Nonspecific Abdominal Complaints Research Articles

Coccidioidal Peritonitis: A Review of 17 Cases.

Coccidioidomycosis is the second most common endemic fungal infection in the United States. Prior descriptions of coccidioidal peritonitis include only single cases. We describe 17 new cases previously unreported from healthcare institutions in California. The majority of cases presented with nonspecific abdominal complaints. PubMed and Google Scholar were searched for additional case series and only single case reports and reviews of single cases were found.The diagnosis was confirmed by culture or histopathology and/or serology in each patient. All patients were treated with anti-fungal therapy. This case series demonstrates that coccidioidal peritonitis may be asymptomatic or present with only subtle abdominal symptoms. In a minority of our patients, the diagnosis was established incidentally during surgery. Based on this series, the overall outcome of coccidioidal peritonitis is favorable with long-term triazole treatment. The term cure is not usually used in disseminated coccidioidal disease because of the risk of late relapse.

S3069 A Disease of Many Names: Sclerosing Mesenteritis

Introduction: Sclerosing mesenteritis (SM) refers to a spectrum of inflammatory disorders of the bowel mesentery adipose tissue whose pathogenesis is poorly understood, but has been associated with prior abdominal surgery, malignancy, and autoimmune disease. Patients can be asymptomatic or have non-specific abdominal complaints. Diagnosis can be made radiographically, but tissue is required for definitive evaluation. We present a case of severe constipation and abdominal distention due to sclerosing mesenteritis. Case Description/Methods: A 55-year-old male presented with two months of constipation, abdominal pain, and severe distention impairing ability to wear regular-sized clothing. Initial laboratory evaluation was normal, CTAP revealed no obstruction, and colonoscopy was normal. A trial of linaclotide briefly improved symptoms, however he re-presented to an ED with severe pain where CTAP showed an ovoid expansile region of mesenteric haziness within the central abdomen, encircling the mesenteric root vessels, reflecting SM with mass effect on the surrounding bowel (Figure 1A). PET/CT did not show evidence of malignancy. Laparoscopic mesenteric biopsy revealed areas of fat necrosis with associated lipid-laden macrophages; fibrosis was not identified, plasma cells were not prominent, and IgG4 positive cells were absent. Immunostains were negative. Laboratory evaluation was notable for: borderline ANA titer 1:80, positive fibrillarin antibody, and negative Scl-70. Systemic steroids were initiated with some improvement in symptoms, and tamoxifen was later added. Discussion: Sclerosing mesenteritis is a rare inflammatory, fibrotic disease of bowel mesentery fat tissue whose presentation ranges from asymptomatic to severe pain and bowel changes due to obstruction. While its exact pathogenesis is unclear, it may be related to prior surgery, underlying malignancy (eg. lymphoma) or an autoimmune etiology (due to association with conditions such as primary sclerosing cholangitis and retroperitoneal fibrosis). Diagnosis is challenging; CT scan is the most sensitive test, but histological analysis is necessary to evaluate for any underlying etiologies. There is no definitive therapy, but systemic steroids and antifibrotic agents such as tamoxifen have been studied; some patients require surgical resection.Figure 1.: CT-Abdomen and Pelvis: An ovoid expansile region of mesenteric haziness within the central abdomen, encircling the mesenteric root vessels, reflecting sclerosing mesenteritis with mass effect on the surrounding bowel loops.

Rare Pseudopapillary Neoplasm of the Pancreas: A 10-Year Experience

Introduction The solid pseudopapillary epithelial neoplasm (SPN) is a rare form of pancreatic neoplasm with an incidence of 2-3% of all pancreatic tumours. The recent increase in incidence is attributed to the increasing use of imaging techniques for nonspecific abdominal complaints. We report our institutional experience in the management of this tumour over the last decade. Method We retrospectively analyzed from a prospectively maintained database of patients from January 2011 to December 2020 who were operated upon for SPN. All the patients were followed till date. Results Of 479 patients operated on for various types of pancreatic tumours during this period, 15 (3.1%) had SPN. The mean age of presentation was 28 years with a female preponderance (12/15, 80%). The most common location was the body and tail of the pancreas (66%), and the mean size was 6.4 cm (2–15 cm). The tumour extent was defined as ‘borderline resectable' in 20% of cases. Distal pancreatectomy was done in 11 patients with spleen preservation in 3. R0, R1, and R2 resection were done in 12, 2, and 1 patient(s), respectively. The operative mortality was 6.7%. All the patients are doing well on follow-up. Conclusion SPN is a low-grade malignant tumour with a strong female predilection. Clinical manifestations have no specificity, imaging examination only contributes tumour location, and the final diagnosis rests on pathology. Surgery is the main modality of treatment and carries a good prognosis.

