Development Of Abdominal Pain Research Articles

Molecular mechanisms of enteric neuropathies in high-fat diet feeding and diabetes.

Obesity and diabetes are associated with altered gastrointestinal function and with the development of abdominal pain, nausea, diarrhea, and constipation among other symptoms. The enteric nervous system (ENS) regulates gastrointestinal motility. Enteric neuropathies defined as damage or loss of enteric neurons can lead to motility disorders. Here, we review the molecular mechanisms that drive enteric neurodegeneration in diabetes and obesity, including signaling pathways leading to neuronal cell death, oxidative stress, and microbiota alteration. We also highlight potential approaches to treat enteric neuropathies including antioxidant therapy to prevent oxidative stress-induced damage and the use of stem cells.

Potential role of short-chain fatty acids in irritable bowel syndrome in overweight and obese individuals

Due to increasing prevalence of functional diseases of the colon in obese patients, the mechanisms by which the intestinal microbiota affects the development of symptoms of irritable bowel syndrome (IBS) in the setting of metabolic activity of adipose tissue should be investigated. The quantitative and qualitative changes in the pool of synthesized short-chain fatty acids, which have a multidirectional impact on the colonic motility is one of the key mechanisms by which the intestinal microbiota affects the occurrence and features of the course of irritable bowel syndrome. But as regards the issue of whether individual short-chain fatty acids have an impact on the severity of abdominal pain and characteristics of colonic motility dysfunction, it remains a subject of discussions. The study of the mechanisms of impact of short-chain fatty acids on the development and progression of obesity deserves special attention. Increased serum and faecal short-chain fatty acid levels in obese patients can either be a result of changes in the intestinal microflora composition associated with special eating habits and lifestyle, or have an independent effect on the development of obesity in individuals due to intestinal microflora composition disorders that have been already developed. Due to special features of the course of irritable bowel syndrome associated with overweight and obesity, studying the intestinal microbiota composition and the short-chain fatty acids produced by it in this cohort of IBS patients is of particular interest. This publication has been prepared to describe and systematize the possible mechanisms of impact of short-chain fatty acids on the development of abdominal pain and impaired colonic motility in IBS patients with overweight and obesity. The literature search was conducted in the databases Embase, PubMed and Google Scholar using the keywords “irritable bowel syndrome”, “obesity”, “short-chain fatty acids”, “gut microbiota”.

Lifestyle Factors Associated with Abdominal Pain in Quiescent Inflammatory Bowel Disease.

Lifestyle factors, including diet, exercise, substance use, and sexual activity, have been shown to influence risk of inflammation and complications in inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC). Little is known about their potential role in abdominal pain generation in IBD. We performed this study to evaluate for relationships between lifestyle factors and abdominal pain in quiescent IBD (QP-IBD). We performed a retrospective analysis utilizing data from our institution's IBD Natural History Registry (January 1, 2017-December 31, 2022). Endoscopic evaluation, concurrent laboratory studies and surveys were completed by participants. Demographic and clinical data were also abstracted. We identified 177 consecutive patients with quiescent disease (105 females:72 males; 121 with CD:56 with UC) for participation in this study, 93 (52.5%) had QP-IBD. Compared to patients with quiescent IBD without pain (QNP-IBD, patients with QP-IBD exhibited no significant differences in IBD type, location, severity or complication rate. Patients with QP-IBD were more likely to have anxiety/depression (55.9% vs. 32.1%, p = 0.002) and to use antidepressants/anxiolytics (49.5% vs. 21.4%, p < 0.001). They were also less likely to engage in exercise at least three times per week (39.8% vs. 54.8%, p = 0.05) or participate in sexual activity at least monthly (53.8% vs. 69.1%, p = 0.04). On logistic regression analysis, antidepressant and/or anxiolytic use was independently associated with QP-IBD [2.72(1.32-5.62)], while monthly sexual activity was inversely associated [0.48(0.24-0.96)]. Lifestyle factors, including the lack ofsexual activity and exercise, are significantly associated with QP-IBD. Further study is warranted to clarify the relationships between these factors and the development of abdominal pain in quiescent IBD.

