Chronic Intermittent Abdominal Pain Research Articles

An unusual case of longest intussusceptum without any pathological lead point in an adult: A rare case report from a peripheral tertiary care institute of Eastern India

Bowel obstruction is known to be caused by intussusception, which is far more common in pediatric patients. The majority of people with adult intussusception require a predisposing cause, which might be a benign lesion, a malignant lesion, or an irregularity of the intestinal wall such as inflammatory bowel disease. Adult intussusception is a very rare condition. We present the case of a patient presenting with upper abdominal pain, nausea, vomiting, and weakness. The patient had ongoing mild intermittent abdominal pain for months which was investigated with an upper gastrointestinal endoscopy that showed gastritis. There were features of peritonism on clinical examination and this was associated with raised inflammatory markers. A contrast-enhanced multidetector computed tomography (MDCT) scan showed a long-segment telescoping of the ileum into the cecum with ascending colon with proximal bowel distension suggesting bowel obstruction: Ileocolic intussusception. The patient underwent emergency surgical resection with a double-barrel stoma. Histopathology assessment did not identify a causative factor for the intussusception. An uncommon instance of adult idiopathic enteroenteric intussusception is presented here. The diagnosis can be established with the use of the clinical history of chronic intermittent abdominal pain, entire abdomen ultrasonography, and abdomen MDCT. In patients who are unstable and exhibit indications of peritonitis, surgery remains the only choice, even though a more cautious strategy is outlined in the literature. Adult intussusception is a rare and challenging diagnosis to make. Individuals suffering from intussusception may experience prolonged bouts of sporadic abdominal pain that intensify suddenly as a result of acute obstruction. The most helpful investigative technique for confirming the intussusception diagnosis is CT.

Jejunojejunal intussusception induced by a gastrointestinal stromal tumor: a case report and literature review.

Intussusception is defined as the invagination of a proximal segment of the bowel into the adjoining or distal segment. In most adults with intussusception, there is a demonstrable lead point with a definite pathologic abnormality. The clinical features of intussusception include chronic intermittent abdominal pain, nausea and vomiting, constipation, and a palpable abdominal mass. The present case report describes a 62-year-old woman with a 2-week history of abdominal pain and 9-day history of vomiting. Clinical, imaging, and histologic evaluations revealed a jejunojejunal intussusception with a gastrointestinal stromal tumor as the lead point. A gastrointestinal stromal tumor should be considered as a possible lead point in adult patients with intussusception. The implication of reducing the intussusception prior to tumor resection requires further evaluation in view of the risk of venous embolism, including direct spread of malignant cells, in cases involving a large polypoid mass with a necrotic surface that extends to the serosa as shown by intraoperative examination. Accordingly, the rationale for adjuvant therapy with imatinib also requires further evaluation.

An Unusual Cause of Diarrhea in Young Adulthood

Question: A 31-year-old woman presented to the gastroenterology clinic for a second opinion regarding chronic intermittent abdominal pain and alternating diarrhea and constipation for more than 10 years. She occasionally noticed a greasy film on the toilet water, but there was no blood in the stool, rectal pain, or weight loss. She had undergone computed tomographic (CT) imaging about 10 years before presentation for similar symptoms (Figure), and recently underwent esophagogastroduodenoscopy and colonoscopy with normal duodenal and colon biopsies, respectively.

S2747 Malignant Peritoneal Mesothelioma Seen on MRI Enterography During IBD Colitis Investigation in a 32-Year-Old Non-Asbestos Exposed Female Healthcare Worker