Gastrointestinal: Recurrent colic and the percutaneous endoscopic gastrojejunostomy.

A 71-year-old lady presented with long-standing colicky epigastric pain and vomiting on a background of advanced Parkinson's disease, treated by third-line medical therapy with duodopa administered by a percutaneous endoscopic gastrojejunostomy (PEG-J) tube. The PEG-J tube provided a steady and constant bioavailability of the drug by overcoming the slow and erratic gastric emptying commonly observed in patients with Parkinson's disease. On examination, the patient was afebrile and hemodynamically stable. She had a soft abdomen with focal epigastric tenderness without peritonism. Her biochemical investigations were unremarkable. Computed tomography scan demonstrated a long segment of thickened small bowel along the PEG-J tubing, with duplicated layers of bowel forming concentric rings consistent with a jejuno-jejunal intussusception (Fig. 1). She underwent a laparotomy demonstrating collapsed proximal loops of jejunum telescoping into distally dilated loops, with a palpable intraluminal mass. Following reduction of the intussusception, a longitudinal enterotomy was performed to deliver a phytobezoar formed over a PEG-J tube knot (Fig. 2). The PEG-J was otherwise well positioned, and no underlying anatomical abnormality was identified. Intussusception is classified according to site of origin: entero-enteric, ileocolic, or colocolic. The vast majority are entero-enteric with jejuno-jejunal intussusceptions being extremely uncommon. Intussusception in adults is almost always due to intraluminal tumors, and rarely are bezoars or PEG-J tubes cited as underlying causes. Unlike children, symptoms in adults are nonspecific, and therefore, abdominal computed tomography is the preferred imaging modality to obtain a diagnosis. Surgery remains the cornerstone of management for adults given the high incidence of intraluminal pathology. Phytobezoars can develop because of a variety of medical pathologies including gastrointestinal motility disorders. Most likely due to her underlying Parkinson's disease, and the rare complication of PEG-J tube knotting, this patient developed a bezoar acting as a lead point causing recurrent intussusception. This case represents an exceedingly rare presentation of a jejunal intussusception secondary to a bezoar forming over a knot in the PEG-J tubing. These images highlight this interesting case, demonstrating the importance of intussusception as a differential diagnosis in patients with nonspecific abdominal complaints, especially those predisposed to gastrointestinal dysmotility, to avoid delays in diagnosis.

Detection of unexpected coronavirus disease (COVID-19) involvement in lung bases on abdominal CT of patients presenting with abdominal symptoms

Aim: Coronavirus disease 2019 (COVID-19) can present with nonspecific abdominal symptoms. The aim of this study is to emphasize the importance of detecting lung basis involvement on abdominal computed tomography (CT) in patients hospitalized with abdominal complaints without known COVID-19 disease. Methods: CT images of 250 patients who underwent abdominopelvic CT scan due to various abdominal complaints were retrospectively evaluated. Inclusion criteria included patients presenting with primary abdominal complaints without respiratory symptoms, who had suspicious COVID-19 CT findings on lung basis. COVID-19 was not among the differential diagnoses of these patients at the time of admission. Results: Among 240 patients, twelve (8 females, 4 males, aged 30-69 years) had suspicious findings of COVID-19 on lung bases. Presenting complaints were abdominal pain (n=7), lack of appetite (n=5), diarrhea (n=7), vomiting (n=3), nausea (n=4) and gastric pain (n=1). Lung base CT findings included ground-glass opacities (100%), which were peribronchovascular (66.6%), bilateral (91.6%), peripheral (91.6%), or multifocal (58.3%). Cases were confirmed with laboratory testing. Conclusion: Considering that some patients present with nonspecific abdominal complaints, identifying the characteristic signs of COVID-19 incidentally in the visualized part of the lung basis on abdominal CT is important for early diagnosis, the protection of health professionals, and in reducing the spread of disease.

