Chronic Lower Abdominal Pain Research Articles

Endoscopic removal of a toothpick perforating the sigmoid colon and causing chronic abdominal pain: a case report

Toothpick ingestion is implicated in gut injuries which may cause severe complications, mimicking diseases causing acute abdomen. However, toothpick ingestion-related perforation may also cause mild, non-specific gastrointestinal symptoms without significant findings or major complications. We describe a young male with chronic postprandial lower abdominal pain caused by a toothpick impaction at the rectosigmoid junction after inadvertent ingestion. The foreign body was detected and successfully removed during flexible sigmoidoscopy. Perforation due to foreign body ingestion must be considered in the differential diagnosis in patients presenting with unexplained symptoms and findings, even when they do not recall any foreign body ingestion.

Surgical Management of Inguinal Neuralgia After a Low Transverse Pfannenstiel Incision

The authors assessed the long-term pain relief after local nerve blocks or neurectomy in patients suffering from chronic pain because of Pfannenstiel-induced nerve entrapment. The low transverse Pfannenstiel incision has been associated with chronic lower abdominal pain because of nerve entrapment (2%-4%). Treatment options include peripheral nerve blocks or a neurectomy of neighboring nerves. Knowledge on adequate (surgical) management is scarce. Patients treated for iliohypogastric and/or ilioinguinal neuralgia after a Pfannenstiel incision received a questionnaire assessing current pain intensity (by 5-point verbal rating scale), complications, and overall satisfaction. Twenty-seven women with Pfannenstiel-related neuralgia were identified between 2000 and 2007. A single diagnostic nerve block provided long-term pain relief in 5 patients. Satisfaction in women undergoing neurectomy (n = 22) was good to excellent in 73%, moderate in 14%, and poor in 13% (median follow-up, 2 years). Complications were rare. Successful treatment improved intercourse-related pain in most patients. Comorbidities (endometriosis, lumbosacral radicular syndrome) and earlier pain treatment were identified as risk factors for surgical failure. Peripheral nerve blocking provides long-term pain reduction in some individuals. An iliohypogastric or ilioinguinal nerve neurectomy is a safe and effective procedure in most remaining patients.

Mucinous cystadenoma of appendix

123 The mucocele of the appendix is rare occurrence, with reported incidence of 0.2–0.3% among all the appendecectomy specimens [1]. A variety of underlying neoplastic and non neoplastic pathological changes can lead to appendicular mucocele. The size of the mucocele helps in predicting the nature of the cyst. Cysts less than 2 cm in diameter are usually simple retention cysts with normal epithelium, whereas those more than 2 cm may occur because of hyperplastic epithelium, cystadenoma or cystadenocarcinoma [2]. One such type of mucocele is reported and the condition is briefl y reviewed. A 46-yrs-old male presented with fi rm, mobile mass in the right iliac fossa for 2 months, associated with mild pain. There was no history suggestive of bowel pathology or past attack of appendicitis. His routine investigations were within normal limits. CECT of the abdomen revealed well encapsulated, hypo attenuated mass in the region of the appendix (Fig. 1). His colonoscopic examination was normal. On exploration, appendix was found to be grossly enlarged (10 × 5 cm), having cystic consistency (Fig. 2). A limited right hemicolectomy with end to end anastomosis was performed. Post operative period was uneventful. Gross pathological examination revealed distended appendix fi lled with mucin. On microscopic examination, appendiceal cyst was lined by single layer of columnar cells having apical mucosal vacuoles. There was no evidence of epithelial atypia or invasion. It was labelled as mucinous cystadenoma of the appendix. Mucinous Cystadenomas (63–84%), are most common cause of mucoceles of the appendix [2]. Histopathologically, these have epithelium similar to that of villous adenoma or adenomatous polyp of the colon. Also the chances of progression to cystadenocarcinoma are similar to that seen with colonic adenomas [3]. Chronic right lower abdominal pain secondary to the cystic dilatation of the appendix is the most common presentation, followed by palpable mass. Among the various available diagnostic modalities, CECT of the abdomen is most useful in diagnosing the cystic neoplasms of the appendix. A hypoattenuated cystic mass in the appendiceal region with curvilinear mural calcifi cations, irregular wall thickening, or both, is considered the most specifi c CT feature of mucocele. Sometimes sonograIMAGES IN SURGERY