Introduction: This case describes an unexpected diagnosis of a malignant peritoneal mesothelioma (MPM) in a 32 y/o female physician without any known asbestos exposure. She presented to our department with a prior diagnosis of non-celiac gluten intolerance and intermittent but worsening left-sided abdominal pain for over 20 years. Several CTs suggested findings associated with IBD-related etiology and IBD specialist consultation was advised. After negative EGD/colonoscopy, an MRI Enterography revealed a small enhancing nodule suggestive of peritoneal malignancy. Pathology report after biopsy revealed a biphasic MPM. This case highlights the insidious nature of MPM and adds to the body of literature suggestive of IBD-mimicking symptomatology associated with this disease. Case Description/Methods: A 32 y/o F presented with chronic intermittent left-sided abdominal pain and gluten intolerance. Throughout her life, she reports 2-week periods of abdominal pain that is usually dull and sometimes sharp. The pain is focused LUQ with occasional LLQ pain. This is worsened by acute angle bending and deep palpation to the area. The patient still experiences pain despite a gluten-free diet. EGD is negative for celiac disease. CT imaging showed a left-sided pericolonic abscess and wall thickening of the lower descending and proximal sigmoid colon. An ill-defined soft tissue density in the left paracolic gutter was also seen and classified as a reactive lymph node. Abscess underwent CT aspiration; follow-up CT noted a new focal area of segmental wall thickening in the ascending colon with an inflamed diverticulum. IBD consult was recommended where negative EGD/colonoscopy resulted in MRI Enterography referral and results suggestive of peritoneal malignancy (Figure). Pathologic examination confirmed the presence of MPM, biphasic type (epithelial/spindle) with cytologic atypia and invasive growth being consistent with malignancy. The patient is on nivolumab, ipilimumab, carboplatin, pemetrexed and leuprolide for the next 3 months and considering debulking. Discussion: MPM presenting with decades long history of LUQ/LLQ pain exacerbations is rarely seen. CT results led to consideration of IBD etiology, as wall thickening, inflamed diverticulum, and a timeline suggestive of IBD was described. The lack of asbestos exposure highlighted the unlikely MPM differential. Prompt advanced imaging was key to diagnosis. Due to the insidious nature of MPM and poor outcomes, further exploration of timely advanced imaging is warranted.Figure 1.: MRI enterography reveals no evidence of active or chronic inflammatory bowel disease and no evidence of diverticulitis or diverticular abscess. There is a 10 mm enhancing nodule along the serosal margin of the splenic flexure in the left upper quadrant that is suspicious for a peritoneal malignancy.

S3384 Choledocystoduodenal Fistula Effectively Treated With a High-Dose Proton Pump Inhibitor: A Case Report

Introduction: Choledocystoduodenal fistulas are a rare complication of biliary or peptic ulcer disease. Approximately 91%-94% of spontaneous internal biliary fistulas are caused by stones in the biliary tract. The second most common cause is peptic ulcer. We present a case of a patient found to have a choledocystoduodenal fistula caused by peptic ulcer disease successfully treated with high-dose PPI. Case Description/Methods: A 73-year-old female with a history of duodenitis and gastritis presented for chronic intermittent abdominal pain. Physical exam was positive for epigastric tenderness. Labs were normal. Imaging revealed a large stool burden, mildly distended gallbladder without gallstones and a normal biliary tree. She was started on a once-daily PPI and a bowel regimen. EGD was performed and demonstrated a large necrotic duodenal lesion with copious purulent drainage (Figure A). Gastric biopsy was negative for H. pylori. The patient was readmitted for persistent abdominal pain, weight loss and loss of appetite. On physical exam, she had epigastric tenderness. She was afebrile and lab work was normal. CT abdomen and pelvis demonstrated small bowel thickening involving the duodenal bulb and first portion of the duodenum and air within the gallbladder with mild pericholecystic inflammatory changes. An EGD performed thereafter revealed the same duodenal bulb ulcer with a likely fistula (Figure B); injection of contrast through the tract under fluoroscopy confirmed a fistula to the gallbladder (Figure C). The patient was discharged on high-dose twice daily PPI, a short course of amoxicillin and clavulanic acid. Her symptoms resolved within 8 weeks. A surveillance EGD performed to assess healing demonstrated a healed scar at the site of the prior ulcer and fistula (Figure D). Discussion: Cholecystoenteric fistulas are a rare complication of gallstone disease and peptic ulcer disease, with an autopsy reported incidence rate of 0.1%-0.5%. Historically, surgical treatment is the most common treatment method for cholecystoenteric fistulas. Our case suggests that a high proton pump inhibitor dose for 8-12 weeks may be sufficient for the fistula to heal. By implementing medical management for this condition, it may be possible to avoid the morbidity and mortality associated with laparoscopic or open fistula repair.Figure 1.: A. Initial EGD showing large necrotic duodenal lesion with copious purulent drainage B. Second EGD demonstrating duodenal bulb ulcer C. Fluoroscopy with contrast injection demonstrating fistula tract communication with gallbladder D. Follow-up EGD after treatment with high dose PPI demonstrating healed choledocystoduodenal fistula with a small residual duodenal ulcer.

18-year-old with Abdominal Pain Due to Congenital Bowel Malrotation: A Case Report.

