Lower Abdominal Cramping Research Articles

Uterine Rupture in Subsequent Pregnancy in a Patient with Previous Uterine Manipulator Associated Uterine Perforation

To report a case who experienced uterine rupture at 38th week of gestation and had a history of manipulator associated uterine rupture. A 25 years old primigravid woman at 38 weeks of gestation was referred to our hospital with the signs of active labor. Heavy lower abdominal cramps and signs of acute abdomen suggested uterine rupture and emergent cesarean section was performed. A 3 cm in size and circular in shape uterin rupture at the fundus that was imitative of enlarged previous manipulator associated rupture was observed. A manipulator associated uterine rupture should be repaired when encountered in reproductive ages in order to prevent a possible uterine perforation during subsequent pregnancy.

1929 Spots and Dots on the Skin and Stomach: Gastrointestinal Vasculitis

INTRODUCTION: Immunoglobulin A (IgA) vasculitis is often seen in the pediatric population but can also be seen in the adult cohort. The classic histopathological finding in IgA vasculitis is leukocytoclastic vasculitis (LCV), which is a neutrophilic inflammation in post-capillary venules. Classic signs of LCV include palpable purpura, small vessel involvement, and less likely but also extracutaneous manifestations. We present a unique case of a gastrointestinal (GI) manifestation of LCV with angiodysplasia in the stomach and duodenum. CASE DESCRIPTION/METHODS: This is a 66-year-old female with a history of hypertension, chronic kidney disease stage III, hypothyroidism, a recent diagnosis of LCV (Figure 1) two weeks prior that returns to the hospital with a complaint of watery diarrhea, bright red blood per rectum, lower abdominal cramping, and nausea. Her vitals were unremarkable and her laboratory studies revealed elevated blood urea nitrogen (BUN), acute kidney injury, mild anemia, and leukocytosis. A computed tomography (CT) scan of her abdomen demonstrated extensive wall thickening, multifocal periduodenal inflammation, and diffuse ileal wall thickening (Figure 2). An esophagogastroduodenoscopy (EGD) revealed ulcerative esophagitis, helicobacter pylori negative duodenal ulcers, and multiple non bleeding angiodysplasias in the stomach and duodenum that were cauterized (Figure 3). A colonoscopy revealed a tubular adenomatous polyp that was removed. The patient’s symptoms resolved and she did not demonstrate any further bleeding. Her hemoglobin stabilized and she was able to tolerate a regular diet on discharge. DISCUSSION: Abdominal pain and bloody diarrhea can have a milieu of differentials. This patient clearly demonstrated a vasculitic GI manifestations with bowel wall thickening and inflammation on imaging, elevated BUN, anemia, bloody diarrhea, and a history of LCV. Having a proper suspicion and confirming this with imaging, endoscopy, and biopsy is imperative for the diagnosis. Without a thorough history and physical, undiagnosed vasculitis can lead to fatal consequences such as gastrointestinal hemorrhage, perforation, or more rarely infarction.

2906 Significantly Increased Mucosal Eosinophils in Patients With Post-IBD IBS-D May Have a New Avenue

INTRODUCTION: Inflammatory bowel disease (IBD) patients in remission who present with irritable bowel syndrome with diarrhea (IBS-D) like symptoms pose a diagnostic and therapeutic dilemma that is called post-IBD-IBS-D. This syndrome was first reported by Isgar et al. who documented IBS-type symptoms in 33% of their patients with chronic ulcerative colitis (CUC) in remission in 1983. In their meta-analysis of 13 studies incorporating 1703 patients, Halpin and Ford in 2012 calculated a pooled prevalence for IBS symptoms among IBD subjects in remission of 35%. The post-IBD IBS-D represents a source of considerable stress, incurs morbidity and impairs quality of life of these patients. The etiology of this syndrome is unknown and may be multifactorial such as environmental, psychological and genetic components and possibly by gut microbiome. METHODS: We conducted a retrospective, single-center electronic medical record review of patients with history of IBD and IBS-D like symptoms. The demographic characteristics, type of IBD, colonoscopy and biopsy findings with GI-hypoallergenic diet and budesonide treatment were analyzed. RESULTS: We have found significantly increased mucosal eosinophils (>30-50 HPF in both side of the colon examined) in our patients with post- IBD IBS-D syndrome. In this study, 15 patients with CUC and 20 Crohn's disease (CD) patients with this syndrome were investigated and showed no clinical, serological, mucosal or microscopic IBD activity. These patients had non-bloody diarrhea (3-20x daily), lower abdominal cramps (90%), mild weight loss (4-6 lbs), and fecal incontinence (25%) who were placed on the GI-hypoallergenic diet and budesonide therapy. Sixty-seven percent of these 35 patients with post- IBD IBS-D responded well clinically to this management. Increased mucosal eosinophils in these patients may have eosinophilic colopathy that may be related to intestinal permeability disarray. The epithelium in these IBD patients who are in remission may have the production of pro-inflammatory cytokines by the eosinophils, especially IL-23 and IL-33. CONCLUSION: In summary, this is an exciting new findings that significantly increased mucosal eosinophils in our patients with post-IBD IBS-D may have a new avenue, eosinophilic colopathy. Interestingly, these patients have responded to the GI-hypoallergenic diet and budesonide therapy. Obviously, we need more patients in the near future with a longer follow-up and we hope that the other investigators may confirm our findings.