Zonulin levels are associated with cortisol, dopamine, and serotonin levels in irritable bowel syndrome

Increase intestinal permeability is one of the main mechanisms for the development of irritable bowel syndrome (IBS). The role of stress and nutrition factors is considered as key modifiable factors contributing to the development of increase intestinal permeability. Purpose of the study: to evaluate the content of a marker of increased intestinal permeability (zonulin in feces) in relation to dietary habits, levels of anxiety and depression, levels of stress hormones (cortisol in saliva) and neurotransmitters (serotonin in blood serum, dopamine in blood plasma) in patients with IBS. Materials and methods: an open cohort prospective study was conducted with the inclusion of 263 patients with an established diagnosis of IBS. The control group consisted of 40 healthy volunteers. All individuals included in the study were assessed for diet and eating habits, the severity of anxiety and depression, including the level of specific anxiety in relation to gastrointestinal symptoms, and quality of life. In addition, the levels of cortisol in the morning and evening portions of saliva, serum serotonin, plasma dopamine and fecal zonulin were assessed. Results: in patients with IBS, the marker of increased intestinal permeability (zonulin in feces) is closely related to the nature of nutrition, anxiety levels, cortisol and serotonin secretion, and is also associated with the development of abdominal pain, diarrhea, and the severity of the disease.

Terminal ileitis and cytotoxic lesion of corpus callosum as the presenting features of Multisystem inflammatory syndrome in children (MIS-C): a case report

BackgroundMultisystem inflammatory syndrome in children (MIS-C) is a post-viral inflammatory vasculopathy characterized by persistent fever, multiorgan dysfunction, significant laboratory markers of inflammation, lack of an alternative diagnosis, and prior SARS-CoV-2 infection or exposure in children and adolescents. The most common early symptoms include a prolonged fever, as well as dermatologic, mucocutaneous, and gastrointestinal symptoms such abdominal pain, vomiting, and diarrhea.Case presentationWe present a pediatric patient with multisystem inflammatory syndrome with the development of abdominal pain and seizure who was found to have a circumferential wall thickening of the terminal ileum and ileocecal junction in abdominal CT scan. The brain MRI of the patient showed cytotoxic lesions of the corpus callosum (CLOCC) which had hypersignal intensity with a few diffusion restrictions in the splenium of the corpus callosum.ConclusionThis case is being reported to raise awareness of MIS-C presenting characteristics. Given the rising number of MIS-C patients and a lack of understanding regarding early diagnostic clinical characteristics and therapy, further research into clinical presentations, treatment, and outcomes is urgently needed.

Prevalence and mechanisms of abdominal pain development among athletes during exercise (results of an online survey)

Objective: to study the frequency and intensity of abdominal pain that occurs in professional and amateur athletes during endurance sports.Materials and methods: a single-stage cross-sectional study was carried out. A questionnaire was developed, the questionnaire included questions about the training process and about the presence and nature of abdominal pain. The intensity of abdominal pain have been assessed by a 7-point scale. The survey involved 107 people aged 18 to 29 years (average age 21.58 ± 2.86 years). Participation in the study was offered to students of the Siberian State University of Physical Culture and Sports (SibGUFC) and the Omsk Olympic Reserve School (UOR Omsk), who are professionally engaged in endurance sports (long-distance running, cycling and swimming), as well as amateur athletes who study at Omsk State Medical University (OmSMU). Among the respondents, 43 (40.19%) were men and 64 (59.81%) were women. 45 (42.68%) people are engaged in professional sports, and 62 (57.94%) amateur athletes were surveyed.Results: abdominal pain occurred in 37 (82.22%) professional athletes and 22 (83.87%) amateur athletes. When comparing the intensity of pain during training in professional athletes (3.75±2.32) and amateurs (2.5+-1.42), it was revealed that the intensity of pain is greater in professional athletes (p=0.004). 22 (59.46%) people among professionals and 34 (65.38%) among amateurs noted the localized nature of pain. The majority of the questionnaire participants in two groups indicated the stabbing nature of pain - 21 (56.76%) professionals, 28 (53.85%) amateur athletes. 26 (70.27%) and 34 (65.38%) respondents in the groups of professional and amateur athletes, respectively, note that they had to reduce the intensity of exercise.Conclusion: sports are associated with the development of abdominal pain among both amateur and professional athletes, which requires a reduction in the intensity of physical activity. The intensity of abdominal pain is higher in professional athletes engaged in endurance sports. The results obtained require the development of appropriate measures to prevent the development of abdominal pain in athletes during exercise.

Inhibition of Serine Proteases as a Novel Therapeutic Strategy for Abdominal Pain in IBS.