IntroductionCongenital bowel malrotation resulting in midgut volvulus is traditionally regarded as a diagnosis of infancy. Rarely, congenital bowel malrotation is diagnosed in adolescents or adults and requires a high index of suspicion. Presentations can be acute or chronic, and physical examination findings are nonspecific. Diagnosis is primarily achieved through abdominal computed tomography (CT) or during exploratory laparotomy. The pathophysiology in late-onset malrotation is similar to neonatal malrotation, with a division of Ladd’s bands – peritoneal fibrous bands that connect the cecum to the right lower quadrant retroperitoneum – as the definitive treatment. We present a case of congenital bowel malrotation in an adolescent with persistent and worsening migratory abdominal pain.Case ReportAn 18-year-old female presented to the emergency department with two days of poorly localized abdominal pain and nausea. Initial evaluation was unremarkable and she was discharged home with a diagnosis of constipation. She returned two days later with worsening abdominal pain and new onset emesis. Given her persistent and worsening symptoms an abdominal CT was performed, which revealed malrotation of the bowel. Taken together, her CT findings and abdominal symptoms were concerning for symptomatic congenital bowel malrotation and she underwent a Ladd procedure. She remained asymptomatic both at discharge and at two-week postoperative follow-up.ConclusionSymptomatic congenital bowel malrotation is more common in older children and adults than has traditionally been thought. Physicians must consider this diagnosis in their differential when working up a patient for acute or chronic intermittent abdominal pain to prevent potentially severe sequelae.

S1777 Polyps and an Uninvited Host

Introduction: Blood fluke illness like Schistosomiasis is considered rare in the United States. Most cases are reported in patients that have migrated from endemic zones like Africa or Asia. Occasionally this infection is seen in individuals from non-endemic regions whereby travel history plays an important role in diagnosis. Zoonotic diseases can be life threatening, thus prompt treatment is crucial to avoid major complications. Herein, we present an European individual living in the United States who underwent routine colon cancer screening in which the polyps that were biopsied revealed calcified Schistosoma eggs. Case Description/Methods: A 67-years-old male with past medical history of hypertension, goiter, and hyperlipidemia presented to the outpatient gastroenterology clinic for routine screening. Coloscopy done showed multiple colonic polyps, the largest being 1 cm in diameter. Pathology reported tubular adenomatous polyps with calcified Schistosoma eggs. Patient was asymptomatic and the physical exam was benign. On social and travel history, he pointed out that he lived in Angola from 1971-1973. Treatment with Praziquantel 600 mg three times daily was started, and the patient was asked to be followed up in 3 months. Negative serology was reported after treatment. Colonoscopy done 3 years later showed complete resolution of the polyps. Discussion: Schistosoma is a blood fluke causing Bilharziasis, an infection caused by freshwater parasitic worms. The parasite itself can be found living in certain freshwater snails. About 5 Schistosoma species have been identified to infect the human body with S. Mansoni and S. Japinicum being the main culprit for intestinal disease. Schistosomiasis is more prevalent in Sub-Saharan Africa with approximately 200 million cases reported worldwide. Infection occurs once the cercariae released by the snail penetrates the skin and begins its life cycle. Most individuals are asymptomatic. Migrating eggs cause bowel inflammation by triggering granulomatous reactions resulting in ulcerations, blood loss, and scaring. The same is true for Host immune response. The most common symptoms for intestinal Schistosomiasis are chronic intermittent abdominal pain, poor appetite, and diarrhea. Chronic ulcerations can be seen in severe cases with strictures as late complications. A combination of Polypectomy plus Praziquantel is often use as treatment. Follow up Colonoscopy to assure resolution is recommended.Figure 1.: Endoscopic mucosal removal of a Cecal granular cell tumor.

Intestinal malrotation in adults: prevalence and findings based on CT colonography.

Intestinal malrotation is largely a pediatric diagnosis, but initial detection can be made in adulthood. CT colonography (CTC) provides an ideal means for estimating prevalence. Our purpose was to evaluate the prevalence and imaging findings of intestinal malrotation in asymptomatic adults at CTC screening, as well as incomplete optical colonoscopy (OC) referral. The CTC database of a single academic institution was searched for cases of intestinal malrotation (developmental nonrotation). Prevalence was estimated from 11,176 adults undergoing CTC. Demographic, clinical, imaging (CTC and other abdominal exams), and surgical data were reviewed. 27 cases of malrotation were confirmed (mean age 62 ± 9years; 15M/12F), including 17 from the CTC screening cohort (0.17% prevalence) and 10 from incomplete OC (0.75% prevalence; p < 0.001). Most cases (59%; 16/27) were initially diagnosed at CTC. In 67% (12/18); the presence of malrotation was missed on at least one relevant abdominal imaging examination. At least 22% (6/27) had a history of unexplained, chronic intermittent abdominal pain. At CTC, the SMA-SMV relationship was normal in only 11% (3/27). The ileocecal valve was located in the RLQ in only 22% (6/27). Two patients (7%) had associated findings of heterotaxy (polysplenia). The prevalence of intestinal malrotation was four times greater for patients referred from incomplete OC compared with primary screening CTC, likely related to anatomic challenges at endoscopy. Malrotation was frequently missed at other abdominal imaging examinations. CTC can uncover unexpected cases of malrotation in adults, which may be relevant in terms of potential for future complications.