The Diagnosis and Therapy of Helicobacter pylori Infection in Hungary: Comparison of Strategies Applied by Family Physicians and Internists

Background Aims: Most patients with Helicobacter pylori infection are consulted for the first time by family physicians. We aimed to survey the adherence to the newest guidelines of the management of H. pylori infection in the primary and secondary care settings in Hungary. Methods: From a total of 793 physicians, 94 trainees in family medicine, 334 family physicians without and 195 with board certification in internal medicine, 87 internists, 78 family paediatricians were invited to take part in the study. Diagnostic and therapeutic attitudes towards H. pylori infection were compared by a voluntary and anonymous questionnaire. Results: Participants test for H. pylori infection in 92.8% of cases with a family history of peptic ulcer or 76.9% of gastric cancer, 68.9% of dyspepsia and 49.9% of non-specific abdominal complaints, before initiation of non-steroidal anti-inflammatory drug (NSAID; 17.3%) and antiplatelet treatment (14.5%), respectively. They confirm the success of eradication therapy in 88.1% mainly by urea breath test. Most of them initiate eradication therapy by themselves and only 22.4% refer their patients to a gastroenterologist. Clarithromycin-based standard triple therapy is the most preferred (62.1%) and only 3.7% choose quadruple combination with bismuth as first-line and 48.1% as second-line therapy. We found significant differences between groups with respect to the physicians’ own infection, localization of practice, and sources of information on H. pylori infection. Internists are more likely to clarify H. pylori status before the initiation of NSAID and antiplatelet therapies, initiate second-line therapies and use bismuth compared to the other groups. Family physicians with board certification in internal medicine are also prone to start eradication therapy and less prone to refer patients to a gastroenterologist. Family paediatricians prefer stool antigen determination, screen family members and prefer gastroenterologist consultation more often, and use bismuth less frequently than the other groups. Family physicians with previous infection check for H. pyloriinfection more frequently before the initiation of NSAID treatment and are more likely to use histology to detect H. pylori. Postgraduate trainings were the most popular source of information. Conclusion: The adherence to the recent recommendations of current guidelines is moderate. There is a need to increase adherence to current recommendations by family physicians and internists.

A rare case of primary gastric tuberculosis presenting as gastric outlet obstruction mimicking malignancy

<p>Gastric tuberculosis (TB), both primary and secondary is a rare condition. It is less common in immunocompetent individuals and in those without any antecedent pulmonary infection. The nonspecific complaints like epigastric pain, vomiting and weight loss may be confounding and lead to difficulty in diagnosis and differential diagnosis may include adenocarcinoma. We present a case of an immunocompetent male who presented with the above mentioned symptoms and on endoscopy showed an ulcerated region in the pyloric antrum with gastric outlet obstruction. A differential diagnosis of adenocarcinoma was suggested by the clinician. The endoscopic biopsy revealed granulomas and giant cells with no evidence of dysplasia. However, Ziehl-Neelson stain for acid fast bacilli was negative. The diagnosis of gastric tuberculosis was confirmed on Polymerase chain reaction (PCR) test for TB. A possibility of gastric tuberculosis should always be kept in mind in an endemic country like India with nonspecific abdominal complaints like epigastric pain, weight loss, vomiting etc. along with other differential diagnosis. A correct clinicopathological diagnosis would help in the appropriate treatment of the patient and would prevent unnecessary surgical excision.</p>