Serine proteases are heavily present in the gastrointestinal tract where they are essential in numerous physiological processes. An imbalance in the proteolytic activity is a central mechanism underlying abdominal pain in irritable bowel syndrome (IBS). Therefore, protease inhibitors are emerging as a promising therapeutic tool to manage abdominal pain in this functional gastrointestinal disorder. With this review, we provide an up-to-date overview of the implications of serine proteases in the development of abdominal pain in IBS, along with a critical assessment of the current developments and prospects of protease inhibitors as a therapeutic tool. In particular, we highlight the current knowledge gap concerning the identity of dysregulated serine proteases that are released by the rectal mucosa of IBS patients. Finally, we suggest a workflow with state-of-the-art techniques that will help address the knowledge gap, guiding future research towards the development of more effective and selective protease inhibitors to manage abdominal pain in IBS.

Iléon et encéphale, des sites métastatiques inhabituels pour un thymome

Thymomas are epithelial neoplasms of thymic origin, preferentially localized in the anterior mediastinum. Recurrences after surgery are uncommon and usually occur in the intrathoracic area. The occurrence of extra-thoracic metastases is an unusual phenomenon. Here we report the case of a 61-year-old man with no special medical history. He smoked about 40 pack years but stopped in 1999. Initially he presented with a mediastinal thymoma and underwent surgical resection. One year later the development of abdominal pain and bowel disorders lead to the discovery of an ileal ulcero-necrotic tumour. After surgical resection, histological examination revealed secondary thymoma. A few months later he underwent cerebral MRI because of neurological symptoms. This revealed a second metastasis located in the brain. Stereotactic radiotherapy led to an improvement. After more than one year of follow-up the patient developed a papillary thyroid carcinoma but there were no signs of recurrence of the thymoma. Extra-thoracic metastases of thymoma are exceptional but their existence should not be overlooked. Their management is not standardised because of lack of data in the literature. Though surgical excision in oligo-metastatic subjects is a frequently reported therapeutic option, a radiotherapeutic approach, particularly in cerebral situations, could be a credible alternative.

Differential diagnostics of abdominal pain in children

The causes and mechanisms of development of abdominal pain in children are analyzed and their differential characteristic is presented.

Retroperitoneal Schwannoma Presents as a Peripancreatic Cystic Structure: The Utility of EUS/FNA in the Diagnosis

Retroperitoneal schwannomas are extremely rare tumors that arise from the Schwann cell of the peripheral nerves. Patients are typically asymptomatic, however, large tumors may lead to the development of abdominal pain or obstructive symptoms. Herein we describe a case of a 57 year-old male with a known peripancreatic cystic mass presenting with new onset abdominal pain and a CT demonstrating a 40 × 42 mm peripancreatic cystic structure previously 17 × 20 mm. Endoscopic ultrasound with fine needle aspiration was performed and cytological examination revealed a peripheral nerve sheath tumor. The patient underwent uneventful laparoscopic resection. Analysis of the surgical specimen revealed a spindle cell tumor with positive S100, negative CD117/CD34 and pancytokeratin consistent with a schwannoma

Giant Hepatic Hemangioma Presenting as Gastric Outlet Obstruction

Hemangioma, a most frequently encountered primary benign tumor of the liver, is generally determined incidentally during the course of radiologic tests for other reasons. Most lesions are less than 3 cm and a significant proportion of patients are asymptomatic, although the size and location of the lesion in some patients may be associated with the onset of symptoms. Pressure on the stomach and duodenum of giant hemagiomas developing in the left lobe of the liver, in particular, may result in the development of abdominal pain, nausea, vomiting, and feeling bloated, which are characteristic of a gastric outlet obstruction. A 42-year-old man presented with findings of gastric outlet obstruction and weight loss as a result of a giant hepatic hemangioma.

