Nonspecific Abdominal Symptoms Research Articles

An ovarian torsion in a 2-year-old girl: a case report

BackgroundAbdominal pain is one of the most common complaints by patients in the emergency department. Diarrhea, constipation, and urinary tract infection are the commonest etiologies among these patients, but there are surgical emergencies, such as appendicitis and volvulus of the intestine, which are less common. Torsion of the ovary is rarer than all of the above conditions. Ovarian torsion occurs following the twisting of the ovary on its ligamentous attachment, possibly with a cyst, leading to the impediment of blood flow. Prompt diagnosis with a high clinical suspicion is essential to salvage the ovaries and to prevent complications, including death.Case presentationHere, we present a case of ovarian torsion in a 2-year-old Sri Lankan girl who presented with nonspecific abdominal symptoms after being symptomatically treated twice by her general practitioners for 3 days. Following biochemical and radiological investigations, she was diagnosed with a twisted necrotic ovarian torsion and underwent laparoscopic right-sided oophorectomy.ConclusionsFinding the etiology of a child with abdominal pain is challenging, especially because of the limited history, examination findings, the difficulty in carrying out radiological investigations, and the poor specificity of the results compared with adults. This is a case presentation and a brief discussion about the dilemmas and difficulties in the diagnosis and treatment of ovarian torsion in young children.

Epigastric pain associated with herpes esophagitis: case report

BackgroundHerpes esophagitis is uncommon disease caused by Herpes simplex virus (HSV). While the disease most often occurs in immunocompromised patients, including post-chemotherapy, immunosuppression with organ transplants, and in AIDS, Herpes esophagitis can also occur in immunocompetent individuals.Case presentationWe report a case of herpes esophagitis in a 72 year- old woman who was presumed to be immunocompromised following prolonged radiotherapy and chemotherapy for lymphoma. Her main symptom was epigastric pain.Upper endoscopy showed multiple rounded ulcers in lower esophagus. The diagnosis was confirmed histologically by multiple biopsies. The patient received Valacyclovir for 2 weeks and started to get better within 3 days of treatment.ConclusionAlthough there are few published cases of Herpes esophagitis disease in the medical literature, we recommend that this disease should be considered as one of the differential diagnoses when assessing immuno-compromised patients presenting with non-specific abdominal symptoms.

An Autopsy Case of Acute Pancreatitis Caused by Cholesterol Crystal Embolization.

Cholesterol crystal embolization (CCE) shows a poor prognosis and it can cause ischemic organ damage due to a cholesterol embolism from atherosclerotic lesions in large blood vessels. Such an embolism mainly affects the kidneys and skin, although cases involving digestive organs have also been reported. We encountered an autopsy case of CCE with damage mainly to the digestive organs, including the pancreas. The patient had non-specific abdominal symptoms or image findings. Symptomatic therapy failed to save him. CCE can involve the digestive organs, and so must be differentiated from abdominal pathologies. Moreover, conventional treatments may be ineffective, and new treatments might thus be necessary.

Small Intestinal Bacterial Overgrowth: Clinical Presentation in Patients with Roux-en-Y Gastric Bypass.

Small intestinal bacterial overgrowth (SIBO) is defined by an increased number of bacteria measured via exhaled hydrogen and/or methane gas following the ingestion of glucose. This condition is prevalent following abdominal surgery, including Roux-en-Y gastric bypass (RYGB), and associated with a variety of non-specific abdominal symptoms, often requiring an extensive diagnostic work-up. To assess the frequency that individuals with RYGB anatomy are diagnosed with SIBO and if they are more likely to report specific gastrointestinal (GI) symptoms compared to individuals with native anatomy. This large matched cohort study evaluated patients with GI symptoms who underwent a glucose breath test (GBT) for SIBO evaluation, utilizing 1:2 matching between RYGB and native anatomy. Patients with positive GBT were included in univariate and multivariate analyses to distinguish the presence of ten specific GI symptoms between RYGB and native anatomy. A total of 17,973 patients were included, where 271 patients with RYGB were matched to 573 patients with native anatomy that underwent GBT. Patients with RYGB anatomy and a positive GBT (199; 73.4%) as compared to those with native anatomy and a positive GBT (209; 36%) more often reported nausea, vomiting, bloating, and diarrhea. There were no differences between the two groups in the report of heartburn, regurgitation, chest pain, gas, or constipation. SIBO is common in patients with RYGB and more commonly report nausea, vomiting, bloating, and diarrhea. The results of this study suggest that the report of these symptoms in RYGB should prompt early evaluation for SIBO.

