Unexplained Chronic Abdominal Pain Research Articles

TYPE I HEREDITARY ANGIOEDEMA ASSOCIATED WITH SERPING1 GENE MUTATION

<h3>Introduction</h3> Type I hereditary angioedema (HAE) is characterized by recurrent episodes of swelling of the skin, gastrointestinal tract, and upper airway. Here we present a child with chronic abdominal pain who was found to have a novel deleterious variant in the serine protease inhibitor 1 (<i>SERPING1</i>) gene resulting in autosomal dominant (AD) HAE. <h3>Case Description</h3> The patient is a 9-year-old boy with a history of behavioral changes during febrile illnesses and IgA deficiency who presented with chronic abdominal pain and headaches. He was previously diagnosed with pediatric acute-onset neuropsychiatric syndrome (PANS) at another facility. He had a longstanding history of daily episodes of abdominal pain. He had no personal or family history of angioedema. Laboratory results showed low C4 complement levels (7 mg/dL), which prompted a workup for HAE. Lown C4 was confirmed on multiple occasions and the patient had low C1 esterase inhibitor protein and functional levels. Targeted genetic testing showed a "likely pathogenic" variant in SERPING1 c.1481G>A (p.Arg494Gln). An immune workup showed no abnormality except for partial IgA deficiency with negative anti-IgA antibodies. He was started on prophylactic plasma-derived concentrate of C1 esterase inhibitor with resolution of his symptoms. <h3>Discussion</h3> HAE should be considered in the differential of patients with chronic unexplained abdominal pain even with a negative personal and family history of HAE. The combination of low C4 complement levels, decreased C1 esterase inhibitor levels and excellent response to plasma-derived C1 esterase inhibitors confirm the deleterious effect of the c.1481G>A <i>SERPING1</i> variant and the diagnosis of type I HAE.

Efficacy-safety profile of the video capsule endoscopy in the study of the small bowel: experience over 100 consecutive procedures.

Video capsule endoscopy (VCE) is currently considered the first-line study in the evaluation of the small bowel (SB). Retrospective study including consecutive patients from 2010 to 2021 in two referral endoscopic centers in Peru, who underwent VCE. Inclusion criteria were patients with middle gastrointestinal bleeding, chronic diarrhea and unexplained chronic abdominal pain (endoscopic studies prior to VCE: normal). We mainly used Pillcam SB VCE (Given Imaging, Israel) SB2 and SB3 generations.

Predictors of Positive Video Capsule Endoscopy Findings for Chronic Unexplained Abdominal Pain: Single-Center Retrospective Study and Meta-Analysis.

Video capsule endoscopy (VCE) is an effective diagnostic modality for detecting small bowel lesions. However, the value of VCE for patients with chronic recurrent abdominal pain (CAP) of unknown etiology remains obscure. We retrospectively analyzed factors that could predict enteropathy based on the medical records of 65 patients with unexplained chronic recurrent abdominal pain (CAP) who were assessed using VCE between 2001 and 2021. We also conducted a systematic review and meta-analysis of the literature to validate our results. The positive findings of 27 (41.5%) of the 65 patients were mostly ulcerative lesions including stricture (n = 14, 60.9%) and erosion (n = 8, 29.7%). Multivariate analysis identified elevated ESR (OR, 1.06, 95% CI, 1.02–1.1, p = 0.004) as a significant risk factor for enteropathy predicted by VCE. Three eligible studies in the meta-analysis included 523 patients with CAP. Elevated C-reactive protein (CRP) (OR, 14.09; 95% CI, 2.81–70.60; p = 0.001) and erythrocyte sedimentation rate (ESR) (OR, 14.45; 95% CI, 0.92–227.33; p = 0.06) indicated VCE-positive findings in patients with unexplained abdominal pain. Elevated levels of the inflammatory markers ESR and CRP can thus predict positive VCE findings in patients with CAP.

Single-balloon enteroscopy in management of small-bowel disorders.