Luminal hypertonicity and acidity modulate colorectal afferents and induce persistent visceral hypersensitivity

Carbohydrate malabsorption such as in lactose intolerance or enteric infection causes symptoms that include abdominal pain. Because this digestive disorder increases intracolonic osmolarity and acidity by accumulation of undigested carbohydrates and fermented products, we tested whether these two factors (hypertonicity and acidity) would modulate colorectal afferents in association with colorectal nociception and hypersensitivity. In mouse colorectum-pelvic nerve preparations in vitro, afferent activities were monitored after application of acidic hypertonic saline (AHS; pH 6.0, 800 mosM). In other experiments, AHS was instilled intracolonically to mice and behavioral responses to colorectal distension (CRD) measured. Application of AHS in vitro excited 80% of serosal and 42% of mechanically-insensitive colorectal afferents (MIAs), sensitizing a proportion of MIAs to become mechanically sensitive and reversibly inhibiting stretch-sensitive afferents. Acute intracolonic AHS significantly increased expression of the neuronal activation marker pERK in colon sensory neurons and augmented noxious CRD-induced behavioral responses. After three consecutive daily intracolonic AHS treatments, mice were hypersensitive to CRD 4-15 days after the first treatment. In complementary single fiber recordings in vitro, the proportion of serosal class afferents increased at day 4; the proportion of MIAs decreased, and muscular class stretch-sensitive afferents were sensitized at days 11-15 in mice receiving AHS. These results indicate that luminal hypertonicity and acidity, two outcomes of carbohydrate malabsorption, can induce colorectal hypersensitivity to distension by altering the excitability and relative proportions of colorectal afferents, suggesting the potential involvement of these factors in the development of abdominal pain.

Factors predictive of perforation during endoscopic submucosal dissection for the treatment of colorectal tumors

Although perforation of the colon is known as one of the main complications of endoscopic submucosal dissection (ESD) for colorectal tumor management, factors predictive of perforation have not been fully evaluated. This study aimed to determine the factors associated with perforation during colorectal ESD. Patients with colorectal tumors undergoing ESD were enrolled and their records were reviewed retrospectively. Age, sex, co-morbidity, medication history, procedure time, resection method, tumor size, location, gross morphology, the presence of fibrosis, and histologic findings were included as possible risk factors. In the cases where perforation had occurred, factors associated with the duration of hospitalization were analyzed. One hundred eight lesions in 108 patients were eligible for inclusion in the study (68 patients were male; mean patient age was 63.01 ± 10.71 years). Mean tumor size was 27.59 ± 10.10 mm (range: 8 - 53 mm). Laterally spreading tumor was the most common type (75 %), followed by the protruding type (25 %). Procedure time was 61.95 ± 41.90 minutes (range: 5 - 198 minutes). Complete en bloc resection was achieved for 85 lesions (78.7 %). Perforation occurred in 22 patients (20.4 %). Multivariate analysis confirmed that tumor size [odds ratio (OR): 1.084; 95 % confidence interval (CI): 1.015 - 1.158; P = 0.017] and the presence of fibrosis (OR: 4.551; 95 %CI: 1.092 - 18.960; P = 0.037) were independent risk factors for perforation. All cases of perforation were managed with nonsurgical treatment. Younger age and abdominal pain appeared to be related to prolonged hospitalization. Tumor size and fibrosis are important factors related to complications during colorectal ESD. Younger age and development of abdominal pain can predict the hospital course in patients with perforation after ESD.

Development of Abdominal Pain and IBS Following Gynecological Surgery: A Prospective, Controlled Study

Development of Abdominal Pain and IBS Following Gynecological Surgery: A Prospective, Controlled Study

Antiangiogenic therapy in metastatic prostate carcinoma complicated by cutaneous lupus erythematodes