A Rare Case of Thymoma Associated Autoimmune Enteropathy

Purpose: A 61-year-old female with history of bronchiectasis and resection of benign thymoma presented to The Mount Sinai Hospital with severe weight loss and malnutrition. She reported having chronic watery diarrhea and lower abdominal pain since 2004. A diagnosis of celiac disease was made based on an extensive work up at an outside hospital, which included abnormal small intestinal biopsies, but she had minimal clinical response to a gluten free diet. After a repeat colonoscopy 9 months later, Crohn's disease was diagnosed and she was treated with 4–5 courses of steroid tapering and 6-MP until February 2007, when she was hospitalized twice for severe constipation. On presentation to the Mount Sinai Hospital, she had persistent abdominal pain and reported weight loss of 45 lbs, despite continued gluten restricted diet. On examination, she appeared malnourished and had severe tenderness in left lower quadrant but no palpable mass. Lab data included Hb 10 g/dl, ESR 83, CRP 20.5, albumin 3.5 g/dl and negative HLA-DQ2/DQ8. Immunoglobulin quantitation and absolute T and B cell counts were within normal range. Small bowel series and abdomen CT were normal. On colonoscopy, the colon and terminal ileum appeared normal. Random colonic biopsies revealed loss of goblet cells and Paneth cells, presence of lymphocyte infiltrates in the lamina propria and and multiple apoptotic bodies. The findings were interpreted as autoimmune enteritis (AIE). Indirect immunofluorescence using patient's serum and frozen section of normal small bowel showed linear staining along the gut epithelium, consistent with anti-enterocyte antibodies. The patient resumed a gluten unrestricted diet and started oral prednisone and 6-MP. Her abdominal pain and diarrhea promptly improved and oral prednisone was successfully tapered over the next two months. Clinical remission of GI symptoms was maintained with 6-MP for over 1 year. Worsening bronchiectasis due to recurrent pseudomonas infections resulted in multiple hospitalization and the patient succumbed to respiratory failure in April, 2008. AIE was first described in 1982 by Unsworth and Walker-Smith and characterized by protracted diarrhea, circulating enterocyte antibody and associated autoimmune conditions. Only 3 of 30 reported cases had associated with thymoma. No standard approach for the treatment has not been established and immunosuppressive treatment is required in most cases. 60% of patients respond to steroid and 2/3 of steroid responders require additional immunomodulators for maintenance of remission. AIE should be considered in the differential diagnosis of malabsorption and refractory celiac disease.

A Rare Case of Appendiceal Endometriosis

Purpose: Endometriosis is a common gynecological disorder characterized by the presence of functional endometrial glands outside of the uterus. It is thought to occur through either retrograde menstruation into the peritoneal cavity or metastases through blood and lymphatic vessels. Various radiographic studies including CT scan, MRI, transvaginal ultrasound, and rectal ultrasound have been used to detect peritoneal implants, but definitive diagnosis requires laparoscopy and biopsy. Endometriosis of the gastrointestinal tract most commonly involves the rectosigmoid colon due to its close proximity to the reproductive organs. Here we describe a rare case of endometriosis involving the appendix. The patient is a 56 year-old healthy woman with a history of prior hysterectomy and bilateral salpingo-oophorectomy for endometriosis who was found to have a 1 cm polypoid mass at the appendiceal orifice on screening colonoscopy. Endoscopic ultrasound of the mass with the miniprobe revealed a 10 × 7 mm anechoic structure suggestive of a cystic lesion. Biopsies of this lesion were nondiagnostic. A subsequent CT scan of the abdomen revealed a 9–10 mm area of decreased attenuation adjacent to the cecum, possibly representing the lesion of interest. The patient otherwise was asymptomatic and denied any abdominal pain, weight loss, night sweats, hematochezia, or diarrhea. The patient was referred to a colorectal surgeon, as a mucocele of the appendix was suspected. The patient underwent laparascopic right hemicolectomy several months later and the final pathology of the resected specimen revealed endometriosis. Appendiceal endometriosis is a rare phenomenon with a reported prevalence of 0.054%. Many cases are asymptomatic and pass undiagnosed. However, symptoms of acute appendicitis, chronic right lower quadrant abdominal pain, cecal intussusception, and intestinal perforation have been reported. Diagnosis is difficult as endometriosis of the gastrointestinal tract mimics other disorders such as irritable bowel syndrome and requires histological demonstration of ectopic endometrial glands and stroma. Methods: N/A Results: N/A Conclusion: N/AFigure