3058 An Unusual Case of Ischemic Colitis

INTRODUCTION: 48-year-old obese (BMI: 40) female, G0P0A0 LMP 1 year ago, with hypertension and hypercholesterolemia who presented with sudden left lower abdominal cramping pain associated with bloody diarrhea of one day duration. Denied associated systemic symptoms. She was using aspirin, simvastatin, metoprolol and had a progestin-only intrauterine device (IUD) placed 2 years ago. Physical examination with tenderness at the left lower quadrant. Digital rectal examination unremarkable. Laboratories with leukocytosis, lactatemia and positive fecal leukocytes. Abdominopelvic CT with IV contrast revealed left-sided peri-colonic and colonic inflammatory changes. CASE DESCRIPTION/METHODS: Gastroenterology service consulted due to non-specific colitis and there was concern for ischemic colitis as CT revealed inflammation in a watershed area. Colonoscopy showed edematous mucosa from the splenic flexure to the sigmoid colon associated with multiple large longitudinal ulcers. Biopsies revealed mucosal hemorrhage and neutrophil infiltration, suggestive of ischemic injury. Etiology of ischemia not clear given no obvious risk factors. Cardiovascular, myeloproliferative and prothrombotic workups were negative. The last piece of the puzzle rested on the IUD which was removed by the OBGYN service. A few days later, a follow up CT showed marked inflammation improvement. DISCUSSION: Ischemic colitis is generally considered a disease of the elderly. The most common causes include low-flow states due to cardiac dysfunction and hypovolemia. However, in younger patients, hypercoagulable states and drugs are the most common etiologies. In our patient, it was hard to initially find a reasonable cause of ischemia but, after excluding all etiologies, patient's IUD was the most likely cause of bowel ischemia. Combination contraceptives are a well-known risk factor for venous thromboembolism (VTE). However, few data have been published regarding whether the risk of VTE increases with progestin-only contraceptives (1). Mechanism is unclear, although it is hypothesized that protein concentrations influenced by hormones affect coagulation homeostasis (2). This risk appears to increase if additional VTE risk factors are present such in our patient with an elevated BMI (3). This rare case proves the importance of acquiring a detailed medical history including the use of contraceptives. Moreover, awareness of this diagnosis is essential so that early recognition can lead to individualized treatment decision and better patient's outcome.

1594 A Rare Case of Nivolumab-Induced Colitis

INTRODUCTION: Over the past decade immune-checkpoint inhibitors have been playing an increasing role in cancer treatment. One of the targets of these therapies is the Programmed Death (PD-1) protein; a protein that prevents T cells from recognizing and attacking inflamed tissues and cancer cells. Our reports describes a case in which a patient treated with nivolumab, a PD-1 inhibitor, presented with endoscopic findings characteristic of ulcerative colitis (UC). CASE DESCRIPTION/METHODS: Our case involves a 69-year-old male with past medical history of metastatic melanoma who presented with complaints of diarrhea rectal bleeding. Patient was on nivolumab 3 mg/kg every 2 weeks which was started 5 months ago. He reported lower abdominal cramping, bright rectal bleeding and diarrhea ongoing for 4 days. Physical examination was significant for moderate tenderness to palpation in lower abdomen. Initial abnormal laboratory results including hemoglobin of 11.2 g/dL otherwise unremarkable comprehensive metabolic panel. On computed tomography (CT) of abdomen and pelvis he was noted to have marked colitis involving the ascending, transverse and descending colon. All the following stool testing was negative for clostridium difficile, stool cultures camplyobacter, salmonella, shigella, ova and parasite. Patient was noted to have pancolitis on colonoscopy and pathology showed acute and chronic inflammation with superficial ulceration. Nivolumab was stopped and he was started on IV methylprednisolone 80 mg TID. Patient had little improvement over the next three days and hemoglobin decreased to 8.0 g/dL. Therefore he was given a dose of infliximab 5 mg/kg. His symptoms improved and he was in complete clinical remission soon after discharge. Patient was continued on oral prednisone 100 mg daily and instructed to taper slowly over the coming months. DISCUSSION: The PD-1 pathway will continue to be manipulated in future cancer treatments. Inhibition of PD-1 pathway in mice has resulted in various autoimmune diseases. In a safety profile study with 576 patients on nivolumab dosing of 3 mg/kg the most common adverse effect was noted to be a fatigue in 25% of patients. The incidence of grade 3 or 4 colitis was noted to be present in 0.7% of patients or 4 in total. Although the incidence of severe colitis may be low, infectious etiology must be ruled out prior to initiating immunosuppressive therapy. Patients with corticosteroid resistant colitis should have prompt initiation of infliximab therapy.