A 61-year-old man was diagnosed with progressive hormone-refractory prostate cancer complicated by paraneoplastic subacute cutaneous lupus erythematodes (SCLE). The fi rst diagnosis of prostate carcinoma was made in March, 1995, by prostatectomy. Liver metastases were fi rst diagnosed in January, 2002. From April, 2002, to November, 2003, the patient received 75 mg/m docetaxel every 21 days. In November, 2003, the patient presented with well-demarcated, raised erythematous macules and plaques with pityriasic scales and hyperaesthesia on the arms and trunk (fi gure 1). Histopathological assessment confi rmed the clinical diagnosis of SCLE (fi gure 2). Direct immunofl uorescence of involved skin was positive with a band-like deposition of immunoglobulins (IgG, IgM) and C3. We recorded no serum antibodies against double stranded DNA, Ro-SSA, or La-SSB. At this time (November, 2003), on the development of abdominal pain, renewed staging by CT showed progression of the prostate cancer, particularly of the liver metastases. The patient was therefore started on capecitabine (two doses of 1 g/m per day for days 1–14, repeated every 3 weeks), plus 60 mg pioglitazone per day and 25 mg rofecoxib per day, similar to a non-randomised phase II study regimen for the treatment of various advanced cancers at our institution. After 3 weeks, capecitabine had to be discontinued because the patient developed severe hand and foot syndrome; it was therefore replaced by trofosfamide (three doses of 50 mg per day). After 3 months’ treatment, the concentration of prostatespecifi c-antigen stabilised and went into remission— 90·23 ng/mL at treatment initiation and 60·24 ng/mL after 3 months. Repeated ultrasound scans of a large reference metastasis in segment VIII of the liver showed control of tumour progression—from 5·2 × 4·4 × 4·3 cm to 4·0 × 4·0 × 3·7 cm (fi gure 3). Stable disease was sustained for a further 12 months. By 3 months, the paraneoplastic SCLE showed complete remission (fi gure 1). For topical supportive treatment the patient received 1% mometasone and 0·1% tacrolimus ointment. Strict sun protection was also recommended. No severe side-eff ects were recorded with this regimen. During treatment, the patient developed anaemia, which might have been treatment related. The haemoglobin concentration decreased slowly from 133 g/L to about 104 g/L (nadir) during the fi rst 3 months of treatment, at which point it levelled out for the rest of the observation period. Diff erential blood counts and other standard blood measures for liver and kidney (ie, aspartate aminotransferase, glutamate pyruvate transaminase, bilirubin, alkaline phosphatase, and creatinine concentrations) were normal. Overall, the patient had no subjective symptoms. In the search for new therapeutic strategies against advanced metastatic cancer, stroma-targeted angiostatic approaches combining metronomic chemotherapy (daily long-term application of low non-toxic doses) with biomodulating drugs seem to be promising alternatives to classic chemotherapy that applies cycles of maximum tolerated doses. Specifi cally, daily low-dose metronomic scheduling of chemotherapy has antiangiogenic stromaeff ects that can control well-advanced, chemoresistant tumours of quite diff erent histogenesis even for long periods of time. Furthermore, metronomic dosing can be complemented synergistically by combination with biomodulators such as cyclo-oxygenase-2 inhibitors (eg, rofecoxib) or peroxisome proliferator activated receptor (PPAR) γ agonists (eg, pioglitazone). These substances not only have anti-infl ammatory eff ects, but also contribute to angiostasis and direct induction of apoptosis in tumour cells. They can also induce immunoaugmentive eff ects. We have found that this Lancet Oncol 2006; 7: 695–97

Appendicitis among liver transplant recipients

Appendicitis among liver transplant recipients has not been described in the current literature. We report 8 recipients who experienced appendicitis three weeks to 181 months after liver transplantation (LT). Initial presenting findings differed from the nonimmunosuppressed population in that a majority of the patients did not have leukocytosis (>10,000 cells/mm3). Four patients experienced perforation, three of whom presented three days after the development of abdominal pain. All patients recovered after surgery without untoward sequela.

Endoscopic Diagnosis and Treatment of Small Intestinal Diseases Using the Double-Balloon Endoscopy

Background: A new insertion method of enteroscopy “the double-balloon method” was devised and a prototype of the system was developed in corporation with Fuji Photo Optical Incorporated Company. The aim of this study was to evaluate the usefulness of the new system of the double-balloon endoscopy in the diagnosis and treatment of small intestinal disorders. Methods: For 99 patients, 140 enteroscopies were performed using the Fujinon double-balloon system between September 2000 and October 2003. Assessed were the insertion rate to the small intestine, the success rate of total endoscopic examinations of the small intestine, complication rates, diagnostic yields and therapeutic capabilities. Results: Endoscopic observation of the jejunum with insertion beyond the ligament of Treitz was possible in all 73 cases of oral insertion. Endoscopic observation of the ileum with insertion beyond the ileocecal valve was also possible in all 67 cases. The average depth of insertion was about 1/2 to 2/3 of the entire small bowel for either approach, and an endoscopic observation of the entire small bowel was possible in 16 cases out of 19 trials (84 %) of total enteroscopy by combining both approaches. Diagnostic yields of the procedure according to the indications were as follows. Bleeding source was confirmed in 39 cases out of 51 GI bleeding cases, scrutiny of strictures was possible in 18 cases out of 20 cases with suspected strictures, and a tumor was confirmed endoscopically in 7 out of 8 cases with suspected small intestinal tumors. Among the 140 procedures, two complications were experienced. One patient underwent surgical repair because masked perforations due to chemotherapy of the small intestinal lymphoma became obvious after the enteroscopy. The other patient had exacerbation of the activity of Crohn's disease with the development of abdominal pain and fever after the procedure, which could be treated conservatively. Endoscopic therapies in the small intestine such as hemostasis with electrocoagulation (12 cases), polypectomy (1 case) and balloon dilation (3 cases) were performed safely using this system. Conclusions: Enteroscopic insertion using the double-balloon method has a high success rate of intubation into the deep small intestine. This method enabled the total enteroscopy in as high as 84% of cases by combining both the oral and anal approaches. The double-balloon enteroscopy is proven to be a safe and useful method with a high diagnostic yield and therapeutic capabilities.