Superior Mesenteric Thrombosis as the Harbinger of Inflammatory Bowel Disease

Background: Superior Mesenteric vein thrombosis is a rare and potential catastrophic, complication of inflammatory bowel disease (IBD). The purpose of this case report is to describe an unusual presentation where a mesenteric venous thrombosis (MVT) seen on abdominal CT imaging was the heralding sign for the diagnosis of Crohn's Disease. IBD is considered a hypercoagulable state, and the presence of non-specific abdominal complaints and thrombosis on imaging should drive consideration of this etiology. Case presentation: A 58-year-old Caucasian male with no significant past medical history was admitted for evaluation of a one month history of worsening abdominal pain and a ten pound weight loss. Abdominal CT imaging showed a near complete thrombosis of his portal and mesenteric veins, along with wall thickening of the distal ileum and proximal large bowel. His infectious workup was negative. Macroscopic appearance of the luminal mucosa during a subsequent ileo-colonoscopy, along with the supportive histologic findings led to the confirmation of his suspected Crohn's Disease. MRI-enterography also revealed active penetrating Crohn's disease in his small bowel. His medical management consisted of combination therapy with Infliximab and Azathioprine, along with his anticoagulation. On follow-up, the patient reported resolution of his abdominal complaints, and repeat abdominal imaging demonstrated resolution of his MVT. Conclusion: Mesenteric vein thrombosis is a rare and well documented complication of the hypercoagulable nature of IBD. In the context of non-specific abdominal complaints of unclear etiology, it is imperative that GI physicians consider the presence of a MVT as a harbinger of undiagnosed IBD disease.

Visceral artery pseudoaneurysms: two case reports and a\xa0review of the literature

BackgroundVisceral artery pseudoaneurysms are relatively rare but have a high mortality rate in case of rupture. Their detection in the last decades is rising due to an increased use of computed tomography and angiography. However, due to the nonspecific nature of the clinical symptoms and signs, diagnosis is often delayed or missed. We describe two cases of patients presenting with nonspecific abdominal complaints and anemia leading to a diagnosis of visceral pseudoaneurysm. Both cases are successfully treated with a different endovascular intervention.Case presentationThe first case is a 67-year-old Caucasian man presenting with diffuse abdominal pain, vomiting, diarrhea, and weight loss. Digital angiography showed a complex pseudoaneurysm of the superior mesenteric artery. The patient was treated with stent placement and selective embolization of the afferent branches.The second patient is a 78-year-old Caucasian man with a history of chronic pancreatitis admitted with epigastric pain, rectal bleeding and melena. Angiography showed a pseudoaneurysm of the gastroduodenal artery. The patient was successfully treated with coil embolization.ConclusionsWe report two cases of visceral pseudoaneurysms and review the literature concerning etiology, presentation, diagnosis, and treatment.Visceral artery pseudoaneurysms should be considered in the differential diagnosis of a patient with nonspecific abdominal symptoms. Diagnosis is often made with computed tomography or computed tomography angiography but digital angiography remains the gold standard. Treatment options include surgical, endovascular or percutaneous interventions. The choice of treatment is case specific.

Benign Pancreatic Hyperenzymemia (Gullo Syndrome), Histamine Intolerance, and Carbohydrate Malabsorption

Benign pancreatic hyperenzymemia (Gullo syndrome) is characterized by a more than threefold increase of the pancreatic enzymes lipase and amylase in the absence of a pancreatic disease over a period of more than 1 year, with elevations and significant undulations of pancreatic enzyme serum concentrations occurring on a day-to-day basis for 5 consecutive days. Nonspecific abdominal complaints may be caused by carbohydrate and/or protein malabsorption. We report a patient with benign pancreatic hyperenzymemia with lactose and histamine malabsorption; the symptoms of gastrointestinal malabsorption were treated successfully with an individually tailored lactose- and histamine-free diet.

Pancreatic Cystic Lesions: Diagnostic, Management and Indications for Operation. Part I.

We notice an increasing frequency in the detection and evaluation of pancreatic cystic lesions (PCLs) over the last three decades. They show awide spectrum of imaging and clinical features. The diagnosis and discrimination of these lesions are very important because of the risk for concurrent or later development of malignancy. The main reason is the increased awareness of these lesions and the extensive use of cross-sectional imaging, an always improving technique (1). Commonly, PCLs are diagnosed incidentally during investigation for often unrelated and nonspecific abdominal complaints using state-of-the art abdominal imaging (CT, MRT). The term PCN denotes a histologically heterogeneous collection of neoplasms showing a wide spectrum of diagnoses, ranging from completely benign to potentially malignant, to carcinoma in situ, to frankly invasive and malignant (2,3). In 1978, Compagno and Oertel were the first to recognize the crucial distinction between the serous and the mucinous cystic neoplasms of the pancreas by explaining the importance of identifying the mucinous neoplasms because of their overt or latent malignant potential (4,5). Since then, the interest in PCLs increased markedly, especially so with the recognition of the importance and prevalence of intraductal papillary mucinous neoplasms (IPMNs). Nowadays, PCLs represent a common and often difficult challenge in clinical practice, because of the increase in their detection in asymptomatic patients and our still immature understanding of some aspects of their biologic behavior. Their important differences regarding their outcome and the fact of being increasingly often identified has put a special focus on these neoplasms by surgeons, pathologists, gastroenterologists, radiologists, and oncologists alike. Management of patients with PCNs can be challenging and varies considerably among the various subtypes of PCNs. Their treatment ranges from resection of malignant lesions, to resection and/or surveillance in the case of premalignant lesions, to simple observation in the case of benign or indolent lesions. Under these circumstances, the accurate classification of PCNs becomes crucial. Therapeutic decision making and classification rely mainly on the presenting symptoms and radiologic findings, often without actual histologic tissue. It is of extreme importance to identify suspicious features indicating potential or certain malignancy in order to select the appropriate treatment. The risk of overtreatment (unnecessary pancreatectomy) should he balanced carefully with the risk of under treatment (missing the opportunity to cure a potentially curable malignant or premalignant disease).