S2893 A Common Malignant or a Rare Benign? Diagnostic Dilemma: A Case Report

INTRODUCTION: Sclerosing mesenteritis (SM) is a rare benign disease of unknown etiology. About 15 % of patients are asymptomatic or have minimal symptoms. It is usually benign in its clinical course, however, SM can mimic certain malignant disorders, such as lymphoma. It poses a diagnostic challenge for clinicians as it can be mistaken for malignancy and vice versa. In our case, the patient diagnosis of lymphoma was obscured by the picture of sclerosing mesenteritis, especially with negative multiple lymph node biopsies. CASE DESCRIPTION/METHODS: A 31 years old Caucasian male with a medical history of PTSD and a history of intussusception of colon requiring large and small bowel resection at age 14 who presented with severe generalized abdominal pain. CT abdomen ruled out any acute abdominal process, though enlarged mesenteric and retroperitoneal lymph nodes worrisome for lymphoma were noted. No history of weight loss, night sweats, or B symptoms. Laboratory investigations demonstrate transaminitis, otherwise, they are relatively unremarkable. CT chest and neck were significant for cervical chain lymphadenopathy. EGD showed gastritis and colonoscopy showed sigmoid colitis. Given his prior laparotomy for intussusception, the patient had retroperitoneal LN biopsy by IR and the pathology was reactive lymph nodes. Excisional cervical LN biopsy revealed the same diagnosis. After an extensive diagnostic work-up including biopsy sampling, which was negative for malignancy, the symptoms and findings were thought to be related to sclerosing mesenteritis. A trial of steroids and tamoxifen did not improve the symptoms. The patient eventually had mesenteric LN resection and pathology revealed follicular lymphoma. DISCUSSION: Sclerosing mesenteritis is rare. In most cases, it is discovered incidentally on abdominal imaging for evaluation of nonspecific abdominal or systemic symptoms. Our case highlights an important clinical finding that lymphoma can masquerade as sclerosing mesenteritis. A presumptive diagnosis of SM can be based on abdominal CT findings of a halo sign or fat ring. However, a histologic evaluation is necessary to rule out other etiologies and confirm SM. Percutaneous biopsies might be non-diagnostic because fine-needle specimens often lack sufficient architectural representation to exclude malignancy. Excisional biopsy by laparoscopy or laparotomy is usually required to obtain tissue. Pathologic confirmation should be obtained in all cases of suspected sclerosing mesenteritis.

S2214 Unusual Initial Presentation of HIV With Disseminated Kaposi Sarcoma (KS) as Rectal Bleeding

INTRODUCTION: Kaposi's sarcoma (KS) is a cancer that develops from the cells that line lymph or blood vessels. It usually appears as tumors on the skin or on mucosal surfaces such as inside the mouth, but these tumors can also develop in other parts of the body, such as in the lymph nodes, the lungs or digestive tract. KS involvement of GI tract may remain asymptomatic in the beginning or may present with mild non-specific abdominal symptoms, unlikely to be diagnosed in late stage. Here we are presenting a case of disseminated KS presented with rectal bleed in homosexual undiagnosed HIV patient. CASE DESCRIPTION/METHODS: A 33 yr old male with no significant past medical history, presented with 3-month history of constipation and progressive unintentional weight loss (40 lbs in 3 months). Lately, patient noticed his stool mixed with blood and mucus, early satiety and fatigue. Patient has family history significant for breast cancer and biliary cancer in mother. Patient is sexually active with 5 male partners. On presentation, vitals were stable and physical examination revealed multiple purple non-blanchable lesions on his extremities and trunk, a mass on the hard palate, supraclavicular and inguinal lymphadenopathy, external hemorrhoids, and a palpable mass in the rectum. Labs showing normocytic anemia with Hb of 10.3, ESR of 95 and CRP of 9.88. Patient was found to be positive for HIV with viral load of 118,255 and CD4 count of 236. Patient also had high IgG titers for Chlamydia trachomatis and CT abdomen and pelvis showed rectosigmoid mass with perirectal lymphadenopathy, inguinal adenopathy, and mild retroperitoneal lymphadenopathy. CT chest showed pulmonary metastasis and colonoscopy showed mild non-specific ileitis, nodule in descending colon and neoplasm in the rectum. Biopsy from the descending colon and rectal mass showed ulcerated Kaposi’s sarcoma and positive immunostaining for human herpes virus -8 (HHV-8). Patient was diagnosed with disseminated KS and started on anti-retroviral therapy (ART) and systemic chemotherapy. DISCUSSION: AIDS-associated disseminated KS is a rare entity. ART has resulted in marked decline in the incidence of KS. Due to the rapid and progressive nature of AIDS related KS, early diagnosis and institution of ART is crucial to achieving favorable prognosis. In addition, co-infection of HHV-8 with HIV promotes the oncogenicity of HHV-8 leading to rapid onset and progression of KS. Above patient responding well to the ART and Chemo going for surveillance Colonoscopy.Figure 1.: Kaposi Sarcoma on Hard Palate.Figure 2Figure 3.: Kaposi Sarcoma in Rectum.