Reimaging the Female Pelvis With Ultrasound After CT

Ultrasound is the most appropriate first imaging test to perform when gynecologic pathology is suspected based on clinical history or physical examination, and imaging is required. However, as a practical matter, a woman's first imaging test evaluating her pelvis may be a computed tomographic (CT) scan; this is especially true when these women present to an acute care facility or emergency department with chronic or acute lower abdominal pain. Radiologists need to be able to recognize the CT features of a variety of gynecologic conditions. However, just as importantly, radiologists should have a firm understanding of general principles that help to clarify when reimaging the pelvis with ultrasound is indicated; furthermore, a clear understanding of these principles helps to focus the sonologist's attention on the sonographic features that will be most helpful in further characterization of abnormal CT findings. This pictorial essay discusses these general principles that clarify when ultrasound is and is not helpful in reimaging the female pelvis after CT.

Laparoscopic biopsy in patients with abdominal lymphadenopathy

Background:Abdominal lymphadenopathy (AL) - a common clinical scenario faced by clinicians - often poses a diagnostic challenge. In the absence of palpable peripheral nodes, tissue has to be obtained from the abdominal nodes by image-guided biopsy or surgery. In this context a laparoscopic biopsy avoids the morbidity of a laparotomy.Aim:This retrospective analysis of prospectively collected data represents our experience with laparoscopic biopsy of abdominal lymph nodes.Materials and Methods:Between October 2000 and November 2005, 28 patients with AL underwent laparoscopic biopsy. Pre-operative radiological imaging studies had identified a nodal mass in 20, a solitary node in 1, a cold abscess in 1 and a mesenteric cystic lesion in 1 patient. In five patients with chronic right lower abdominal pain and normal ultra-sonographic findings mesenteric nodes were identified and biopsied during diagnostic laparoscopy.Results:The sites of biopsied lymph nodes included para-aortic (10), mesenteric (8), external iliac (3), left gastric (2), obturator (1), aorto-caval (1) and porta hepatis (1). One patient with enlarged peripancreatic nodes mass and another with a mesenteric cystic mass had cold abscesses drained in addition to biopsy. There were no perioperative complications and the median postoperative stay was 2 days (range 1-4 days). Histopathology revealed tuberculosis in 23 patients, reactive adenitis in 2, lymphoma in 1 metastatic carcinoma in 1, and a retroperitoneal sarcoma in 1.Conclusions:In patients with AL, laparoscopy provides a safe and effective means of obtaining biopsy. It is of particular value in patients in whom (a) the nodes are small or present in locations unsuitable for image-guided biopsy, (b) adequate tissue cannot be obtained by image-guided biopsy or (c) previously undiagnosed lymphadenopathy is encountered during diagnostic laparoscopy.

Chronic appendicitis “syndrome” manifested by an appendicolith and thickened appendix presenting as chronic right lower abdominal pain in adults

In this short report, we describe a small series of adult patients with chronic appendicitis presenting with chronic right lower quadrant abdominal pain. The clinical presentation was unusual and atypical for classic appendicitis because of the absence of fever, peritoneal tenderness on focused graded compression of the abdomen, and leukocytosis. Computed tomography (CT) findings included the presence of an appendicolith and appendiceal thickening, without mesenteric infiltration, abscess, or collection. In this series, the appendicolith appeared to represent a marker rather than an actual cause of appendicitis. Focused CT scans with additional lung and bone windows proved optimal in detecting appendicoliths, which were not visible on the scout localizer scans, despite windowing modifications. Our findings suggest that chronic appendicitis may be a phenomenon unique to adults and should be included in the differential diagnosis of chronic right lower quadrant pain in patients seen in the emergency room setting. Surgery is curative in such patients, although expectant management is an alternative when tolerated by the patient.