Malrotation with midgut volvulus and bowel gangrene in a 45-year-old man

Midgut volvulus due to intestinal malrotation is a rare occurrence in adult life. Malrotation is a congenital, developmental anomaly that results from an arrest of the physiological rotation of the gut through 270°. It is often thought that complications due to it, present themselves early during childhood and rarely occur among adults. However, a few cases have occurred and have been reported among adults. When it does occur in adults, it is often associated with catastrophic consequences. We present the case of a 45-year-old man with malrotation resulting in midgut volvulus. Our patient is a 45-year-old man, who presented with sudden onset of colicky abdominal pain and abdominal swelling of 24 h duration. He had been having recurrent abdominal pain since childhood. Physical examination revealed a patient in shock with markedly distended abdomen and anterior abdominal wall edema. Plain abdominal X-ray showed multiple air-fluid levels with thickened bowel outline. A diagnosis of intestinal obstruction was made. The patient was fully resuscitated and planned for emergency exploratory laparotomy under general anesthesia. Intraoperative findings revealed a 360° clockwise rotation of the small bowel around the mesenteric pedicle of the superior mesenteric artery and vein including about 350 cm of bowel gangrene. Resection and anastomosis were done. The early postoperative period was uneventful. However, he had anastomotic dehiscence on the 5th postoperative day and had to be reoperated but sadly he died 24 h later due to complications of anesthesia. Nonspecific recurrent abdominal complaints in adults of any age should raise suspicion of the possibility of a midgut malrotation or malfixation with or without intermittent volvulus. This case highlights the importance of early diagnosis and treatment.

ACE Inhibitor-Induced Angioedema of the Small Bowel

Angiotensin-converting enzyme (ACE) inhibitors are routinely prescribed for patients with hypertension, coronary artery disease (CAD), heart failure with systolic dysfunction, diabetes and chronic kidney disease (CKD). This category of medications is also the leading cause of drug-induced angioedema, occurring in 0.1% to 0.7% of patients. A 49-year-old female presented for evaluation of worsening abdominal pain with nausea, vomiting, and severe bloating, worsening over the next 12 months. Her past medical history included hypertension, depression, hiatal hernia, and an abdominal hysterectomy 20 years prior. Her only medication was Lisinopril 20 mg daily which she had been on for two years. Work up included an EGD and colonoscopy which showed no abnormalities, laboratory workup were all normal except for mildly elevated CRP of 21 and lipase of 73, and the only abnormality seen on imaging came from the CT which showed borderline thickening of distal small bowel loops. She continued to experience symptoms for a total of 15 months, at which point her ACE-inhibitor was stopped. Her symptoms resolved shortly afterwards and did not return, suggesting angioedema caused by her ACE inhibitor. This was likely seen on her initial abdominal CT as the cause for the borderline wall thickening of the small bowel loops. This case demonstrates the angioedema may be exclusive to the GI tract with no overt evidence of swelling elsewhere. We recommend consideration of ACE inhibitor-induced angioedema in any patient using ACE inhibitors presenting with non-specific abdominal complaints without evidence of other causes. Practice recommendations would include reviewing medications while considering ACE inhibitor induced angioedema, checking bradykinin levels which may be elevated with ACE inhibitor use, and a trial off of the ACE inhibitor to see if symptoms resolve. We also recommend discussion of angioedema, including GI symptoms, with patients prior to starting ACE inhibitors.Figure 1Figure 2