Metastatic Choroidal Melanoma and Liver Metastasis: A Case Report

Metastatic melanoma to liver is rare in adults. Melanoma can arise from the skin and uveal tract of eyes and metastasizes to other organs, including liver. A middleaged an who had right eye enucleation 5 years ago due to choroidal melanoma was presented with nonspecific abdominal symptoms for a 6-month duration. He had mild tenderness in the right hypochondriac region. An abdominal ultrasound examination showed two hypoechoic lesions that are suggestive of metastatic deposits. Triphasic computed tomography scan of the abdomen showed heterogeneously enhancing lesion that is indicative of hepatoma. Magnetic resonance imaging revealed T2 iso- to hyperintense lesion, giving differential diagnoses of focal nodular hyperplasia, hepatic adenoma, and fibrolamellar carcinoma. Immunohistochemistry results showed that the tumor cells derived from liver biopsy contain melanin as they are positive for both S-100 and MART-1, indicating that the tumor is melanoma. The histopathological examination should be performed on tumor cells from patients who have an increased risk for metastatic melanoma in the liver due to choroidal melanoma.

Case Report of Rare Entity for Atypical Hemolytic Uremic Syndrome

Background: Atypical Haemolytic Uremic Syndrome (aHUS) is a genetic or acquired disorder of regulatory component of the complement system. It is associated with mutations in genes coding for complement components. The abnormality in components of complement makes it susceptible and predispose to chronic uncontrolled hyperactivation of the alternative complement pathway, which results in endothelial damage and microvascular thrombosis. This case report describes a patient diagnosed with Thrombotic Microangiopathy (TMA) due to factor H autoantibody having haemolytic anemia, thrombocytopenia and acute kidney injury. Patient's anemia and renal parameters improved after treatment with plasma exchange therapy. Conclusion: Atypical HUS must be strongly suspected in any patient who presents with nonspecific abdominal or respiratory symptoms along with anemia and thrombocytopenia. As extrarenal involvement is a rare entity of aHUS, the clinician should also keep a high index of suspicion to the possibility of thrombotic microangiopathy manifestation in almost any organ system. In a suspected or diagnosed case of aHUS, the development of new non renal symptoms and signs should prompt clinician for further evaluation to rule out ongoing thrombotic microangiopathy process.

A Neglected Case of Colonic Tuberculosis With Thoracolumbar Enterocutaneous Fecal Fistulae