41-Year-Old Man With Fever and Bloody Diarrhea

41-Year-Old Man With Fever and Bloody Diarrhea

Management Placenta Percreta Succesfully With Total Abdominal Hysterectomy. A Case Review :

Background: Placenta accreta spectrum is one of the most serious complications of placenta previa and is frequently associated with severe obstetric hemorrhage usually necessitating hysterectomy. The management of placenta accrete spectrum will be discussed here and is essentially the same. The following discussion of management of placenta accreta spectrum applies to all depths of placental invasion. Incidence: In 1950 placentaaccreta was rare, occurring 1 in 30.000 deliveries in the United States. Duringbetween 2008 and 2011 in a cohort of over 115.000 deliveries in 25 hospitals in the United States reaching 1 in 731 deliveries. The marked increase has been attributed to the increasing prevalence of cesarean delivery in recent decades.The incidence of placenta accreta spectrum will also increase due to increasing of caesarean section rate. Case: Mrs.44 yo, G3P2 36-37weekslive, previous cesarean section 2 time,placenta previa totalis, placenta percreta. She’s comes with a chief complaint of lower abdominal cramps, patients regularly antenatal care at obstetrician. Ultrasound finding, a single fetus lives at transvers lie, dorso superior, corresponding to 36-37 weeks, placenta previa, placenta percreta (PAI:83%). This patient planned for elective conservative surgery management, due to cesarean section and or cesarean hysterectomy. Discussion:Surgical conservative management giving birth a baby without a placenta, followed by a hysterectomy, has been shown to reduce the risk of bleeding and the need for blood transfusion. The discovery of placenta accreta spectrum earlier when antenatal care, better birth planning than multidisciplinary science includedfetomaternal, gyneco-oncologist, anesthesiologist, thorac& cardiovascular surgeon, radiology intervention, intensivist - obstetric intensive care, urologist and neonatology can determine the success of handling cases of placenta accreta spectrum so as to reduce maternal, fetal morbidity and mortality. Conclusions: The discovery of placenta accreta spectrum earlier when antenatal care, planning delivery is better than multidisciplinary science. Management with corporal incisions away from placental implantation, giving birth baby without a placenta, followed by a hysterectomy, has been shown to reduce the risk of bleeding and the need for blood transfusion.

Grandmaʼs Home Remedy: A Hydrogen Peroxide Enema You Should Not Try at Home

Introduction Hydrogen peroxide (H2O2) is known to cause colonic injury. H2O2 enemas were a home remedy commonly used to treat meconium ileus and fecal impaction. H2O2 is caustic to the colon and this practice was largely abandoned. Today, self-induced chemical rectal injuries are rare. We are presenting a patient with chemical proctitis secondary to H2O2 enema. Presentation A 34-year-old female with history of constipation presented to the ED with hematochezia for 3 days. The patient had 6 days of constipation before administering an enema of 100ml 3% H2O2 on her grandmother's advice. Immediately after she evacuated the enema and a large, painfully firm bowel movement followed by abdominal pain, cramping and diarrhea with hematochezia. She denied symptoms of systemic infection. Vital signs: BP 96/47, HR 69, RR 20, O2 sat 100% Room Air, Temp 37.4° C. Physical exam revealed a benign abdomen and rectal exam with tenderness but no visual abnormality. CT abdomen/pelvis with oral and intravenous contrast revealed diffuse wall thickening involving the rectum, likely representing proctitis. Free intraperitoneal air and venous or arterial thrombi were not visualized. Hematochezia, lower abdominal cramping, tenesmus and rectal pain continued. Poison control was contacted and instructed to treat as a lower GI bleed unless imaging showed arterial or venous air emboli in rectum or portal venous system. Treatment included IV fluids, morphine and clear liquid diet. Flexible sigmoidoscopy revealed diffuse severe inflammation characterized by erosions, erythema and shallow ulcerations in the rectum up to 10cm. Findings consistent with proctitis secondary to chemical insult. Biopsies showed small fragments of colonic mucosa with chronic inflammation, focal ulcer and mild lamina propria expansion with architectural distortion. Patient improved during admission and discharged with instructions for Mesalamine suppository for 30 days and outpatient follow up.FigureFigureFigureDiscussion Proctitis is the most common complication resulting from H2O2 enema. The damage is caused when H2O2 meets the H2O2 catalase resulting in microbubbles of oxygen which force the blood out of the intramural vasculature resulting in corrosive, lipid peroxidation and oxygen free radial injury. H2O2 enema can result in colonic gangrene, gas embolization and fulminant colitis which can be fatal. Precaution must be taken with home remedies to ensure they will be safe and effective to prevent injury and fatality.