2649 A Case of Primary Intestinal Lymphangiectasia in an African American Adult Male With Intermittent Abdominal Pain and Diarrhea

INTRODUCTION: Primary intestinal lymphangiectasia is a rare type of protein losing enteropathy in which there is a localized or diffuse ectasia of the enteric lymphatic causing leakage of protein into the intestinal lumen. Here, we describe a case of Primary Intestinal Lymphangeictasia in a patient presenting with chronic intermittent abdominal pain and diarrhea. CASE DESCRIPTION/METHODS: Patient is a 56-year-old African-American male with history of COPD, DM, morbid obesity, GERD who presented to our office as a referral after hospitalization for for evaluation of abdominal pain and diarrhea. Patient was hospitalized for 3 day duration of epigastric pain and watery diarrhea. There, he was noted to have hypocalcemia, hypoalbuminemia, and trace urine proteinuria. Lactate was normal. CT abdomen pelvis showed nonspecific Jujenitis. He was treated empirically with Intravenous antibiotics and discharged home. During follow up visits, initial comprehensive workup for inflammatory bowel disease, celiac disease, stool pathogens, thyroid panel, lipid panel, Alpha-1-Antitrypsin stool clearance, and HIV were all unremarkable. Patient subsequently underwent colonoscopy and EGD. Colonoscopy revealed sigmoid diverticulosis and internal hemorrhoids. EGD revealed nonspecific jejunitis. He had yet another hospitalization for worsening similar acute abdominal pain. During his second hospitalization, labs showed mild leukocytosis, CT abdomen and pelvis revealed jejunal edema. He was taken for diagnostic laparoscopy which only showed mild ascites and thickening of the jejunum. Surgical pathology unfortunately was inconclusive. Patient followed up again as an outpatient and underwent small capsule endoscopy which revealed lymphangiectasia at the jejunum. Patient was referred to a dietitian where he was placed on high protein and Medium chain triglycerides diet. DISCUSSION: Primary Intestinal Lymphangeictasia is a rare cause of protein losing enteropathy that can manifest as non-specific abdominal pain and diarrhea. In this case, the patient had chronic intermittent abdominal pain and diarrhea which required capsule endoscopy in order to diagnose and was missed on surgical pathology. Much like an Inflammatory Bowel disease which can take several studies and biopsies in order to diagnose, albeit different pathophysiology, Primary intestinal lymphaniectasia is a rare cause of abdominal pain that should be on the differential when evaluating chronic intermittent severe abdominal pain and diarrhea of unknown etiology.

2635 Gastrointestinal Hereditary Angioedema Causing Recurrent, Self-Resolving Abdominal Pain

INTRODUCTION: Hereditary angioedema (HAE) is a type of bradykinin-mediated isolated angioedema, characterized by temporary swelling that can affect skin or walls of hollow viscera such as the oropharynx, or gastrointestinal tract (in 43 to 93% of HAE cases respectively) and occurs without pruritus. This case is reported due to its rare presentation that often results in unnecessary invasive procedures. CASE DESCRIPTION/METHODS: A 25-year-old female with a past medical history of hypothyroidism and asthma presented with acute on chronic intermittent abdominal pain and vomiting for a day bearing no relation with meals or defecation. She had recurrent hospitalizations for similar complaints but workup till date showed enteritis on imaging and exploratory laparoscopy showed adhesions with colonic biopsy negative. Extensive history taking revealed prodromal symptom of anxiety and a previous episode of self-resolving finger swelling, retrospectively suspected to be due to angioedema. Labs showed leukocytosis and elevated CRP. Repeat CECT abdomen displayed thickening of jejunal wall. Given her history of prodromal symptoms, finger swelling and a family history of similar self-resolving abdominal pain of unclear etiology in her mother prompted further testing for complements due to concern for hereditary angioedema, which was positive with low C4 and C1 inhibitor. She was referred to an allergy specialist for further management. DISCUSSION: HAE is an autosomal dominant disease that is due to decreased or impaired C1 Inhibitor. Typical GI symptoms are recurrent abdominal pain, vomiting and diarrhea caused by transient small bowel edema. Inciting events include stressful situations like fasting and infections and medicines like ACE-inhibitors. Diagnosis is clinical from history of skin swelling or respiratory distress during attacks, documenting possible triggers and family history of HAE. Physical exam and imaging is useful only during acute attacks. Recommended lab tests include C4 levels, C1 inhibitor antigenic levels, and C1INH functional levels. Endoscopy is not recommended as it may precipitate laryngoedema. Treatment includes C1 INH replacement or icatibant (bradykinin receptor antagonist) for acute attacks and attenuated androgen or lanadelumab for prophylaxis. HAE should be considered when tackling cases of undiagnosed abdominal pain in the right clinical context to prevent years of suffering, unnecessary invasive procedures and life-threatening complications from laryngeal edema or hypovolemic shock.