Although intestinal tuberculosis (ITB) typically affects ileocecal segments, the complication of tubercular enterocutaneous fistula is very rare. As an isolated phenomenon, primary intestinal manifestation without extraintestinal tuberculosis (TB) is exceptional and rarely reported. We present a patient with isolated ITB with six spontaneous thoracolumbar tubercular enterocutaneous fistulae. A 37-year-old Chinese woman was admitted to our institution complaining of escape of fecal matter through several openings in her back over the previous 20 years. She had nonspecific abdominal symptoms (occasional abdominal pain and alteration in bowel habit). External physical examination confirmed the presence of external thoracolumbar fecal fistulae in association with a scoliosis. Abdominal examination was unremarkable. Diagnostic colonoscopy with biopsy did not definitively confirm a diagnosis of TB. Microscopic examination in both microbiology and histopathology labs failed to identify acid-fast bacilli; however, gastrointestinal TB (GITB) was considered high on the differential diagnosis list. It was elected to perform open laparotomy with resection of the left hemi-colon. Postoperatively, she was treated with standard anti-tuberculous treatment for 6 months. The patient had an uneventful postoperative course, during which the fistulae gradually closed over the next year. This case with several low-output fistulas exiting the patient’s back was successfully treated by a combination of surgery and antimicrobial therapy. The aim of this rare case report is to raise the awareness of atypical presentation of tubercular colonic enterocutaneous fistula so that timely diagnosis and intervention can salvage patient quality of life. J Med Cases. 2020;11(5):111-114 doi: https://doi.org/10.14740/jmc3463

Whipple’s disease: imaging contribution for a challenging case

Whipple’s disease is a rare and difficult-to-diagnose infectious disease, related to infection by gram-positive bacillum Tropheryma whipplei. Clinical manifestations are very variable, but the classic form usually begins with recurring...

Abdominal Tuberculosis in Children: Challenges, Uncertainty, and Confusion.

The diagnosis of abdominal tuberculosis (TB) is challenging, and the prevalence of abdominal TB in children is likely underestimated. It may present with nonspecific abdominal symptoms and signs, but children who present with pulmonary TB may have additional abdominal subclinical involvement. Diagnosis is specifically challenging because none of the available diagnostic tools provide adequate sensitivity and specificity. In this review, we summarize the best available evidence on abdominal TB in children, covering the epidemiology, pathogenesis, clinical presentation, diagnosis, and treatment. We propose a diagnostic approach that could be followed for symptomatic children. We believe that a combination of investigations could be useful to both aid diagnosis and define the extent of the disease, and we propose that abdominal ultrasound should be used more frequently in children with possible TB and any abdominal symptoms. This neglected disease has received little attention to date, and further research is warranted.

Pediatric Abdominal Tuberculosis in Singapore: A 10-Year Retrospective Series.

Background. Tuberculosis (TB) remains a major cause of mortality and morbidity globally. Pediatric patients are more likely to develop severe disease. Abdominal TB is a rare manifestation of pediatric TB and can present with chronic and nonspecific abdominal symptoms. This study examines the clinical profile of pediatric patients with abdominal TB and treatment outcomes. Method. A retrospective study of patients admitted to a tertiary pediatric hospital in Singapore over 10 years. Clinical characteristics and outcomes were examined. Results. There were 3 male and 3 female patients with mean age of 11.3 years. Household contacts were traced in 3 cases. The most common presenting symptoms were fever, weight loss, and abdominal symptoms such as diarrhea, vomiting, and loss of appetite. Inflammatory markers were raised with mean C-reactive protein (CRP) and erythrocyte sedimentation (ESR) rate at 70.9 mg/L and 90 mm/h respectively. Abdominal imaging showed abnormalities such as splenic foci and thickened bowel wall with significant intraabdominal lymphadenopathy. Mycobacterium tuberculosis was isolated from stool, rectal swabs and intra-adominal specimens. Two patients underwent excisional biopsy of lymph node to obtain diagnosis. Two patients required emergency laparotomy and 1 patient received esophagogastroduodenoscopy and colonoscopy. Four out of the 6 patients had pulmonary involvement. Conclusion. Abdominal TB should be a differential diagnosis in children with chronic abdominal symptoms for at least 8 weeks with anemia, raised ESR and CRP. The gold standard for diagnosis still remains as positive microbiological culture. However, abdominal imaging studies are also vital in obtaining further supportive evidence for chronic infection.

Eosinophilic gastroenteritis with persistent abdominal pain: a case report.