Psuedo Budd-Chiari Syndrome: An Uncommon Presentation of Very Common Disease

Introduction Alcoholic steatohepatitis and liver cirrhosis are the most common diagnosis in gastroenterology. Here we are writing about a different disease with a similar presentation to this common condition. Before considering this diagnostic possibility, it is important to rule out this common diagnosis. Case description A 25 year old female with Past Medical History of alcoholic liver cirrhosis presented with bright red bleeding per rectum of 2 days duration. She had approximately 15-20 bloody bowel movements, which were associated with lower abdominal cramps. In addition, she was feeling fatigued and occasionally dizzy. On physical examination, her vitals were normal except tachycardia. On examination, she looked pale. Few spider-angioma were present over face and body. Rest of the examination was non-contributory. Pertinent laboratory findings included Hemoglobin 3.6, WBC 16 thousand, INR 1.4, PT 15.2, APTT 29.1, T Bili 1.7, ALP 242, and Albumin 2.2. Initially, she was treated with 3U of Packed Red Blood Cells. Ultrasonography of abdomen with Doppler showed reverse flow within main, right and left portal veins and splenic veins. Left, middle and right hepatic veins were not well visualized. Diagnostic hepatic venography demonstrated decreased flow in the hepatic veins proximal to the Inferior Vena Cava confluence without any visible clot. Hepatic veins to Inferior Vena Cava pressure gradient was 5 mmHg. CT of Abdomen confirmed hepatomegaly, caudate lobe hypertrophy, features of cirrhosis and portal hypertension. She had an endoscopy showing grade 2 esophageal varices and type1 isolated gastric varices. As she continued to bleed, she underwent a colonoscopy which did not show any pathology. Eventually, she was considered for TIPS procedure for ongoing bleeding. Further, liver biopsy showed steatohepatitis with bridging fibrosis to early cirrhosis (Stage 3-4). And her hyper-coagulation panel and myeloproliferative workup were negative. After this extensive workup and management, she recovered well and was discharged in stable condition. Discussion Pseudo-Budd Chiari Syndrome is one of the rare diagnosis in the field of GI. Until this date only 4 cases have been described in the literature and only one case had decompensated liver cirrhosis. As radiological diagnosis may be false positive, arteriography and/or liver biopsy should always be considered. Possible reversibility with alcohol abstinence makes this clinical entity a must for physicians to know.Figure: US abdomen with color Doppler showing decreased flow in the hepatic veins proximal to the IVC.Figure: EGD showing esophageal varices.Figure: Normal colonoscopy.

An Unexpected, Rare and Potentially Dangerous Bump in the Road: Appendiceal Mucocele

Appendiceal mucocele is a rare pathologic entity with an incidence of 0.2% to 0.7% of all appendectomies.It is characterized by a distended appendix filled with mucoid material. These lesions are typically noted as incidental findings following radiographic or endoscopic evaluation. Patients are often asymptomatic or have nonspecific symptoms such as intermittent colicky abdominal pain. A 37-year-old man with no significant medical history presented with diarrhea and intermittent hematochezia for 4 months and associated mild lower abdominal cramping. Review of systems was negative for fevers, melena, weight loss, change in appetite, nausea, vomiting or early satiety. Physical exam revealed mild left lower quadrant discomfort with palpation. Laboratory studies were unremarkable. Stool studies including clostridium toxin and stool culture were negative. Subsequent colonoscopy showed erythematous mucosa in the rectum and recto-sigmoid colon as well as a submucosal lesion measuring 4 centimeters in the cecum (Fig 1). Biopsy revealed colonic mucosa with no pathologic abnormality. CT of the abdomen and pelvis with contrast showed a 10.6x3.0x3.2 cm tubular shaped mass that was appendiceal in origin, likely a mucocele with extension and intussusception into the ascending colon (Fig 2). The patient was treated with oral mesalamine and hydrocortisone enemas, which improved his symptoms. He was discharged home and had an outpatient uncomplicated laparoscopic appendectomy performed (Fig 3). Histology revealed a benign mucinous cystadenoma. Prompt resection of appendiceal mucocele is essential due to poor sensitivity of imaging studies to exclude a neoplastic component within the mucocele. Surgical approach is based on radiographic and endoscopic characterization. Laparoscopic or open appendectomy or hemicolectomy can be performed, with the more invasive approaches reserved for non-homogenous mucoceles with involvement of adjacent structures. Extreme care must be taken during resection to prevent seeding of the peritoneum with mucinous cells as this may lead to pseudomyxoma peritonei. Follow-up imaging in one year may be considered if the peritoneum was contaminated. Colonoscopy is essential in the pre-operative evaluation as approximately 20% of patients may have a concomitant colorectal adenocarcinoma. The course and prognosis depends on the histologic subtypes. Overall, survival is excellent (91-100%) following prompt resection of non-neoplastic appendiceal mucoceles.Figure: Colonoscopic image showing a 4 cm submucosal mass at the cecum.Figure: (A-Transverse cross-section, B-Coronal cross-section): Contrast-enhanced computed tomography scan showing a 10.6 x 3.0 x 3.2 cm tubular shaped mass (arrow) which measures just above fluid attenuation (26 Hounsfield units) and is believed to be appendiceal in origin, likely a mucocele. Also extension, intussusception into the ascending colon is noted.Figure: A- Intraoperative view of appendiceal mass during laparoscopic appendectomy. B- Excised specimen measuring approximately 10 am in largest diameter. C- Specimen transected to reveal gelatinous material.