Diagnostic difficulties of pelvic splenosis: case report

We report the case of a 38-year-old woman who presented with chronic lower abdominal pain. Her past medical history included a splenectomy due to abdominal trauma. Ultrasound examination revealed four pelvic tumors which, upon laparotomy, were found to be the result of splenosis. Approximately 100 cases of splenosis have been reported but only a minority of them have been published in the gynecological literature. Our case indicates that those involved in pelvic scanning (even of asymptomatic women) and/or treating those complaining of lower abdominal pain or presenting with pelvic tumors should be aware of splenosis as a possible diagnosis.

A Model of Neural Cross-Talk and Irritation in the Pelvis: Implications for the Overlap of Chronic Pelvic Pain Disorders

Irritable bowel syndrome, interstitial cystitis, and other chronic pelvic pain (CPP) disorders often occur concomitantly. Neural cross-talk may play a role in the overlap of CPP disorders via the convergence of pelvic afferents. We investigated the hypothesis that afferent irritation of one pelvic organ may adversely influence and sensitize another via neural interactions. We measured pelvic organ smooth muscle and striated muscle reflexes during micturition and colorectal distention (CRD) in urethane-anesthetized rats. The effects of acute cystitis on distal colonic sensory thresholds to CRD and the effects of acute colonic irritation on micturition parameters were assessed. External urethral sphincter (EUS) electromyography (EMG) was typical for the rat, with phasic firing during micturition. External anal sphincter EMG also showed phasic firing during micturition in synchrony with EUS activity but, in addition, showed both tonic bursts and phasic firing independent of EUS activity. Before bladder irritation, graded CRDs to 40 cm H2O produced no notable changes in abdominal wall EMG activity. Following acute bladder irritation, dramatic increases in abdominal wall EMG activity in response to CRD were observed at much lower distention pressures, indicating colonic afferent sensitization. Analogously, following acute colonic irritation, bladder contraction frequency increased 66%, suggesting sensitization of lower urinary tract afferents. We report compelling evidence of bidirectional cross-sensitization of the colon and lower urinary tract in a novel experimental model. This cross-sensitization may account for the substantial overlap of CPP disorders; however, further studies are needed to fully characterize these pathways.

Les diverticules appendiculaires et leurs complications : apport de l’échographie (à propos de 21 cas)

Purpose Diverticulosis is defined by the presence of diverticula along any segment of the GI tract. Diverticulosis and its associated complications may involve the appendix. The imaging and histological findings of 21 cases of diverticulitis of the appendix are reviewed. Materials and methods Sonography, because of its high spatial resolution, is an ideal imaging technique to diagnose diverticulitis of the appendix. Results Similar to diverticulosis of the large bowel, diverticula of the appendix correspond to pseudo-diverticula composed of mucosa and sub mucosa herniating through the muscular layer. Chronic inflammatory changes affect the surrounding appendicular wall, as confirmed by histological examination. Clinical symptoms range from chronic right lower quadrant abdominal pain to acute appendicitis and even peritonitis. Conclusion Based on this retrospective analysis of 21 cases, it is possible to describe the specific and sensitive imaging findings for diagnosis of simple and complicated forms of diverticulitis of the appendix. Surgery is the treatment of choice because of the high risk of perforation.