3041 Eosinophilic Colitis: A Rare Entity

INTRODUCTION: Eosinophilic colitis (EC) is a rare entity characterized by abnormal infiltration of colon mucosa by eosinophils without evidence of any secondary causes. Presentation may include asymptomatic state, chronic diarrhea, abdominal pain, rectal bleed, bowel obstruction or ascites. We present two cases of EC with very different presentations requiring minimal or no therapy. CASE DESCRIPTION/METHODS: CASE 1: 57 year old Filipino male presented with abdominal pain and new onset ascites. Paracentesis revealed elevated SAAG suggestive of portal hypertension. Imaging studies were negative for cirrhosis. Negative liver workup for chronic liver disease. Lab studies revealed microcytic anemia and peripheral eosinophilia of 10%. No eosinophilia noted in ascitic fluid. EGD showed LA Grade C esophagitis. Colonoscopy showed multiple polyps which were removed. Pathology from polyps showed markedly increased eosinophil infiltrate in mucosa and submucosa. There was no evidence of inflammatory bowel disease, Stool studies were negative for infectious etiology. No incriminating medications were found which could lead to above finding. The patient was treated with omeprazole and diuretics with complete resolution of symptoms. CASE 2: 27 year old female presented with chronic intermittent abdominal pain, nausea and diarrhea for 2 years. Her only medications were birth control pills. She had normal blood counts, electrolytes, liver, and renal function. Stool studies were negative for any infectious etiology. She had normal fecal fat and electrolytes. EGD and colonoscopy were unremarkable. Biopsies were negative for celiac disease, Helicobacter and eosinophilic esophagitis. Random colon biopsies showed benign colon mucosa with focal infiltration of colonic mucosa with eosinophils suggestive of eosinophilic colitis. There was no peripheral eosinophilia. Patient was started on probiotics with prompt resolution of symptoms. DISCUSSION: EC is a rare condition, included in the group of eosinophilic gastrointestinal disorders, characterized by eosinophil infiltration of colonic mucosa in the absence of any food allergies, parasitic/helminthic infections, drugs, IBD, celiac and autoimmune diseases. The treatment options include dietary modifications, steroids, mesalamine, immunomodulatory agents, fecal microbiota transplant and surgery. The evidence for most of treatment options is limited to case reports. One of our patients required no specific therapy while other one was treated successfully with probiotics.

1361 Facilitating Direct Cholangioscopy and Lithotripsy in a Roux-en-Y Bypass With a Stuck Dilation Balloon

INTRODUCTION: A 66-year-old woman with a history of Roux-en-Y gastric bypass, thromboembolic CVA on dual antiplatelet therapy, and known common bile duct (CBD) stones presented an outside facility 2 months prior complaining of chronic intermittent abdominal pain and jaundice. She was in sepsis due to cholangitis and MRCP showed a 2.1 cm CBD stone. ERCP was unsuccessful due to her altered anatomy; therefore, she was treated medically and referred for repeat attempt at ERCP, lithotripsy and bile duct clearance. CASE DESCRIPTION/METHODS: ERCP was performed using a double balloon enteroscope (DBE). Ampulla was seen next to a periampullary diverticulum. Retrograde cannulation and cholangiogram showed 2 large stones (Figure 1). Sphincterotomy and balloon dilation was done to 10 mm and stone extraction attempted but failed due to their large size. The procedure was repeated with plans to perform cholangioscopy and electrohydraulic lithotripsy (EHL). The ampulla was further dilated using a 14 mm balloon to allow direct cholangioscopy using the DBE. Unfortunately, attempt at removing the dilating balloon afterwards failed due to the small lumen size of the scope. Therefore, the scope was removed while keeping the overtube in place. The balloon at the tip of the DBE was removed to facilitate direct cholangioscopy and the scope was readvanced through the overtube to the ampulla. The DBE without the scope balloon passed easily into the CBD. Two stones, a black pigmented and a brown pigmented, were seen (Figure 2) and fragmented using EHL. Stone fragments were cleared in the usual fashion and direct cholangioscopy confirmed bile duct clearance (Figure 3). DISCUSSION: ERCP is difficult in patients with prior Roux-en-Y gastric bypass. The newest approach is to place a lumen apposing metal stent (LAMS) from the gastric pouch to the remnant stomach then perform antegrade ERCP in the usual fashion. If this is not possible (e.g., unfavorable anatomy, patient, or surgeon refusal) then the only approach is retrograde using a DBE; our patient underwent ERCP prior to the introduction of LAMS. DBE ERCP is cumbersome at best due to the small channel size and limited maneuverability of the scope as well as lack of an elevator. For these reasons, the only way to perform lithotripsy is by direct cholangioscopy after large balloon dilation.