Endometriosis: A Masquerade

KR is a 31 year-old woman with past medical history significant for an atrial septal defect who first presented in August 2016 with constant lower abdominal cramping with nausea, diarrhea, and vaginal bleeding during her usual menstrual cycle. The patient's menstrual cycles had been painful prior and she had been on an oral contraceptive (OCP) for 13 years though had stopped 3 months prior to presentation. Upon presentation, the patient's physical exam was notable for guarding and diffuse tenderness along both lower abdominal quadrants. The patient's pregnancy testing was negative and urinalysis unremarkable. Initial labs were notable only for mild leukocytosis and endovaginal ultrasound was unremarkable. On CT of the abdomen/pelvis, a right lower quadrant soft tissue mass was identified - perhaps an inflamed appendix. The plan was for non-operative management with pain control and antibiotics as the patient completed 7 days of Levaquin and Flagyl. Upon discharge and after completion of antibiotics, the patient felt better. However, in October, the patient presented once more with right lower quadrant abdominal pain - again during menses. Upon re-imaging, CT was unchanged and MRI demonstrated the same soft tissue mass at the ileocecal valve. Given no improvement in symptoms, the patient was planned for open ileocectomy and concurrent diagnostic laparoscopy. Upon laparoscopy, midline endometrial implants were noted scarring the cul-de-sac as well as the anterior bladder. A specimen obtained from the terminal ileum demonstrated full-thickness endometriosis and was, in fact, not a phlegmon. Endometriosis, affecting 10-15% of women of reproductive age, most frequently affects ovaries, the cul-de-sac, and the uterosacral ligaments. Under rarer circumstances, it has been noted to involve the GI tract. Notably, GI involvement by endometriosis has been noted to occur in 3-7% of menstruating women and ileal localization is even rarer - noted in 1-7% of all cases. Given the rarity of such a presentation, it is easy to commit diagnostic errors and consider more common pathologies such as abscesses. One such case discussed a similar diagnostic dilemma to ours in which the only means by which diagnosis of endometriosis was made was via histopathology. This information highlights the uniqueness of our case and adds perspective to a differential diagnosis we often consider when evaluating abdominal pain in the menstruating woman.Figure: CT imaging demonstrating RLQ mass in August 2016.Figure: CT imaging demonstrating RLQ mass in September 2016 upon repeat.Figure: MR imaging demonstrating RLQ mass upon second presentation in October 2016.

Time-Varying Effects of Signs and Symptoms on Pregnancy Loss

Although pregnancy loss affects one-third of pregnancies, the associated signs/symptoms have not been fully described. Given the dynamic nature of maternal physiologic adaptation to early pregnancy, we posited the relationships between signs/symptoms and subsequent loss would vary weekly. In a preconception cohort with daily follow-up, pregnancies were ascertained by self-administered sensitive home pregnancy tests on day of expected menses. We evaluated the effects of weekly time-varying signs/symptoms (including vaginal bleeding, lower abdominal cramping, and nausea and/or vomiting) on pregnancy loss <20 weeks in Cox proportional hazards models and calculated the week-specific probability of loss by the presence/absence of each sign/symptom. Of 341 pregnancies ascertained by home pregnancy test, 95 (28%) ended in loss. Relationships between signs/symptoms and loss varied across time since first positive pregnancy test. In the first week following pregnancy confirmation, when many losses occurred, bleeding [hazard ratio (HR) 8.7, 95% confidence interval (CI) 4.7, 16.0] and cramping (HR 1.8, 95% CI 1.2, 2.7) were associated with loss even when accompanied by nausea and/or vomiting (HR 5.2, 95% CI 2.6, 10.5). After the second week, new relationships emerged with nausea and/or vomiting inversely associated (HR range 0.6-0.3, all 95% CI upper bounds <1.00) and bleeding no longer associated with loss. Probabilities of loss of ranged from 78% (95% CI 59%, 96%) with bleeding present in week 1 to 8% (95% CI 5%, 12%) with nausea/vomiting present in week 5. Relationships between signs/symptoms and pregnancy loss vary in early pregnancy possibly reflecting maternal physiologic response.