Two months ago, a 9-year-old boy experienced intermittent abdominal pain regardless of food intake, without diarrhea, bloody stool, or nausea. Blood test results revealed a peripheral blood eosinophil count of 660 cells /µL, which was marginally elevated, without inflammatory reaction, occult blood, or enteric pathogens. The intestinal mucosa from the terminal ileum to the rectum was endoscopically normal, but mucosal biopsy revealed eosinophilic infiltration of the terminal ileum and whole colon with ≥20 eosinophils/high power field (HPF). Subsequent upper gastrointestinal endoscopy revealed normal endoscopic mucosa from the esophagus to the second part of the duodenum, but mucosal biopsy showed an eosinophil infiltration of ≥20 eosinophils/HPF. Based on the above findings, he was diagnosed with eosinophilic gastroenteritis (EGE). The cause of EGE and mechanisms of eosinophil infiltration have yet to be fully elucidated. For these nonspecific abdominal symptoms, evidence of eosinophilic infiltration of the gastrointestinal mucosa, specifically 20 eosinophils/HPF in each intestinal mucosa, is required for the definitive diagnosis of EGE. Even if only persistent abdominal pain develops, EGE diagnosis should be confirmed with the analysis of mucosal biopsy in addition to the review of allergic disease history and peripheral blood eosinophil counts.

Acute mesenteric venous thrombosis after laparoscopic sleeve gastrectomy: a case report and a literature review

Over the last decade, laparoscopic sleeve gastrectomy has become an increasingly popular surgical procedure for morbid obesity. Moreover, post-laparoscopic sleeve gastrectomy mesenteric venous thrombosis is very rarely reported. The presentation varies from mild non-specific abdominal symptoms to life threatening surgical emergency. Superior mesenteric vein thrombosis after bariatric surgery is a difficult diagnosis that needs a high index of suspicion. We report a case of thrombosis of the superior mesenteric vein, who presented as acute emergency to emergency room, shortly after sleeve gastrectomy. Patient underwent laparotomy and offered a resection of 60 cm of infarcted proximal jejunum with restoration of bowel continuity later. Patient subsequently recovered and followed several times in our outpatient and was free of symptoms.

3085 Delayed Diagnosis of Cecal Adenocarcinoma in a Premenopausal Female

INTRODUCTION: Cecal adenocarcinomas can present with anemia and non-specific abdominal symptoms. It is a rare colon cancer associated with aggressive course and poor outcomes. In premenopausal women it can be masked by other gynecological pathologies, resulting in delayed diagnosis and poor outcomes. CASE DESCRIPTION/METHODS: A 48 yo Hispanic female presented with acute onset nausea, vomiting and epigastric pain radiating to the right lower abdominal quadrant (RLQ). Her past medical history included active smoking, overactive bladder syndrome, sickle cell trait, hirsutism, uterine fibroids with chronic menorrhagia, constipation, and chronic iron deficiency anemia (IDA). In addition, she had multiple visits to the emergency room with similar symptoms. Prior work up was remarkable for microcytic hypochromic anemia with Hgb of 7.4, Hct of 24 and MCV of 62, severe iron IDA with ferritin 6, total iron 26, TIBC 358, iron saturation 7.3, normal LDH and reticulocyte count. Stool occult was negative. Her usual symptoms were attributed to either gynecological etiologies or her chronic constipation. During this admission her CT abdomen was consistent with acute appendicitis. However, laparoscopy revealed a right colon mass requiring hemicolectomy. Pathology report confirmed grade II cecal adenocarcinoma stage pT3, pN2a. DISCUSSION: IDA in men prompts extensive workup for colon cancer. In contrast in women it is normally attributed to gynecological/benign gastrointestinal (GI) conditions resulting in delayed diagnosis. Most of the times IDA can be the only manifestation of right sided colon cancer. In the last years, our patient had persistent abdominal discomfort which were attributed to either uterine fibroids or iron supplement induced constipation. Stool occult test was negative correlating with its low sensitivity, especially in small amounts of bleeding. Many pelvic ultrasounds were done but no advanced investigation was considered to evaluate her GI symptoms. Her anemia was always assumed to be secondary to menorrhagia, which confounded the clinical judgment and underestimated the diagnosis of colorectal cancer. This case illustrates the need for low threshold in screening for colorectal malignancies especially in premenopausal women in which anemia can be overlooked as caused mainly by gynecological conditions.