Device-assisted enteroscopy including single-balloon enteroscopy (SBE) allows direct visualization of the small bowel and has good safety and efficacy in experienced hands. Our study is aimed to share our single-centre experience of SBE in diagnosing and treating small-bowel disorders. We reviewed the prospectively collected data (from December 2016 to December 2019) of 180 consecutive anterograde and/or retrograde procedures. Analysis of baseline characteristics, endoscopic findings, and diagnostic and therapeutic rates was done. SBE was done in 158 patients with a median age of 55years (range, 13-94years) for suspected small-bowel lesions. Dual enteroscopy (anterograde plus retrograde) was done in 22 patients (13.92%). The indication for the procedure was obscure gastrointestinal bleeding in 129 (71.66%), chronic unexplained abdominal pain in 20 (11.11%), suspected small-bowel abnormality in the form of narrowing and/or mass on imaging in 10 (5.5%), chronic diarrhea in 9 (5%), unexplained iron deficiency anemia in 9 (5%), and retained capsule in 2 (1.11%). The most common finding was ulcer, which was noted in 45 (25%) patients followed by stricture in 8 (4.44%) and both ulcers and strictures in 6 (3.33%) patients. SBE was normal in 61 (33.88%) patients. SBE gave a diagnosis in 66.11% while in 28.43% cases, therapeutic intervention was done. Minor complications like bleeding were noted in 3 patients and mild acute pancreatitis in 2 patients. Jejunal perforation requiring surgical intervention was noted in 1 patient. SBE is a safe and effective procedure in diagnosing and treating small-bowel diseases.

Mo1934 – Unexplained Chronic Abdominal Pain in 50-Year-Old Male

Mo1934 – Unexplained Chronic Abdominal Pain in 50-Year-Old Male

Prevalence and Risk Factors for Chronic Abdominal Pain After Roux-en-Y Gastric Bypass Surgery: A Cohort Study.

To investigate the prevalence and risk factors for chronic abdominal pain after Roux-en-Y gastric bypass (RYGB) surgery. Abdominal pain is a frequent postoperative complication after RYGB surgery. Even if there have been defined several long-term complications, the literature regarding patients with unexplained chronic abdominal pain is sparse. A single-center register-based cohort study with inclusion of all patients who underwent RYGB surgery between 2010 and 2015. Data from multiple registries, medical records, and a questionnaire were used. Patients with chronic abdominal pain were defined as those using strong analgesics, diagnosed with chronic pain, or referred to a specialized pain clinic. Patients with severe self-reported abdominal pain were defined as those reporting abdominal pain more than 2 times weekly within the last month. A total of 787 patients were followed for a median of 63 months. The prevalence of postoperative chronic abdominal pain was 11% and the prevalence of severe self-reported abdominal pain was 21%. Preoperative use of strong analgesics was a risk factor for chronic abdominal pain (OR, 2.26; 95% CI, 1.59-3.23) and severe self-reported abdominal pain (OR 2.82, 95% CI 1.64-4.84). Further risk factors for severe self-reported pain were unemployment or retirement (OR 1.80, 95% CI 1.09-2.93), postoperative complications (OR 2.75, 95% CI 1.44-5.22), and smoking (OR 1.80, 95% CI 1.09-2.96). One in 10 patients undergoing RYGB surgery developed chronic abdominal pain requiring strong analgesics, and one in five suffered from severe abdominal pain. Risk factors were preoperative use of strong analgesics, unemployment, postoperative complications, and smoking.

Su1586 - Prevalence of Anterior Abdominal Wall Pain in Patients Presenting to a Neurogastroenterology Clinic with Unexplained Chronic Abdominal Pain

Su1586 - Prevalence of Anterior Abdominal Wall Pain in Patients Presenting to a Neurogastroenterology Clinic with Unexplained Chronic Abdominal Pain

Initial experience of video capsule endoscopy at a tertiary center in Saudi Arabia.