Diverticulum of the vermiform appendix is associated with chronic abdominal pain

Background Diverticulum of the vermiform appendix is rarely encountered. Previous reports in the literature indicate that appendiceal diverticulum without inflammations are asymptomatic. Methods During the past 10 years, 217 patients have been evaluated in our office for chronic lower abdominal pain. Six patients in this group were unusual in that no diagnosis could be made after a complete history, physical examination, and multiple imaging and laboratory studies. Each patient had a normal computed tomography scan of the abdomen, upper endoscopy, colonoscopy, barium enema, and small bowel enteroclysis. Each of the 6 patients underwent an exploratory laparoscopy and appendectomy. Results All 6 patients in this series had acquired diverticulum of the appendix with inspissated intraluminal secretions without histological evidence of inflammation. The age range was 37 to 57 years. Most patients were male, and most had a single diverticulum projecting into the mesoappendix. All 6 patients had complete resolution of their chronic abdominal pain after the laparoscopic appendectomy. Conclusions An unusual cause of mild chronic abdominal pain can be the presence of appendiceal diverticulum with inspissated intraluminal secretions. The evaluation of these patients is usually normal. Exploratory laparoscopy with appendectomy should be the final evaluation for patients with mild chronic abdominal pain.

Case Study: Chronic Lower Abdominal Pain With Urinary Retention and Dysuria

Case Study: Chronic Lower Abdominal Pain With Urinary Retention and Dysuria

Surgical management of chronic lower abdominal and groin pain in high-performance athletes.

Formerly, most of the causes and treatments of chronic lower abdominal and groin pain in high-performance athletes eluded sports medicine specialists. Now we are much better at identifying and managing the different syndromes. Most of the advances are based on empiric evidence, although many pitfalls remain with respect to diagnosis and management of the various syndromes. This article reviews our current understanding of several of these clinical entities. We focus on lessons learned from a large 15-year experience.

Questionnaire as diagnostic tool in chronic pelvic pain (CPP): a pilot study

Objectives: No standard screening instrument is available enabling physicians to assign the diagnosis chronic pelvic pain (CPP) to women with lower abdominal pain. Therefore, our aim was to evaluate an easy-to-use questionnaire, which can be applied as a validated primary screening test for diagnosing CPP. Study design: From the general female population, 577 women completed a questionnaire addressing chronic symptoms in the pelvic region. Included were (amongst others) questions on lower abdominal pain, low back pain, voiding symptoms, dyspareunia, pelveo-perineal dysesthetic feelings and evacuation problems. Serious chronic lower abdominal pain of unknown origin was considered as CPP. Three criteria were applied to validate the questionnaire: construct validity, comparison with results of a previous study and content validity. In addition, the internal consistency was checked to ascertain the reliability of the questionnaire. Results: All items, with the exception of those concerning voiding symptoms and dyspareunia, withstood the validity tests applied, were interrelated and occurred significantly more often in women with CPP than those without. There were no significant differences in the frequency of the occurrence of low back pain, dyspareunia and evacuation problems between CPP women in the current community study and outpatients diagnosed with CPP in an earlier study performed at the University Hospital Rotterdam. Compared to our current study group, pelveo-perineal dysesthesia (PPD) and voiding symptoms were significantly more often reported by the CPP outpatients. Conclusion: The CPP questionnaire can be considered as a validated tool for primary screening of CPP.

Granulomatous peritonitis after laparoscopic cholecystectomy mimicking pelvic endometriosis

Background: Spillage of bile or gallstones, a relatively common occurrence during laparoscopic cholecystectomy, is believed to be inconsequential, but we describe a case of postlaparoscopic granulomatous peritonitis mimicking endometriosis. Case: A 20-year-old gravida 0 presented with chronic lower abdominal pain and dysmenorrhea. Laparoscopy showed red-brown pigmented pelvic adhesions, which on biopsy showed foreign-body–type granulomatous reaction, both suggesting endometriosis, but a history of laparoscopic cholecystectomy and a positive Fouchet’s stain for bile gave the true etiology of the granulomatous reaction. Conclusion: With increasingly widespread use of laparoscopic cholecystectomy, and relatively common spillage of bile or gallstones at surgery, granulomatous peritonitis mimicking endometriosis might become more frequent.