Ileal Perforation Caused by Cytomegalovirus Infection in a Critically Ill Adult

Cytomegalovirus (CMV) infection of the gastrointestinal (GI) tract is common and is most often seen in patients with acquired immunodeficiency syndrome (AIDS), inflammatory bowel disease, or those receiving immunosuppressive therapy. CMV infection of the small bowel accounts for only 4.3% of all CMV infections of the GI tract. Isolated cases of small bowel perforation due to CMV have been reported in AIDS patients, and all but one patient has died. This article reports the first case of an ileal perforation due to transfusion-associated CMV infection in a critically-injured non-AIDS patient. Immediate surgical resection and antiviral therapy led to complete recovery. The development of abdominal pain, fever, watery diarrhea, and GI bleeding in a critically ill patient should prompt the clinician to consider the diagnosis of CMV enteritis. If standard stool pathogens and Clostridium difficile toxin studies are nondiagnostic, endoscopic evaluation and CMV serology should be obtained. If CMV infection is confirmed, ganciclovir therapy should be initiated without delay. If bowel perforation occurs. prompt surgical resection is indicated. A heightened level of suspicion for CMV infection in multiply injured trauma victims and other critically ill patients, with earlier recognition of potential small bowel involvement, can hopefully decrease the incidence of bowel perforation, which is usually a fatal event.

How safe is endoscopic sphincter of Oddi manometry?

The safety of endoscopic manometry of the sphincter of Oddi was evaluated in a prospective survey of 158 consecutive procedures in 126 patients with either unexplained pain after cholecystectomy or idiopathic recurrent pancreatitis. The only complication was that of pancreatitis which was defined as the development of abdominal pain in association with a plasma amylase above the reference range. This occurred in 13 patients (8%) and was more frequent (P = 0.001) when the indication for the procedure was idiopathic recurrent pancreatitis (29%) than unexplained pain (6%). Pancreatitis was also more frequent (P = 0.02) in patients with abnormal manometry (14%) than in those with normal manometry (3%) and occurred at highest frequency (50%) in a subgroup of patients with idiopathic recurrent pancreatitis and sphincter stenosis (high sphincter basal pressure). All episodes of pancreatitis were mild with a median increase in hospital stay of 2 days; no patients died. The risk of pancreatitis after endoscopic manometry is relatively low but increases in patients with abnormal sphincter manometry, particularly those with idiopathic recurrent pancreatitis.

Anticoagulants and Abdominal Pain

The development of abdominal pain in the patient receiving anticoagulants, especially with a documented drop in hematocrit levels, almost certainly indicates a major hemorrhage. If loss of blood from the GI tract is not documented, some form of internal bleeding must have occurred. Unfortunately, the site of the bleeding is frequently unclear. Even small hemorrhages in critical locations (eg, the adrenal gland) can have serious consequences. In the obese patient, a rectus sheath hematoma may remain hidden at the time of repeated physical examinations. Generally, the cause of a mass palpated or perhaps demonstrated by conventional radiological studies cannot be diagnosed accurately. Computed tomography can demonstrate the size and location of the mass and its relation to normal intra-abdominal structures. By careful evaluation of the attenuation coefficient, it is possible to establish the definitive diagnosis of hemorrhage. Should the attenuation value of a mass be insufficiently high to diagnose hemorrhage conclusively on the initial scan, serial scans demonstrating a decrease in size and/or attenuation of the mass confirm the diagnosis of hemorrhage. In our opinion a negative CT examination is a reliable indicator that such a bleeding complication has not occurred.