Background/Aim:No prior experience with video capsule endoscopy (VCE) has been published from Saudi Arabia. In this study, we aim to report the first Saudi experience with VCE.Patients and Methods:A prospective study was conducted between March 2013 and September 2017 at King Abdulaziz Medical City, Riyadh, Saudi Arabia. Eligible patients underwent VCE and their data (age, sex, indication for VCE, type of obscure gastrointestinal bleeding [OGIB: overt vs occult], VCE findings, and complications) were recorded. Approval was obtained from the institutional ethics board before the study began and all patients provided verbal and signed consent for the procedure. The procedure was performed according to the established guidelines.Results:During the study period, a total 103 VCE procedures were performed on 96 patients. Overall, 60 participants (62.5%) were male (mean age, 58.8 years; range, 25–97 years) and 36 (37.5%) were female (mean age, 52.8 years; range, 18–78 years). The most frequent indication for VCE was OGIB (n = 91, 88.35%; overt, n = 46, 50.55%; occult, n = 45, 49.45%). Other indications were suspected Crohn's disease (n = 4, 3.88%), suspected complicated celiac disease (n = 4, 3.88%), and unexplained chronic abdominal pain (n = 4, 3.88%). The VCE results were categorized as incomplete (n = 2, 1.94%), poor-quality (n = 7; 6.8%), normal (n = 39, 37.86%), and abnormal (n = 55, 53.4%). The completion rate was 98.06% (n = 101), and the overall diagnostic yield was 53.4%. Of the 55 patients with abnormal VCE results, 43 (78.2%) had small bowel (SB) abnormalities and 12 (21.8%) had abnormalities in the proximal or distal gut. The most frequent SB abnormalities were angiodysplasia (n = 22, 40.0%) and tumors (n = 7, 12.7%).Conclusion:The diagnostic yield of VCE for Saudi patients with OGIB is comparable to that reported internationally; however, data for other VCE indications, including inflammatory bowel disease, are still lacking.

Undiagnosed pancreatic exocrine insufficiency and chronic pancreatitis in functional GI disorder patients with diarrhea or abdominal pain.

A previous UK study showed that 6.1% of patients with diarrhea-predominant irritable bowel syndrome (IBS-D) had evidence of severe pancreatic exocrine insufficiency (PEI), but these findings need replication. We aimed to identify the prevalence of PEI based on fecal elastase stool testing in consecutive outpatients presenting with chronic unexplained abdominal pain and/or diarrhea and/or IBS-D. Patients aged over 40years presenting to hospital outpatient clinics from six sites within Australia with unexplained abdominal pain and/or diarrhea for at least 3months and/or IBS-D were studied. Patients completed validated questionnaires and donated a stool sample in which elastase concentration was measured by ELISA. A concentration of <100mcg/g stool represented severe and <200mcg/g mild to moderate PEI. Patients whose fecal elastase was <200mcg/g underwent testing for pancreatic pathology with an endoscopic ultrasound or abdominal CT. Two hundred eighteen patients (mean age of 60years, 29.4% male) were studied. PEI was found in 4.6% (95% CI 2.2-8.3%) (n=10), with five patients (2.3% (95% CI 0.8-5.3%) having severe PEI. Only male sex and heavy alcohol use were significantly associated with abnormal versus normal pancreatic functioning. Of seven patients who underwent endoscopic ultrasound or CT, two had features indicative of chronic pancreatitis. One in 50 patients with IBS-D or otherwise unexplained abdominal pain or diarrhea have an abnormal fecal elastase, but unexpected pancreatic insufficiency was detected in only a minority of these. This study failed to confirm the high prevalence of PEI among patients with unexplained GI symptoms previously reported.

Unexplained Chronic Abdominal Pain Manifesting as Celiac Artery Compression Syndrome

Celiac artery compression syndrome (CACS), also known as median arcuate ligament syndrome, is a rare condition which causes chronic recurrent abdominal pain related to compression of the celiac artery by the median arcuate ligament with resultant ischemia. Clinical presentation involves the triad of upper abdominal pain, weight loss and epigastric bruit in examination. The diagnosis is one of exclusion. The purpose of this case report is to describe a common presentation of an infrequently described rare disorder in literature. A 28-year-old healthy female presented to the emergency department (ED) with recurrent progressively worsening post-prandial sharp right upper quadrant abdominal pain for the past four months. Her pain has been associated with a 10-pound weight loss and intermittent episodes of nausea and vomiting without any fever, chills, diarrhea, or loss of appetite. She reported to no improvement with use of antacids, antiemetics and analgesics. She previously underwent outpatient ultrasonography revealing gallstones and esophagogastroduodenoscopy (EGD) revealing mild gastritis. Examination, laboratory studies, repeat ultrasound and computerized tomography (CT) scan revealed no acute abnormalities, including no gallstones. Due to nature of her chronic pain to be postprandial, a duplex ultrasound was ordered, which revealed elevated systolic velocities of the celiac artery, suggesting celiac artery stenosis and subsequently confirmed with angiography. Patient underwent a laparoscopic celiac artery decompression with a median arcuate ligament resection release. Patient was discharged following an uneventful postoperative period during her hospitalization. CACS is a rare syndrome. The pathophysiology, while not completely understood, is believed to be celiac arterial compression by variations in median arcuate ligament position. Patients are typically asymptomatic as the incidence of attributable clinical symptoms is much lower than the imaging finding. However, we present a case of a patient with chronic post-prandial pain and weight loss, in the absence of any obvious etiology, found to have a rare diagnosis of median arcuate ligament compressing on the celiac artery. We encourage clinicians to consider celiac artery compression syndrome in patients with chronic abdominal pain without a clearly established etiology.