2726 Dilemma of Hypercalcemia and Persistent Peptic Ulcer Disease: Case Report and Literature Review

INTRODUCTION: Hypercalcemia has been linked to peptic ulcer disease (PUD), but between the two is not well understood. We are presenting a case of PUD that did not respond to long term twice daily PPI but did improve when the hypercalcemia was corrected with parathyroidectomy. CASE DESCRIPTION/METHODS: A 48-year-old male patient underwent one yearlong evaluation for persistent abdominal pain. His evaluation included three CT scans, EGD as well as octreotide and parathyroid scans. Initially, it was believed that his symptoms were related to severe PUD that did not respond to prescribed medical treatment due to poor patient compliance. He presented to the ED complaining of epigastric pain. Abdominal imaging revealed inflammation and narrowing of the entire duodenum as well as non-obstructive nephrolithiasis. His Calcium level was 11 mg/dl. An EGD revealed many non-bleeding cratered duodenal ulcers in the entire duodenum. An acquired non-obstructing, benign-appearing, intrinsic stenosis was found in the third portion of the duodenum. Biopsies were negative for H. pylori infection. He denied NSAID use. He was discharged on oral PPI therapy twice daily. Two months later, he returned with recurrent abdominal pain after running out of his PPI. CT scan showed persistent inflammatory changes involving the entire duodenum to the jejunum. Serum gastrin level was 201 pg/ml. Calcium level was 10.4 mg/dL. He was treated symptomatically with plans for outpatient push enteroscopy. The patient’s clinical course was complicated by obstructive nephrolithiasis requiring bilateral ureteral stents. Almost one year later, he returned with abdominal pain. Another CT scan showed persistent duodenitis. His labs showed evidence of Hypercalcemia 12 mg/dl. Gastrin Level 382 pg/ml. Octreotide scan was performed and was negative for any active neuroendocrine tumor. Parathyroid scan revealed parathyroid adenoma. The patient underwent parathyroidectomy and did well. He was discharged home on PPI twice daily. He was seen in follow-up and denied any PUD symptoms. DISCUSSION: This patient with severe non-resolving peptic ulcers. Removal of the parathyroid adenoma resulted in complete resolution of his symptoms. The gastric secretory response to hypercalcemia may be responsible for the occurrence of peptic ulcer disease in patients with hyperparathyroidism. In conclusion, serum calcium level must be considered among the usual tests in patients with rare and/or non-specific abdominal symptoms and part of the workup for persistent PUD.

1830 Granular Cell Tumor as a Rare Cause of Dysphagia

INTRODUCTION: Granular cell tumors are a rare cause of dysphagia and dyspepsia. While rare and difficult to detect, diagnosis and resection of GCTs can often provide symptomatic relief in patients. We present a case of a patient with chronic dyspepsia and dysphagia, with a seemingly incidental finding of an esophageal granular cell tumor. CASE DESCRIPTION/METHODS: Patient was a 32-year-old female with a past medical history significant for SLE-Sjogren’s overlap syndrome who presented to the GI clinic for a follow-up appointment with new complaint of dysphagia for two weeks. Patient was evaluated one year prior with complaints of nausea, vomiting, and dyspepsia which was managed with levbid and amitripyline; however, she continued to have symptoms of epigastric abdominal pain. Physical exam was unremarkable. Given continued epigastric abdominal pain and now dysphagia, PPI was increased to twice daily. Repeat EGD showed a nodule in the esophagus, and pathology was consistent with granular cell tumor (GCT) (Figure 1). Patient underwent endoscopic ultrasound (EUS) which showed a sub epithelial 7x3mm hypoechoic nodule in upper third of esophagus within the luminal interface/superficial mucosa and deep mucosa (Figure 2). Patient underwent endoscopic mucosal resection (EMR) of the nodule one month later. On histological evaluation, the resection appeared complete, but there was one margin with tumor extending to the margin, so there was a plan for the patient to repeat EUS/EGD in six months. At six month follow-up, her dysphagia had resolved and her functional abdominal pain had improved enough to allow decreasing her medication requirements. DISCUSSION: Thought to originate from Schwann cells, GCTs are extremely rare tumors that can occur at any anatomical location. Nestin expression in GCTs indicates that they may arise from a common stem cell in the GI tract, which can differentiate along both interstitial cells of Cajal and peripheral nerve pathways, leading to the common abdominal symptoms of abdominal pain, distention, and dysphagia. Decision for removal is determined based on size, with those less than 1 cm in diameter usually being treated conservatively, and those greater than 1cm typically removed, regardless of symptoms, due to increased incidence of malignancy. Our case highlights that GCTs are a rare cause of non-specific abdominal symptoms and of dysphagia but should be considered in all middle aged patients presenting with these symptoms.