Meckel's diverticulum misdiagnosed as a small intestinal polyp

Background: Meckel’s diverticulum is the most common congenital abnormality of the small intestine, with an incidence about 2% of the population. It is asymptomatic in most cases. When symptomatic, it’s most common clinical presentation is bleeding in children and intestinal obstruction in adults. Small intestinal polyps are a challenging clinical problem. They present with various symptoms and their diagnosis is difficult due to limitations in radiographic and endoscopic detection. Case report: We present a case of a 25 –years old male patient with chronic intermittent abdominal pain, who was admitted to our department for an elective laparoscopic resection of a small intestinal polyp, diagnosed via CT and MRI enterography. However, laparoscopy revealed a Meckel’s diverticulum and no other pathology of the small intestine. Conclusion: Both Meckel’s diverticulum and small intestinal polyps are rare conditions and their differential diagnosis is challenging. A high clinical index of suspicion is demanded, as well as accurate radiographic and endoscopic tests in order to diagnose and therefore treat symptomatic patients.

A Colorectal Myxoid Nodule: Is It a BUMP or a Myxoma?

Benign polyps from the mesenchyme can arise in the mucosa or submucosa anywhere in the Gastrointestinal tract. They are typically solitary, small, and found incidentally on screening colonoscopies. Most are asymptomatic, however, some may lead to bleeding, abdominal pain, obstruction, or local invasion. Anatomical and molecular pathology are important in categorizing these lesions. A 33 y.o. female presented for the evaluation of rectal bleeding and chronic intermittent, dull and crampy lower abdominal pain that resolves with defecation. She had rectal bleeding at age 9, and, at that time, a polyp was identified on flexible sigmoidoscopy. The pathology report was unavailable. Her brother also had polyps in his 40s requiring surgery. No family history of colon cancer was reported. Her general physical exam was normal and her abdominal exam was benign. Blood work showed a normal complete blood count, basic metabolic panel, and liver function test. A colonoscopy was recommended, which revealed a single sessile polyp measuring 5 mm in size at the recto-sigmoid junction along with another 5 mm flat polyp in the rectum. (Image 1) Saline was injected at the base of the polyp for lifting and complete removal with a hot snare cautery polypectomy. Upon withdrawal of the needle from the polyp after a saline lift, oozing white mucoid material was noted from needle site. Firm texture was appreciated during polypectomy. On pathologic examination, routine light microscopy revealed colonic mucosa overlying a hypo-cellular submucosal hyalinized myxoid nodule. (Image 2) Additional histochemical staining was negative for collagenous or elastic fibers on a trichrome-elastic stain and negative for amyloid on a Congo red stain. (Image 3) The second polyp was also removed and pathology showed a small well-differentiated neuroendocrine tumor. This is the first documented case of a colorectal myxoid nodule. All myxoid nodules of the large intestine should be characterized on a case by case basis to determine whether they are clinically indolent and pathologically benign or locally aggressive and potentially pathologically malignant. The anatomic layer in which they are found, among other histologic features, helps elucidate these lesions. For lesions that do not fit into a currently well-described entity, the Benign Unclassified Mesenchymal Polyps category may be appropriate. Their full clinical significance will be better understood when more are reported in the literature.1559_A Figure 1. A single sessile polyp measuring 5 mm in size at the recto-sigmoid junction on colonoscopy.1559_B Figure 2. The submucosa is expanded by a hypocellular myxoid matrix with scattered smooth muscle cells and hyalinized blood vessels (H&E, X100).1559_C Figure 3. The myxoid matrix is non-collagenous and without elastosis. There are scattered smooth muscle cells from splaying of the muscularis mucosae fibers (Trichrome/elastic, X100).

Schistosomiasis: An Infrequently Recognized Cause of Rectal Bleed in the Western World