Gastric Sarcoidosis: A Difficult to Diagnose Rare Disease

Gastrointestinal sarcoidosis is a rare clinical entity. Diagnosis of isolated gastric sarcoidosis is difficult as it is usually asymptomatic; when symptomatic it presents with non-specific symptoms such as abdominal pain, nausea and vomiting. We here present a case of a 32-year-old black lady who presented with non-specific abdominal complaints; a diagnosis gastric sarcoidosis was established following endoscopic biopsy. Here symptoms resolved promptly with steroidal therapy as with most cases. Gastric sarcoidosis should be suspected in sarcoid patients who present with nonspecific abdominal complaints. This case serves as an important clinical reminder of the atypical manifestations of sarcoidosis.

Anomaly of the inferior vena cava and lactose malabsorption

SummaryPatients with anomalies of the inferior vena cava (IVC) are rare, are usually asymptomatic and this developmental anomaly is detected during radiologic evaluation of deep vein thrombosis or incidentally during abdominal radiologic evaluation. We report on time resolved three-dimensional magnetic resonance angiography (4D MRA) in a patient with congenital anomaly of the IVC and nonspecific abdominal complaints. 4D MRA is shown for evaluation and detailed diagnosis in vascular venous anatomy. However, due to continuing bloating and irregular bowel movements we investigated carbohydrate malabsorption and a lactose malabsorption was diagnosed. The nonspecific abdominal complaints in this patient with IVC anomaly were due to lactose malabsorption and were treated successfully with a lactose-free diet.@Supplementary material online: www.phlebologieonline.de: http://dx.doi.org/10.12687/phleb2285-1-2016

Mobile EMR Use for Epidemiological Surveillance on a Medical Service Trip in Honduras: A Pilot Study

Rationale: Medical treatment on short-term primary care medical service trips (MSTs) is generally symptom-based and supplemented by point-of-care testing. This pilot study contributes to the effective planning for such austere settings based on predicted symptomology. Objective: We aimed to prospectively document the epidemiology of patients seen during two low-resource clinics on a MST in Honduras and apply predefined case definitions adapted from guidelines used by international healthcare organizations (e.g. World Health Organization). Methods: An observational design was used to track the epidemiology during two clinics on an MST in Limon, Honduras in March 2015. The QuickChart mobile electronic medical record (EMR) application was piloted to document diagnoses according to predefined case definitions. Results: The most commonly diagnosed syndromes were upper respiratory complaints (20.19%), nonspecific abdominal complaints (20.19%), general pain (15.38%), hypertension (9.62%), pruritus (6.73%), and asthma/ COPD (4.81%). The case definitions accounted for 94% of all complaints and diagnoses on the brigade. Discussion: The distribution of common patient diagnoses on this MST was similar to that which had been reported elsewhere. The use of broader symptom-based case definitions for epidemiologic surveillance could also facilitate the syndromic management of patients seen on MSTs, and improve the consistency of treatment offered. Conclusion: Case definitions for common syndromes on primary care MSTs may be a feasible method of standardizing patient management. Preliminary use of the QuickChart EMR was acceptable for documentation of epidemiology in the field. Further study is necessary to investigate the reliability of syndromic diagnostic criteria between different clinicians and in a variety of MST settings.

Revisiting the potential signs of colorectal cancer on contrast-enhanced computed tomography without bowel preparation.

Colorectal cancer (CRC) is the second most common cause of cancer death in the US. Earlier detection can allow treatment with curative intent and improve prognosis. Optical and virtual colonoscopy are widely used in screening for colonic polyps and in the investigation of suspected CRC. However, contrast-enhanced computed tomography (CT) is still performed to investigate various non-specific abdominal complaints. Hence, a significant number of CRC are identified on contrast-enhanced CT without bowel preparation. We describe several signs, which when present in tandem, raise suspicion of CRC, and may warrant further investigation with optical colonoscopy. These include an intraluminal mass, eccentric or circumferential wall thickening >3 mm, focal wall enhancement, pericolic fat stranding, a cluster of >3 local lymph nodes, and enlarged lymph nodes >10 mm in short axis. Multiplanar evaluation of the bowel should be performed on all CT abdominal studies, including those without bowel preparation, to identify subtle features of CRC.