A rare cause of small bowel diaphragm disease presenting with palpated abdominal mass

Small bowel diaphragm disease is a rare complication related to non-steroidal anti-inflammatory drug (NSAID) use. It presents with non-specific symptoms such as vomiting, abdominal pain, subacute bowel obstruction and occasionally as an acute abdominal condition. We report a case of diaphragm disease in a 33-year-old female who presented with vomiting, constipation and abdominal pain started 5 days earlier. Physical examination revealed palpated abdominal mass. The patient’s past medical history was remarkable for NSAID use. The patient was managed by surgical resection of involved intestine and diagnosis was confirmed by histological examination. Although there are few published cases of diaphragm disease in the medical literature, we recommend that this disease should be considered as one of the differential diagnoses when assessing patients presenting with non-specific abdominal symptoms with remarkable past medical history of NSAID use.

Rare cause of massive gastrointestinal bleeding. A case of metastatic melanoma

Abstract The case of a 76-year-old patient, with a history of melanoma, admitted to the department of gastroenterology with symptoms of hypovolemic shock, caused by massive gastrointestinal bleeding. Clot-covered melanoma metastases were detected in both gastroduodenoscopy and colonoscopy. Gastrointestinal melanoma metastases are found in the majority of patients with advanced melanoma during autopsy; however, they are rarely detected in intravital studies and can be misdiagnosed as other benign lesions in endoscopy. In cases of patients with history of melanoma, metastases should be considered as the cause of non-specific abdominal symptoms, anemia, or bleeding from the gastrointestinal tract.

Prolonged Recurrent Abdominal Pain is Associated With Ongoing Underlying Mucosal Inflammation in Patients who had an Episode of Acute Complicated Diverticulitis.

Recent data suggest continuous chronic inflammation in patients after an acute diverticulitis (AD) episode. The aim of this article was to compare clinical parameters, inflammatory cytokine expression, and immune-cell infiltrates between patients after severe versus nonsevere AD, as defined by radiology examination during the acute episode. Sixteen patients, after suffering an episode of AD, were included, and, of them, 8 had severe disease. Demographic data, disease characteristics, and inflammatory markers were collected. Tissue samples from diverticular and unaffected tissue were obtained during colonoscopy. Mucosal inflammation was assessed histologically and by measuring inflammatory cytokine mRNA expression. Clinically, continued nonspecific abdominal symptoms were significantly more prevalent among patients after severe AD compared with patients after nonsevere AD (P=0.0002). Patients after severe AD also had significantly higher C reactive protein levels (9.85±7.5 vs. 3±2.1 mg/dL; P=0.027) and tendency for higher calprotectin levels (115.7±85 vs. 35±8.7 mg/g; P=0.08). Reverse transcription polymerase chain reaction-determined cytokines levels were 5.4±4.4, 5.14±10, and 0.8±0.82 for tumor necrosis factor alpha, interleukin-6, and interleukin-1β, respectively, in affected mucosa compared with 1.06±1.57, 1.56±2.1, and 0.35±0.5, respectively, in nonaffected mucosa (P=0.01, 0.05, 0.14, respectively). Cytokine expression in patients after nonsevere AD did not differ significantly between affected and nonaffected mucosa. Histologic scores for crypt distortion, lymphoid aggregates, and lymphocyte infiltration were all significantly higher in patients after severe AD compared with patients after nonsevere AD (P<0.05 for all comparisons). Patients after severe AD have more prolonged chronic symptoms, higher inflammatory markers, higher tissue inflammatory cytokine levels, and more inflammatory infiltrates in diverticular colonic tissue than patients after nonsevere AD. These results may contribute to patients' risk stratification and guide therapeutic decisions.