Intestinal Schistosomiasis is a common cause of chronic intermittent abdominal pain in endemic regions and can often lead to intestinal bleeding. It is due to deposition of eggs in the colonic loose submucosa where they trigger inflammation with subsequent formation of granulomas. We present a case of Schistosomiasis manifesting as rectal bleed. A 35-year-old man from Nigeria came with intermittent rectal bleed for 3 months. Laboratory workup was negative for anemia and peripheral eosinophilia. Colonoscopy was normal except for mild loss of vascularity in the sigmoid and rectum (Figure A and B). Biopsies from here revealed egg deposits in colonic mucosa, morphologically consistent with Schistosoma species. Treatment with praziquantel was initiated. He had resolution of rectal bleeding when seen in follow up visit in 1 month. Clinical manifestations of Schistosomiasis are a result of acute granulomatous response to eggs and not the adult worm. The intensity of such response and resultant inflammation is variable and dependent on antigen load. It can acutely present as cercarial dermatitis and Katayama syndrome. As the granulomatous response to eggs weans over time, the chronic intestinal form of the disease matures as superficial ulcers or hyperplastic polyps, which manifests as non-specific intermittent abdominal pain, diarrhea and rectal bleeding. It is diagnosed by demonstrating the presence of viable eggs in urine or tissue biopsies from endoscopic approaches. Praziquantel is the drug of choice to treat Schistosomiasis and is effective against all species, however kills only the adult worms. It is ineffective against the immature larvae, which would grow into adult worms and cause re-infection, implying drug failure. A common approach to deal with this issue is to re-treat with praziquantel in 3-6 weeks to kill the initially immature larvae that may have matured to an adult one. It is more commonly encountered in immigrants in the western world and should be a consideration with dealing with gastrointestinal bleed among such patients.1495_A Figure 1. Mild loss of vascularity in rectum1495_B Figure 2. Mild loss of vascularity in sigmoid colon

My tummy hurts - a case report of abdominal pain and macrocytic anemia caused by hypothyroidism.

SummaryA 6-year-old female presented with chronic intermittent abdominal pain for 1 year. She underwent extensive investigation, imaging and invasive procedures with multiple emergency room visits. It caused a significant distress to the patient and the family with multiple missing days at school in addition to financial burden and emotional stress the child endured. When clinical picture was combined with laboratory finding of macrocytic anemia, a diagnosis of hypothyroidism was made. Although chronic abdominal pain in pediatric population is usually due to functional causes such as irritable bowel syndrome, abdominal migraine and functional abdominal pain. Hypothyroidism can have unusual presentation including abdominal pain. The literature on abdominal pain as the main presentation of thyroid disorder is limited. Pediatricians should exclude hypothyroidism in a patient who presents with chronic abdominal pain. Contrast to its treatment, clinical presentation of hypothyroidism can be diverse and challenging, leading to a delay in diagnosis and causing significant morbidity.Learning points:Hypothyroidism can have a wide range of clinical presentations that are often nonspecific, which can cause difficulty in diagnosis.In pediatric patients presenting with chronic abdominal pain as only symptom, hypothyroidism should be considered by the pediatricians and ruled out.In pediatric population, treatment of hypothyroidism varies depending on patients’ weight and age.Delay in diagnosis of hypothyroidism can cause significant morbidity and distress in pediatrics population.

An Unexpected Massive Colonic Dilation on a Chest X-ray

Internal hernias are uncommon and often misdiagnosed because of non-specific symptoms. They occur when there is protrusion of an internal organ into a retroperitoneal fossa or a foramen leading to bowel obstruction. We report a case of asymptomatic internal hernia diagnosed incidentally during an emergency department visit. A 43-year-old Caucasian female with a history of cervical cancer status post partial hysterectomy presented to the emergency department for evaluation of pre-syncope. At the time of evaluation, she denied abdominal pain or distention and reported some nausea and vomiting that preceded her pre-syncope. A chest X-ray was obtained and showed massive gaseous dilation of the transverse colon up to 12 cm. A computed tomography of the abdomen was performed and revealed twisting of the mesenteric vessels, which was suspicious for an internal hernia. Also, a portion of the ascending colon looked entrapped within the suspected internal hernia and the transverse colon was dilated up to 13 cm. The patient was evaluated by the surgical team who recommended surgical correction and a possible colectomy, the patient refused any surgical intervention because she was asymptomatic and was discharged home. Internal hernias account for 0.6% to 5.8% of all intestinal obstructions. When a loop of bowel herniates through a mesenteric defect, it carries a high risk of strangulation and incarceration. The mesenteric defect can occur in seven different locations in the abdominal cavity accounting for the different types of internal hernias. The defect can be congenital or acquired secondary to trauma, surgical intervention, and vascular or inflammatory diseases. While some patients with internal hernias are asymptomatic, others have nonspecific symptoms such as chronic dyspepsia or intermittent colicky abdominal pain that renders the diagnosis difficult. Surgical intervention is the treatment of choice in symptomatic and asymptomatic cases. This reduces the risk of urgent surgery needed for incarcerated hernias. Among internal hernia cases reported in the literature, this is the first to describe a massive dilation of the transverse colon up to 13 cm without any symptoms. It is important to recognize that internal hernias have nonspecific symptoms and may be asymptomatic for decades, which makes the initial diagnosis challenging. Patients may refuse surgery since they are asymptomatic however surgical correction is necessary to prevent the morbidity of the disease.Figure: Chest X Ray showing colonic dilation.Figure: CT abdomen revealing colonic dilation.Figure: CT abdomen revealing colonic dilation.

