be closed or resected.

Diagnostic laparoscopy for chronic abdominal pain after gastric bypass

To evaluate, in an observational study, the utility of diagnostic laparoscopy as a tool to evaluate patients with abdominal pain of unknown etiology after gastric bypass surgery. A retrospective analysis was performed of data from patients who had undergone laparoscopy for diagnosis or treatment of abdominal pain. This study included 13 patients with negative preoperative radiographic and/or endoscopic findings. A total of 13 patients who had undergone Roux-en-Y gastric bypass underwent diagnostic laparoscopy for abdominal pain. The findings included internal hernia (4), adhesions (3), ventral hernia (2), partial small bowel obstruction (1), and chronic cholecystitis (1). There were 2 negative laparoscopies, while a diagnosis was made in 85%. After an average follow-up of 3.2 months, 7 of 11 patients had unresolved abdominal pain and 4 patients experienced pain resolution (2 patients were lost to follow-up). The results from this small retrospective study suggest that significant pathologic findings can be identified in most patients who have negative preoperative evaluation findings; however, the efficacy of diagnostic laparoscopy to eliminate pain in this patient population requires additional study. Despite the potential complications, we believe that diagnostic laparoscopy has a role in the diagnosis and treatment of chronic abdominal pain after gastric bypass.

Presentación atípica de tuberculosis peritoneal: Caso clínico diagnosticado por laparoscopia

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.

Gastric outlet obstruction due to gastroduodenal eosinophilic gastroenteritis

Eosinophilic gastroenteritis is a rare but important cause of abdominal pain of unknown etiology [1]. It can sometimes be recognized on the basis of macroscopic abnormalities, such as erythema, focal erosions, ulcerations, and thickening of mucosal folds [2]. Small-bowel obstruction can occur in eosinophilic gastroenteritis involving the muscularis layer [3], but gastric outlet obstruction is extremely rare [4].