Transient Descending Colo-Colonic Intussusception Due to a Large Fecaloma in an Adult: A Rare Case Report

Introduction: Adult intussusception represents 5% of all cases of intussusception and accounts for only 1%-5% of intestinal obstructions in adults, and 0.003-0.02% of all hospital admissions. Transient nonobstructing intussusception is frequently idiopathic and resolves spontaneously without any specific treatment. We describe a case of transient non-obstructing colo-colonic intussusception due to a large fecaloma. Case Report: 53 years old African American lady presented to Emergency Department with severe progressive lower abdominal cramping pain of 12 hours' duration. Abdominal examination was significant for bilateral lower abdominal tenderness with hypoactive bowel sounds. CT scan of the abdomen and pelvis demonstrated a “colocolonic intussusception” in the descending colon extending over a length of 3.5 cm. Subsequently she underwent an emergent colonoscopy for possible reduction of the intussusception. On colonoscopy, in mid-descending colon, solid stool was found which was packing the entire lumen and it was deemed not safe to advance further so procedure was aborted. Patient was managed conservatively in the absence of peritoneal signs and underwent a water-soluble rectal enema next day that showed a filling defect in the mid descending colon. She was subsequently prepped for an elective colonoscopy for further evaluation of colonic mucosa. Colonoscopy demonstrated the presence of a large stool ball (fecaloma) in left colon even after colonic prep with polyethylene glycol. She was started on round the clock laxatives and she continued to have multiple bowel movements in hospital and her abdominal pain subsided.Figure 1Figure 2Figure 3Discussion: The incidence of intussusception is low in adults, particularly in the descending colon, due to the anatomical attachment of the descending colon to the retroperitoneum. Primary or idiopathic intussusception is usually transient while secondary intussusception due to a lead point is usually permanent or recurrent. In our patient, Intussusception was secondary to a fecaloma that served as a lead point but was transient. Abdominal computed tomography (CT) is currently considered as the most sensitive radiologic method to confirm intussusception. 70 to 90% of adult cases of intussusception require definitive treatment and often surgical resection is the treatment of choice. However, an isolated episode of transient non-obstructive intussusception can be managed conservatively.

Signs and symptoms associated with early pregnancy loss: findings from a population-based preconception cohort.

What is the relationship between signs and symptoms of early pregnancy and pregnancy loss <20 weeks' gestation? Vaginal bleeding is associated with increased incidence of early pregnancy loss, with more severe bleeding and bleeding accompanied by lower abdominal cramping associated with greater incidence of loss; conversely, vomiting is associated with decreased incidence of early pregnancy loss, even in the setting of vaginal bleeding, while nausea alone is not. Two previous cohort studies with preconception enrollment suggested that bleeding is associated with loss while nausea is inversely associated with loss though these studies were limited by small study size and reporting after loss ascertainment. No prior preconception cohort study has examined multiple signs and symptoms in relation to pregnancy loss. Population-based preconception cohort of 501 couples discontinuing contraception to try for pregnancy in 16 counties in Michigan and Texas, USA. Participants were followed daily until positive home pregnancy test or 12 months of trying without an hCG pregnancy; women who became pregnant were followed daily from 2 to 7 weeks post-conception. Three hundred and forty-seven women had a positive home pregnancy test denoting hCG pregnancy. Three hundred and forty-one women remained after excluding ineligible pregnancies. Women recorded daily from 2 to 7 weeks post-conception their signs and symptoms, including vaginal bleeding (none, spotting, light, moderate and heavy), lower abdominal cramping, nausea and vomiting. Pregnancy losses were ascertained by a subsequent negative home pregnancy test, clinical confirmation or onset of menses, depending on gestational age at loss; time-to-loss was measured in days post-conception. Cumulative incidence functions and 95% confidence intervals (CIs) were constructed for each sign or symptom, and hazard ratios (HRs) and 95% CIs for presence compared with absence of signs or symptoms were estimated using Cox proportional hazard models. Women experienced lower abdominal cramping (85%), nausea (48%), vomiting (46%) and light/moderate/heavy vaginal bleeding (24%) during early pregnancy. Ninety-five (28%) women experienced a loss. Cumulative incidence of pregnancy loss varied by symptomatology: 19% for vomiting, 27% for lower abdominal cramping, 35% for nausea only, 52% for vaginal bleeding, 81% for vaginal bleeding with lower abdominal cramping. Incidence of pregnancy loss was increased among women with vaginal bleeding (HR: 3.62, 95% CI: 2.29-5.74) and among women with vaginal bleeding and lower abdominal cramping (HR: 5.03, 95% CI: 2.07-12.20). Incidence of pregnancy loss was decreased for women with vomiting (HR: 0.51, 95% CI: 0.30-0.86). In the setting of vaginal bleeding with lower abdominal cramping, vomiting reduced the incidence of pregnancy loss (HR: 0.24, 95% CI: 0.11-0.56). There were few losses beyond 14 weeks gestation; thus, the precision of our findings related to losses occurring after the first trimester is limited. By using sensitive home pregnancy tests, we are able to document and characterize the cumulative incidence of the earliest pregnancy losses, which constitute the majority of losses. The use of daily, prospective capture of signs and symptoms relative to ascertainment of pregnancy loss minimizes potential biases associated with reporting after rather than before a loss, which could potentially distort the relationship between signs and symptoms and pregnancy loss. The findings of our study suggest that it may be useful to develop prognostic models for pregnancy loss based on signs and symptoms. This study was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (contract numbers N01-HD-3-3355; N01-HD-3-3356; N01-HD-3-3358). The authors have no conflict of interest to declare.