Remnant gastropathy due to bile reflux after Roux-en-Y gastric bypass: a unique cause of abdominal pain and successful treatment with ursodiol.

Chronic abdominal pain can occur after Roux-en-Y gastric bypass (RYGB), and can remain unexplained despite extensive investigation. Bile can pool in the gastric remnant and create a bile reflux gastropathy. The aim of this study was to assess gastric remnant findings in patients with RYGB and chronic abdominal pain of unclear etiology, and to determine the effectiveness of ursodiol therapy for patients with confirmed remnant gastropathy. All consecutive patients with RYGB and a diagnosis of chronic abdominal pain, and a negative diagnostic workup (including physical examination, routine laboratory work, cross-sectional imaging, and standard upper endoscopy), who underwent device-assisted enteroscopy for evaluation of the gastric remnant, were included. Pathology reports, treatments, and clinical follow-up were recorded. 28 post-RYGB patients (all female) with chronic abdominal pain and negative evaluation were included. Pooling of bile with gastric erythema was noted in 22/28 patients. All 22 patients with endoscopic erythema had pathology consistent with bile reflux chemical gastropathy. Of these patients, 12 were started on a proton pump inhibitor (PPI) alone, and 10 were started on ursodiol. Of the ursodiol group, 8/10 (80%) patients reported substantial improvement or resolution of abdominal pain at clinical follow-up. All three ursodiol patients with repeat endoscopic examination of the gastric remnant had endoscopic and histologic resolution of gastropathy. Of the PPI patients, 1/12 reported improvement in abdominal pain at clinical follow-up (p=0.002), and both patients with repeat endoscopic examination of the gastric remnant had persistent remnant gastropathy. Roux-en-Y gastric bypass patients with unexplained chronic pain, and biopsy-confirmed chemical gastropathy, had a significantly higher rate of abdominal pain resolution with ursodiol treatment compared to PPI. Remnant gastropathy due to bile reflux is a treatable cause of chronic abdominal pain in RYGB patients, and ursodiol should be considered for empiric treatment in RYGB patients with unexplained chronic abdominal pain.

The Nutcracker Syndrome as a Rare Cause of Chronic Abdominal Pain: A Case Report

Introduction: Renal vein entrapment, named nutcracker phenomenon, is a contraction of renal vein between abdominal aorta and superior mesenteric artery. Patients can be asymptomatic or clinically manifested, called nutcracker syndrome. Proteinuria, hematuria, flank pain, varicocele in males and pelvic congestion in females are reported in such patients. Case Presentation: The current report presented an eight-year-old girl with microscopic hematuria and chronic abdominal pain along with short review of anatomy, pathophysiology, clinical significance and management of this syndrome. Conclusions: The nutcracker syndrome should be differentiated from unexplained chronic abdominal pain.

Role of Diagnostic Laparoscopy in Unexplained Chronic Abdominal Pain

Introduction: Patients with chronic abdominal pain get repeated hospitalization. They fail to perform their duties continuously and thus become burdens for their families. These patients are occupying a good number of indoor beds with dilemmatous diagnosis. This indirectly creates pressure on health care facility and plays a notable negative role to our economy.Aim: To determine the usefulness of diagnostic laparoscopy for diagnosis and also to find out the therapeutic scope in unexplained abdominal pain.Method: This is a prospective cross-sectional observational study and was carried out in the Department of surgery, CMH, Dhaka over a period of 2 years from July 2008 to June 2010.Results: Among the study population, 8 (26.67%) patients underwent abdominal and pelvic operation in the past for various diseases. The duration of chronic abdomen pain in these patients was between 6 months to 24 months or more. Twenty five (83.5%) cases out of 30 were diagnosed. Postoperative band &amp; adhesions (28%), recurrent appendicitis (24%), endometriosis (16%), abdominal tuberculosis (16%) were the most frequently found etiologies of unexplained chronic abdominal pain in these patients. Eighteen (59.4%) patients underwent therapeutic procedure during Diagnostic Laparoscopy and biopsy was taken from 7 (23.1%) patients. Patients were provided treatment according to histopathology report. Patients were followed up for 2 years at Out Patient Department (OPD) at CMH. Around 75% cases became symptom free following therapy, 15% had short term minimal symptom for 6 months and persistent pain was present in small percent of patients (10%). 09 JAFMC Bangladesh. Vol 10, No 2 (December) 2014Conclusion: Laparoscopy is a safe diagnostic modality. It is useful to establish diagnosis or for exclusion of suspected abdominal pathology whenever chronic abdominal complaints remain undiagnosed. It also provides an opportunity for definitive treatment by laparoscopy or open surgery in unsuspected lesions.Journal of Armed Forces Medical College Bangladesh Vol.10(2) 2014