Carbohydrate malabsorption and carbohydrate-specific small intestinal bacterial overgrowth: diagnostic approach and overlap

Background: Carbohydrate malabsorption is a considerable problem in patients with non-specific abdominal complaints. While lactose malabsorption is well investigated, few epidemiologic data are available for fructose and sorbitol malabsorption or combined carbohydrate malabsorption syndromes. The purpose of this study was to assess the prevalence rates for primary lactose malabsorption, fructose and sorbitol malabsorption, and carbohydrate-specific small intestinal bacterial overgrowth (cs-SIBO) in an Austrian outpatient center. Additionally the diagnostic value of methane (CH4) measurements in carbohydrate malabsorption breath testing was evaluated.

Symptom clusters on primary care medical service trips in five regions in Latin America

Short-term primary care medical service trips organized by the North American non-governmental organizations (NGOs) serve many communities in Latin America that are poorly served by the national health system. This descriptive study contributes to the understanding of the epidemiology of patients seen on such low-resource trips. An analysis was conducted on epidemiologic data collected from anonymized electronic medical records on patients seen during 34 short-term medical service trips in five regions in Ecuador, Guatemala, and the Dominican Republic between April 2013 and April 2014. A total of 22,977 patients were assessed by North American clinicians (physicians, nurse practitioners, physician assistants) on primary care, low-resource medical service trips. The majority of patients were female (67.1%), and their average age was 36. The most common presenting symptoms in all regions were general pain, upper respiratory tract symptoms, skin disorders, eye irritation, dyspepsia, and nonspecific abdominal complaints; 71–78% of primary care complaints were easily aggregated into well-defined symptom clusters. The results suggest that guideline development for clinicians involved in these types of medical service trips should focus on management of the high-yield symptom clusters described by these data.

A Case of Adult Intussusception

Introduction: A 38-year-old Indian man with B-cell adult lymphocytic leukemia on chemotherapy was admitted with diarrhea, nausea, vomiting, and worsening abdominal pain. On presentation, a CT of his abdomen and pelvis found a mild colonic and small bowel distention. The patient was managed with IV fluid hydration and pain medication, and his symptoms improved. Three days later, the patient developed severe colicky abdominal pain. On abdominal exam, he had peri-umbilical tenderness with guarding. The patient was neutropenic and thrombocytopenic throughout his hospital stay, with a WBC of 500/μL and platelets of 16000/μL. Given his acute change in symptoms, another CT scan was performed, which showed small bowel intussusception. Surgery evaluated the patient, and given his neutropenia and thrombocytopenia, opted for conservative management. Five days later, the patient had a repeat CT scan that showed resolution of the intussusception and the patient was eventually discharged home and continued on his chemotherapy regimen. Intestinal invagination or intussusception is the leading cause of intestinal obstruction in children. Intussusception in adults accounts for only 5% of intussuception cases. Intussusception can present as acute, intermittent, cramping, and abdominal pain with nausea and vomiting; however, vague abdominal symptoms is a common presentation. While in children, 95% of cases are idiopathic, about 90% of causes of intussusception in adults are due to a distinct pathologic abnormality. In the small bowel, this consists of benign neoplasms, inflammatory lesions, and adhesions. Malignant lesions are found in only 30% of cases of intussusception in the small intestine, in contrast to 60% in colonic intussusception. Abdominal x-rays often show signs of intestinal obstruction, and can give information regarding the site of obstruction. CT has been reported to be the most useful diagnostic tool for the diagnosis of intussusception, with an accuracy of 58-100% with a finding of a homogenous mass that is target or sausage-shaped. The optimal management of adult intussusception is controversial, particularly in the small bowel. While resection of colonic intussusception is generally advocated due to the high percentage of associated malignancies, small bowel intussusception is less commonly due to malignancy, and thus intraoperative manual reduction with careful palpation of the intestinal wall might allow for limited bowel resection. Intussusception in adults is rare, and can present with non-specific abdominal complaints. Gastroenterologists should be aware of this rare condition for abdominal pain and the current treatment methods.