Intestinal goblet cell carcinoid presenting with recurrent sterile peritonitis in a patient on peritoneal dialysis: a case report

BackgroundGoblet cell carcinoid is a rare variant of appendiceal carcinoid with mixed endocrine and exocrine features. The most common symptom and signs are abdominal pain, acute appendicitis and palpable mass. Additionally, abdominal pain is common in patient on peritoneal dialysis, which may confound the diagnosis in such patient.Case presentationWe report a 71- years- old woman on peritoneal dialysis that experienced several episodes of abdominal cramping pain and sterile peritonitis. She had one episode of severe pain and underwent an appendectomy for suspicion of appendicitis. Goblet cell carcinoid was diagnosed. She had no further abdominal pain after she received appendectomy.ConclusionsMalignant dialysate was rarely reported in patient with peritoneal dialysis. However, goblet cell carcinoid can initially present with acute appendicitis, chronic intermittent abdominal pain and mimicking peritonitis. In systemically reviewing the literature, this is the first case report of sterile peritonitis with peritoneal dialysis caused by goblet cell carcinoid.

Chronic intermittent abdominal pain in young woman with intestinal malrotation, Fitz-Hugh-Curtis Syndrome and appendiceal neuroendocrine tumor: a rare case report and literature review.

BackgroundThere are a lot of different causes of abdominal pain; in this case, a young woman suffers from three diseases with similar symptoms. Adult intestinal mal-rotation is a rare condition of deviation from the normal 270° counter clockwise rotation of the midgut resulting in, not only mal-position of the small intestine, but also mal-fixation of the mesentery. Fitz-Hugh-Curtis syndrome is a rare complication of pelvic inflammatory disease; it involves liver capsule inflammation associated with genital tract infection, which is usually caused by Neisseria gonorrhoea and Chlamydia trachomatis. Neuroendocrine tumors are enterochromaffin cell neoplasms that arise from cells of the endocrine (hormonal) and nervous systems; the appendicular one is the most common primary malignant lesion of these tumors, it’s incidence is about 0.3 – 0.9 % of appendectomies done. Just for knowledge, this is the first described case of concomitant presence of all these diseases with clinical symptoms attributable to each one.Case presentation40-years-old woman suffers from acute abdominal pain, predominantly on the right quadrants, without abdominal distension, no guarding nor rigidity and normal intestinal peristalsis. She has a long history of abdominal intermittent pain, with cramps every 30–40 min, resolving spontaneously. She was diagnosed as intestinal mal-rotation through computed tomography scan which has evidenced a mobilized intra - peritoneal duodenum with cecum/ascending colon predominately lying on the left side and the small intestine almost entirely lying on the right side of abdomen, without evidence of effusion, edema or signs of intestinal ischemia or infarction. Exploratory laparoscopy demonstrated an inflammatory process in the hepatic-renal space, with bloody adhesions above the liver capsule; this is additional to the typical pelvic inflammatory disease signs (Fitz-Hugh-Curtis syndrome). Appendectomy was performed with histological analysis resulting in appendicular neuroendocrine tumor.ConclusionsAlthough the patient has an intestinal mal-rotation which could explain the abdominal painful symptoms, it is not possible to exclude other concomitant causes, such as perihepatitis on pelvic inflammatory disease or neuroendocrine tumors. Even if all these diseases are rarely seen in daily clinical practice, they should be considered in the differential diagnosis of chronic intermittent abdominal pain in a young woman.

Collagenous Gastritis: A Rare Entity

Collagenous gastritis is a rare entity of unknown etiology characterized histologically by the presence of a thick subepithelial collagen band associated with an inflammatory infiltrate of gastric mucosa. A 40-year-old male presented with a history of chronic intermittent abdominal pain for about 6 months. Physical examination was unremarkable, and biological tests were within normal range. The patient underwent esophagogastroduodenoscopy and colonoscopy which showed a nodular mucosa of the stomach. Biopsies of the duodenum and colon were unremarkable. However, biopsies of the gastric fundus revealed a mild chronic gastritis characterized by lymphocytic and plasma cell infiltration of deep mucosa, without lymphoid follicle formation or active inflammation. No microorganisms were identified on routine hematoxylin and eosin or Giemsa-stained sections. Subepithelial collagen in the gastric biopsies was thickened and showed entrapped capillaries. Subepithelial collagen was highlighted by Masson’s trichrome staining and was negative for amyloid by Congo Red. In the areas containing thickened collagen, there were no intraepithelial lymphocytes. The final pathological diagnosis was collagenous gastritis. Collagenous gastritis is an extremely rare disease, but it is important to recognize its characteristic endoscopic and pathologic findings to make a correct diagnosis. Specific therapy for this rare entity has not yet been established.