Small-bowel capsule endoscopy in patients with unexplained chronic abdominal pain: a systematic review

Patients frequently consult primary care physicians and gastroenterologists when experiencing chronic abdominal pain. Although its diagnostic efficacy in these settings is uncertain, small-bowel capsule endoscopy (SBCE) has been used to evaluate the unexplained reasons for abdominal pain. To evaluate the diagnostic yield of SBCE in patients with unexplained chronic abdominal pain. We performed a retrospective review of publications reporting the diagnostic yield of SBCE in patients with unexplained chronic abdominal pain and calculated the overall diagnostic yield. Two investigators independently searched studies from databases and analyzed the results. A total of 1520 patients from 21 studies were included. Small-bowel capsule endoscopy. Per-patient diagnostic yield, with 95% confidence intervals (CI), was evaluated by a random-effect model. Clear categorical analysis also was performed. The pooled diagnostic yield of SBCE in patients with unexplained chronic abdominal pain was 20.9% (95% CI, 15.9%-25.9%), with high heterogeneity (I(2)= 80.0%; P ＜ .001). Inflammatory lesions were the most common (78.3%) positive findings, followed by tumors (9.0%). Heterogeneity among studies, retrospective design, variable chronicity of abdominal pain, and different previous examinations before SBCE. SBCE provides a noninvasive diagnostic tool for patients with unexplained chronic abdominal pain, but the diagnostic yield is limited (20.9%). Among patients with positive findings, inflammatory lesions are the most common.

Fructose Intolerance/Malabsorption and Recurrent Abdominal Pain in Children

The purpose of the present study was to ascertain whether pediatric patients with chronic abdominal pain had concurrent fructose intolerance as determined by a standardized dose breath hydrogen test (BHT), and whether symptoms would improve with a low-fructose diet. The fructose BHT test was administered to patients evaluated in clinic with unexplained chronic abdominal pain alone or associated with constipation, gas or bloating, and/or diarrhea. The patients were given a standard dose of 1 g/kg fructose to maximum of 25 g. Hydrogen and methane were measured at 8 time points. The test was presumed positive if breath hydrogen exceeded 20 ppm above baseline. If positive, patients were given a dietitian-prescribed low-fructose diet. A total of 222 patients were part of the study. Ages ranged from 2 to 19 years with a mean of 10.5. BHT for fructose was performed in all of the patients and it was positive for fructose intolerance in 121 of 222 patients (54.5%). A total of 101 of 222 (45.5%) patients had negative BHT for fructose intolerance. All BHT-positive patients had a nutrition consult with a registered dietitian and were placed on a low-fructose diet. Using a standard pain scale for children, 93 of 121 patients (76.9%) reported resolution of symptoms on a low-fructose diet (P < 0.0001). Furthermore, 55 of 101 patients (54.4%) with negative BHT for fructose reported resolution of symptoms without a low-fructose diet (P = 0.37). Fructose intolerance/malabsorption is common in children with recurrent/functional abdominal pain and a low-fructose diet is an effective treatment.