A Case Report of IgG4-Related Autoimmune Cholangitis

Introduction: Autoimmune cholangitis is a biliary manifestation of IgG4 related disease (IgG4-RD) which can affect many organs and only rarely occurs in the absence of autoimmune pancreatitis. We present a case of IgG4 related cholangitis and discuss differential diagnosis and the role of clinical, laboratory and radiologic findings in establishing the diagnosis. Methods: N/A. Results: A 66 year old man was sent to the ED from his gastroenterologist's office for 3 weeks of jaundice, lower abdominal cramping, pale yellow stools 3-4 times daily, and dark orange urine. An outpatient abdominal ultrasound showed biliary obstruction and diffuse thickening of the common duct. In the ED, the patient appeared jaundiced but hemodynamically stable. Laboratory studies showed total bilirubin 11, direct bilirubin 8.9, AST 60, ALT 45, ALKP 265, amylase 65, and lipase 278. MRCP showed proximal and distal common bile duct strictures with intrahepatic and common duct dilation, circumferential biliary hyperenhancement, and bilateral striated heterogeneous nephrograms. The combination of these findings suggested the possibility of autoimmune cholangitis. ERCP was not initially performed due the location of the more proximal stricture and the possible risk of bacterial seeding of an obstructed biliary system. IgG4 levels were drawn and the patient was discharged on prednisone 40mg daily. Total IgG level and IgG4 returned elevated at 2641 and 459, respectively. Antinuclear antibody and anti-smooth muscle antibody were negative. After 2 weeks of steroid therapy, total bilirubin decreased to 2.4. Conclusion: IgG4 associated cholangitis was first described in the literature in 1995 and since then, there have been only a few case reports. IAC can further be classified into type 1 or 2; type 1 stenosis is exclusively located in the distal CBD, whereas type 2 stenosis is affects intra- and extrahepatic bile ducts. Diagnosis of biliary strictures with painless jaundice is also concerning for cholangiocarcinoma and pancreatic neoplasm, and these should be ruled out in the process of working up for an autoimmune cause. Steroid therapy is the initial treatment modality and many patients have good response. Changes in LFTs are best seen 5 and 10 days after therapy initiation and earlier initiation of therapy reduces risk of biliary cirrhosis. This case highlights the importance of laboratory and radiologic data in obtaining an accurate diagnosis.

Dietary and non-dietary correlates of gastrointestinal distress during the cycle and run of a triathlon

The purpose of this investigation was to assess whether pre-race dietary and non-dietary factors were associated with gastrointestinal (GI) distress during the cycle and run of a 70.3-mile triathlon. Fifty three participants recorded dietary details the day before and morning of the triathlon and retrospectively reported GI symptoms from the cycle and run. Occurrence and severity of nausea, regurgitation and fullness were combined into an upper GI (UGI) category, while lower abdominal cramps, flatulence and urge to defecate were combined into a lower GI (LGI) category. Spearman's rho coefficients were used to examine whether UGI and LGI were associated with: (1) pre-race diet (kilocalories, carbohydrate, fibre, fat, protein, caffeine); and (2) non-dietary factors (age, body mass index, experience, weight change, GI distress history, finishing time). Of non-dietary factors, only a history of GI distress showed significant associations with GI symptoms during the triathlon (ρ = .32–.36; P < .05). Morning kilocalorie (ρ = .28, P = .04) and carbohydrate (ρ = .36, P < .01) intakes were modestly, positively associated with UGI during the cycle, while morning caffeine intake (ρ = .30, P = .03) showed a modest positive association with LGI during the run. The associations between diet and GI distress variables remained significant after adjusting for non-dietary factors. Competitors of 70.3-mile triathlons should carefully weigh the benefits of higher race-morning energy, carbohydrate and caffeine intakes against their potential to increase GI distress.

Animal models of inflammatory bowel disease: a review.

Inflammatory bowel disease (IBD) represents a group of idiopathic chronic inflammatory intestinal conditions associated with various areas of the GI tract, including two types of inflammatory conditions, i.e., ulcerative colitis (UC) and Crohn's disease (CD). Both UC and CD are chronic inflammatory disorders of the intestine; in UC, inflammation starts in the rectum and generally extends proximally in a continuous manner through the entire colon. Bloody diarrhea, presence of blood and mucus mixed with stool, accompanied by lower abdominal cramping, are the characteristic symptoms of the disease. While in CD, inflammatory condition may affect any part of the GI tract from mouth to anus. It mainly causes abdominal pain, diarrhea, vomiting and weight loss. Although the basic etiology of IBD is unknown, there are several factors that may contribute to the pathogenesis of this disease, such as dysregulation of immune system or commensal bacteria, oxidative stress and inflammatory mediators. In order to understand these different etiological factors, a number of experimental models are available in the scientific research, including chemical-induced, spontaneous, genetically engineered and transgenic models. These models represent a major source of information about biological systems and are clinically relevant to the human IBD. Since there is less collective data available in one single article discussing about all these models, in this review an effort is made to study the outline of pathophysiology and various types of animal models used in the research study of IBD and other disease-related complications.