Computed Tomography Guided Core Needle Biopsy Diagnosis of Pelvic Actinomycosis

Background. Pelvic actinomycosis is a chronic suppurative inflammatory disease caused by the anaerobic Gram-positive bacilli Actinomyces israelii. The propensity of this disease to simulate gynecological malignancies has been described previously. The great majority of these patients were diagnosed with actinomycotic diseases during or after exploratory laparotomy, but rarely preoperatively. We reviewed the literature pertaining the management of pelvic actinomycosis.Case. A nulliparous woman with a long history of intrauterine contraceptive device (IUD) and recent Papanicolaou smear findings consistent with the presence of actinomyces presented with chronic vague lower abdominal pain, weight loss, poor appetite, and recent increase in abdominal girth associated with a large immobile pelvic mass. Transcutaneous computed tomography guided core needle biopsy established the diagnosis of pelvic actinomycosis obviating immediate surgical intervention. Intravenous and subsequent long-term oral penicillin therapy was constituted and resulted in a significant decrease in the size of the pelvic mass.Conclusion. In patients presenting with pelvic masses and a history of IUD placement, actinomycotic infection should be considered and diagnosis attempted by imaging guided needle biopsy. Furthermore, this case suggested that correct nonsurgical diagnosis of pelvic actinomycosis followed by prolonged antibiotic therapy might eliminate the need for extensive extirpative surgery and assist in maintaining future fertility.

The career and orthopaedic injuries of Joshua L. Chamberlain. The hero of Little Roundtop.

Joshua L. Chamberlain, a professor of religion and oratory at Bowdoin College, Brunswick, Maine was commissioned Lieutenant Colonel of the 20th Maine Volunteer Regiment in August 1862. He commanded the 20th Maine Volunteer Regiment in the historic defense of Little Roundtop against overwhelming odds and circumstances during the pivotal battle of Gettysburg. In June 1864 while leading a charge at the battle of Petersburg, he sustained what was thought to be a mortal wound when he was struck by a minié ball that entered just below and anterior to his right greater trochanter, injuring vessels, the urinary bladder and urethra, and fracturing his pelvis. Surgery was done in the field hospital, and after 5 months of recuperation, Chamberlain returned to lead his troops in combat. After the war he was elected Governor of Maine for four terms and subsequently served as President of his alma mater, Bowdoin College, for 12 years. Despite the fact that he had chronic lower abdominal pain, wound drainage, and a persistent urethral fistula, he lived a very productive life for 50 years after he was wounded at Petersburg. Included in the current paper are commentaries on the state of the art of surgery during the Civil War.

Appendix perforation by an intrauterine contraceptive device

Perforation of the uterus by an intrauterine contraceptive device (IUD) is a rare, and serious complication, occurring in 1/350 to 1/2500 insertions. Perforation by IUDs can involve several neighboring organs such as the bladder and rectosigmoid. We report two cases of IUD perforations involving the appendix, both inserted during lactation. The first case is an asymptomatic patient in early pregnancy and the second is a woman whose original presentation was chronic lower abdominal pain. The presence of copper in the abdominal cavity can lead to adhesion formation and subsequent abdominal pain, bowel obstruction or infertility. Thus, we believe that when an IUD is located in the abdominal cavity it should be removed even in an asymptomatic patient. In addition, these cases might suggest postponing the use of this contraceptive method in lactating women.

Gynecologically indicated single-endoloop laparoscopic appendectomy

A prospective, observational study was performed to define the laparoscopic appearance of chronic or recurrent appendicitis, and to evaluate a new, simplified technique for laparoscopic appendectomy. Chronic appendicitis was assumed in 42 women with long-term or recurrent lower abdominal pain, and appendectomy was performed when two or all three of the following pathologic changes, which were highly predictive of the diagnosis, were present: vascular injection of appendiceal peritoneum, periappendiceal adhesions, and induration of the appendix. After thorough periappendiceal adhesiolysis, a catgut no. 2 endoloop was placed around the base of the appendix and mesoappendix. The appendix was skeletonized, crushed distal to the ligature, regrasped further distally while simultaneously closing the appendiceal lumen, and cut in the crushed area. It was removed retrograde through the left suprapubic 10-mm port. Iodine was applied to the stump. No major intraoperative or postoperative complications occurred. During mean observation of 12.6 months, 74% of women were free of abdominal pain, 12% had partial relief in a mean of 15.4 months' observation, and 12% experienced no change in abdominal pain. This technique is safe, simple, and effective when chronic or recurrent appendicitis is assumed during diagnostic laparoscopy for chronic lower abdominal pain.