English

BACKGROUND: Chronic idiopathic pain syndromes are among the most challenging and demanding conditions to treat across the whole age spectrum. Potentially it can be unrewarding for both the patients and the medical team. Patients with chronic abdominal pain (CAP) can undergo numerous diagnostic tests with failure to detect any structural or biochemical abnormality. This study was undertaken to assess the diagnostic and therapeutic role of laparoscopy in patients with unexplained chronic abdominal pain (UCAP). PATIENTS AND METHODS: Diagnostic laparoscopy was performed for 100 patients with UCAP not diagnosed by usual clinical examination and investigations. The pain in all patients was of unclear etiology despite all the investigative procedures. All patients were subjected to laparoscopic evaluation for their conditions. The findings and outcomes of the laparoscopy were recorded and analyzed. RESULTS: UCAP is common in females (62%) than in males. The most frequent laparoscopic findings detected were abdominal adhesions (30%), followed by pelvic inflammatory disease (25%), abdominal tuberculosis (12%), chronic appendicitis (8%), mesenteric lymphadenitis (5%) and diverticulosis (2%). In 18% of cases no identifiable cause could be found. Follow after 2 months revealed pain relief in 84% irrespective of cause of pain. CONCLUSION: Laparoscopy is an effective diagnostic and therapeutic modality in the management of patients with chronic abdominal pain.

Perfecting Video Capsule Endoscopy: Is There Need for Training?

See Learning Curve of Capsule Endoscopy by Korean Gut Image Study Group, Yun Jeong Lim, Young Sung Joo, et al., on page 633-636 The small bowel had been a no man's land, inaccessible by direct endoscopic examination until the new millennium. However, an innovative scientific advancement changed the perspectives of small bowel evaluation with the introduction of small bowel video capsule endoscopy (VCE) by GIVEN Imaging (Yoqneam, Israel) in 2001. We were introduced to the VCE during the Asian Pacific Digestive Week 2000 in Sydney, Australia, the first time in Asia, after which it was brought to Korea for clinical use in late 2001. VCE has revolutionized our ability to visualize the entire small bowel mucosa, and this modality is now valuable for evaluating small bowel diseases including obscure gastrointestinal bleeding, nonsteroidal anti-inflammatory drug-associated small bowel injury, Crohn and Celiac disease, back-wash ileitis of ulcerative colitis, unexplained malabsorption syndrome, small bowel tumors including cancer, inherited intestinal polyposis syndrome, chronic unexplained abdominal pain, protein-losing enteropathy, intestinal lymphangiectasia, eosinophilic enteritis, and other conditions involving the small bowel mucosa. The small intestine is no longer a deserted island to gastroenterologists.1-3 The capsule is swallowed and passively passes though the gastrointestinal tract. It is considerably less invasive and requires less technical training than conventional endoscopy and rarely causes complications during the procedure. Accurate interpretation of the images from VCE is important for gastroenterologists; therefore, quality control could be an issue if a qualified individual does not interpret the data. Accordingly, a gastroenterologist who is familiar with small bowel disease diagnosis with experience in performing small bowel endoscopy should interpret the data. Specific interpretation skills are needed for the images provided by VCE. Furthermore, a sharp eye is needed to recognize these rapidly-passing images from the VCE for accurate interpretation.4,5 Once the interpreter is familiar and has more experience with VCE, the time spent in VCE evaluation might be significant in increasing diagnostic accuracy.6,7 In this issue of Clinical Endoscopy, the Korean GUT Image Study Group and their colleagues investigated the learning curve of VCE for beginners.8 They postulated that although VCE has become an important tool for the diagnosis of small bowel diseases and can be performed without technical skill, the images should be interpreted by someone with experience in gastrointestinal mucosal image assessment. Therefore, they attempted to determine the number of cases needed by trainees to gain the necessary experience for attaining VCE competency. They found that the agreement rate of VCE diagnosis between the trainees and an expert increased as frequency of interpretation increased; the majority of mean κ coefficients were >0.60 and >0.80 after weeks 9 and 11, respectively (one case reviewed per week). They concluded that 10 cases of VCE are appropriate for trainees to attain an expert level competency. Similarly, several previous reports and guidelines have recommended 10 to 25 cases of VCE interpretation to ensure competence.2,7 This number is lower than that for endoscopic techniques such as colonoscopy, which usually require >200 cases to ensure competence. A prospective view shows several important developments in the field of VCE in clinical use in the near future. For instance, besides the second generation of VCE for the esophagus and colon, the next generation of VCEs such as those with double lenses, tissue diagnostic capabilities such as brushing cytology, fluid aspiration, drug delivery, and biopsy; those equipped with imaging mass spectroscopy; and confocal endomicroscopic VCE would be beneficial. The esophageal VCEs are already available, and compared to standard esophagoscopy, showed good sensitivity and specificity and were tolerated excellently; thus, adequate training for esophageal VCE is essential, as is similarly required for small intestinal VCE.9 Development of an externally operated capsule has also been attempted and a VCE containing magnets in one of the domes, thus allowing a joystick-like manipulation of the capsule, is being developed.10 This, however, may require a larger number of training cases to ensuring adequate technical skill. In conclusion, a reasonable number of cases are necessary for the trainees to perfect VCE, and this number will further increase as new generations of VCEs emerge.