A Quality Improvement Program: Structured Exercise for the Outpatient Blood and Marrow Transplant Patient

s / Biol Blood Marrow Transplant 20 (2014) S297eS315 S308 practice. The manufacturers of the indwelling urinary catheter had no recommendations regarding irrigation via the sample collection port. Methods, Intervention, & Analysis: A literature search using key search terms included indwelling catheter, catheterassociated urinary tract infections, bone marrow transplant and oncology resulted in limited findings. Therefore, University Healthcare Consortium (UHC) and nursing staff were surveyed for current bladder irrigation practices. Expert clinicians were consulted regarding the practice of closed catheter irrigation. Retrospective case samples of bone marrow transplant patients (n1⁄4 46) with indwelling urinary catheters were screened for catheter usage and triggers for catheter removal. BMT patients were screened weekly for urinary catheter presence and rationale for removal. Our institution has a nurse-driven indwelling urinary catheter protocol to decrease urinary catheter usage and infection. Registered Nurses on the BMT units were surveyed via an online Survey Monkey survey regarding number on years on the BMT unit; nurses perception of number of patient complaints related to lower abdominal cramping, spasms, or pain while having an indwelling urinary catheter; how nurses and physicians treated this complaint and nurses’ awareness of the nurse-driven catheter removal policy. Findings & Interpretation: The majority of indwelling urinary catheters were removed upon expiration, followed by physician order, followed day of discharge or to extended care facility. Only a small number of urinary catheters were removed per the urinary catheter removal protocol. The literature search was limited but consistently recommended maintenance of a closed drainage system, and not routine catheter irrigation. Five United Healthcare Consortium hospitals responded to the survey; three used closed-system irrigation for urinary catheters. Approximately 25% of BMT nursing staff surveyed used closed catheter irrigation when patients complained of pain, cramping, etc. One unexpected finding from the staff survey was that greater than 70% of those surveyed were unaware of the protocol allowing nurses to remove a urinary catheter without a physician’s order. Discussion & Implications: This study impacts safe patient care. BMT have many factors that can potentially lead to catheter obstruction. Timely removal of catheters when no longer needed could eliminate the problem. Staff education was provided regarding the urinary catheter removal protocol. Weekly urinary catheter surveillance continues to monitor the urinary catheter usage and staff nurses’ adherence to the catheter removal protocol. The nurse driven urinary catheter removal have been posted on the unit. Urinary catheter system remains closed when irrigation is needed thereby reducing the risk of infection. Also, by not having to treat the patient’s painful spams with anti-spasmodic medications and pain medication, this decreases the patient’s fall risk and risk of injury. Future studies could examine the incidence of bladder spasms and the impact of closed drainage system irrigation on a multi-site larger BMT patient sample.

Intestinal obstruction due to migration of a thermometer from bladder to abdominal cavity: A case report

Intraperitoneal foreign bodies such as retained surgical instruments can cause intestinal obstruction. However, intestinal obstruction due to transmural migration of foreign bodies has rarely been reported. Here, we report a case of intestinal obstruction due to a clinical thermometer which migrated from the bladder into the abdominal cavity. A 45-year-old man was admitted to our hospital with a one-year history of recurrent lower abdominal cramps. Two days before admission, the abdominal cramps aggravated. Intestinal obstruction was confirmed with upright abdominal radiography and computerized tomography scan which showed dilation of the small intestines and a thermometer in the abdominal cavity. Then laparotomy was performed. A scar was observed at the fundus of the bladder and a thermometer was adhering to the small bowels and mesentery which resulted in intestinal obstruction. Abdominal cramps were eliminated and defecation and flatus recovered soon after removal of the thermometer.

When Nature Meets Nurture: Persistent Yersinia Infection

PRESENTATION When the patient’s symptoms are alleviated, it might seem that the causative infection has cleared. But that was not the case for a 62-year-old man with type 2 diabetes who presented with a 1-week history of constipation, lower abdominal cramping, rectal pressure, and hematochezia. In the emergency department, laboratory testing detected leukocytosis with a white blood cell count of 19 x 10 cells/mm and an elevated neutrophil count. Computed tomography (CT) of the patient’s abdomen and pelvis demonstrated marked inflammation of the rectal wall. He was admitted and underwent colonoscopy, which confirmed the presence of proctitis but was otherwise normal. Four days after admission, his stool culture grew pan-sensitive Yersinia enterocolitica. A diagnosis of Yersinia proctitis was made. Simple hepatic cysts seen on CT were felt to be incidental. The patient was prescribed a 5-day course of oral ciprofloxacin. He returned home and had complete symptom resolution. However, 3 weeks after completing treatment, he experienced gradual onset of severe pain that began in the right upper quadrant of the abdomen and radiated to his back and right shoulder. This was accompanied by malaise, intermittent fevers, and anorexia. He reported a 21-pound unintentional weight loss over the preceding 2 months. One month after discharge, he returned to the emergency department.