Single‐balloon enteroscopy for small bowel diseases: Results from an initial experience at a single Chinese center

This study aimed to evaluate the performance, diagnostic yield, and safety of single-balloon enteroscopy (SBE) at a Chinese tertiary-care center. A total of 67 patients with suspected small bowel diseases who underwent SBE via the oral and/or anal routes from January 2009 to August 2011 were retrospectively analyzed. Data were extracted from electronic clinical and endoscopy records. The indications, SBE procedure time, diagnostic yield and complications were summarized and evaluated. A total of 42 SBE procedures through the oral route and 38 via the anal route were performed in these 67 patients. Patients were referred mainly for obscure gastrointestinal bleeding (OGIB) (40.3%) and abdominal pain (29.8%). The mean procedure duration was 68.1 min from the oral cavity and 77.5 min from the anus. The estimated depth of insertion was 247.6 ± 80.3 cm from the oral cavity and 131.1 ± 68.7 cm from the anus. The overall significant diagnostic yield was 68.7%. In patients with OGIB and unexplained chronic abdominal pain, the diagnostic yield was 74.1% and 50.0%, respectively. There were no significant complications. SBE appears to be a safe and effective method for the diagnosis and treatment of deep small bowel disease.

Medical Student Attitudes About Mental Illness: Does Medical-School Education Reduce Stigma?

Reducing stigma associated with mental illness is an important aim of medical education, yet evidence indicates that medical students' attitudes toward patients with mental health problems deteriorate as they progress through medical school. Authors examined medical students' attitudes to mental illness, as compared with attitudes toward other medical illness, and the influence of the number of years spent in medical school, as well as of several key socio-demographic, ethnic, and cultural variables. A group of 760 U.K. medical students completed a nationwide on-line survey examining their attitudes toward patients with five conditions (pneumonia, depression, psychotic symptoms, intravenous drug use, long-standing unexplained abdominal complaints), using the Medical Condition Regard Scale (MCRS). Students were also asked whether they had completed the psychiatry rotation or had personal experience of mental disorders themselves or among their friends or family members. They were also asked about their ethnic group (using U.K. national census categories), religious affiliation, and how important religion was in their lives. Independent-samples t-tests and one-way ANOVA were used to compare differences between groups on the MCRS. Students showed the highest regard for patients with pneumonia and lowest regard for patients with long-standing, unexplained abdominal complaints. Although attitudes toward pneumonia were more positive in fifth-year students than in first-year students, attitudes toward unexplained chronic abdominal pain were worse in fifth-year students than in first-year students. Personal experience of mental health treatment, or that among family and friends, were associated with less stigmatizing attitudes. Men showed more stigmatization than women for nearly all conditions; Chinese and South Asian students showed more stigmatizing attitudes toward delusions and hallucinations than their white British counterparts. Medical students in this survey showed the lowest regard for patients with unexplained abdominal pain, and these attitudes were worse in the most experienced medical students. Students' gender, culture and direct or indirect experience of mental illness influenced stigmatizing attitudes.

Lessons from Korean Capsule Endoscopy Multicenter Studies

Since its development, video capsule endoscopy (VCE) introduced a new area in the study of small bowel disease. We reviewed and discussed current issues from Korean capsule endoscopy multicenter studies. Main results are as follows: First, there was no significant difference in diagnostic yield according to the method of bowel preparation. Second, VCE represents a reliable and influential screening measure in patients with chronic unexplained abdominal pain and this technique could successfully alter the clinical course especially for patients with small bowel tumor. Third, the inter-observer variation in the expert group was lower than that in trainee group. Fourth, studies about the spontaneous capsule passage after retention showed 2.5% of retention rate and the size of lumen was an important factor of spontaneous passage. We need larger scale studies on the effect of bowel preparation methods on the diagnostic yield and further studies about the learning curve or unique capsule endoscopic findings for small intestinal diseases in Korean patients.