Nonspecific Abdominal Symptoms Research Articles

Current Management and Future Opportunities for Peritoneal Metastases: Peritoneal Mesothelioma.

Diffuse malignant peritoneal mesothelioma (MPM) is a rare and ultimately fatal cancer that was first described just over a century ago. It is a diffuse malignancy arising from the mesothelial lining of the peritoneum; morbidity and mortality from MPM is due to its propensity to progress locoregionally within the abdominal cavity. The purpose of this article is to review the current state-of-the-science related to the diagnosis, staging, and treatment of MPM. The condition afflicts men and women equally and the peak incidence is between 55 and 60 years of age although it can arise in the young and elderly.Patients afflicted with MPM most commonly present with nonspecific abdominal symptoms that usually lead to diagnosis when the condition is relatively advanced. Historically, median overall survival for MPM patients without treatment is<1year. The couplet of systemic pemetrexed and cisplatin has an overall response rate of approximately 25% and a median overall survival of approximately 1year. The available data, almost all retrospective in nature, have shown that in selected patients, operative cytoreduction (CRS) and regional chemotherapy administered as hyperthermic intraoperative peritoneal chemotherapy (HIPEC) or early postoperative intraperitoneal chemotherapy (EPIC) is associated with long-term survival. Studies on the molecular biology of MPM have yielded new insights relating to the potentially important role of the phosphoinsitide-3-kinase/mammalian target of rapamycin (PI3K/mTOR) pathways and immune checkpoint inhibitors that may translate into new therapeutic options for patients with diffuse MPM.

Hepatic Epithelioid Hemangioendothelioma.

Epithelioid hemangioendothelioma is a rare vascular tumor, composed of epithelioid and histiocytoid vascular endothelial cells in myxoid or fibrotic stroma, which can arise in multiple locations throughout the body. In the liver, this neoplasm usually presents on imaging as an incidental finding of multifocal, heterogeneously enhancing nodules in both lobes or presents clinically with nonspecific abdominal symptoms. Histologically, the tumor has been mistaken for metastatic carcinoma, angiosarcoma, hepatocellular carcinoma, and cholangiocarcinoma. The neoplasm usually stains positive for vascular markers, such as factor VIII-related antigen, CD31, and CD34, and negative for cytokeratins. The translocation t(1;3)(p36.3;q25), resulting in the CAMTA1- WWTR1 fusion product, is the most commonly identified genetic abnormality with this tumor. Although hepatic epithelioid hemangioendothelioma can have a varied clinical course, it is generally considered less aggressive than angiosarcoma. There is no consensus treatment protocol and techniques including liver transplantation, liver resection, chemotherapy and/or radiation therapy, and surveillance have all been used with varying outcomes.

PPoma Review: Epidemiology, Aetiopathogenesis, Prognosis and Treatment.

Generally, pancreatic polypeptide-secreting tumor of the distal pancreas (PPoma) is classified as a rare tumor, and may occur sporadically or be associated in families or with multiple endocrine neoplasia type 1 (NEM 1). It grows slowly, reaching large dimensions at the time of diagnosis and the symptomatology is fundamentally due to the mass effect, causing either non-specific abdominal pain or symptoms suggestive of obstruction of the pancreatic or biliary duct. Therefore, when detected, they are usually malignant, with metastases mainly in the liver. The combination of serum analysis of increased levels of chromogranin A and pancreatic polypeptide and pancreastatin is very useful with a sensitivity of up to 95%. However, in addition, scintigraphicexams with somatostatin analogues should be performed to better clarify the diagnosis. Surgical resection is the treatment of choice, despite surgical difficulty and because they are generally palliative due to the metastases. Surgeries for tumor volume reduction are also performed to relieve symptoms. Chemotherapy commonly uses streptozotocin and somatostatin analogues to treat residual disease. Unfortunately, the survival rates are still very low, less than 10%, and if metastases already exist, this percentage drops to 3%.

Fatal rupture of descending thoracic aortic aneurysm in a Nigerian patient

Aortic aneurysms are rare conditions in black patients and carry a high mortality if detected late. Unfortunately, the rarity of the condition makes detection a difficulty for many physicians as diagnosis in the early stages requires a high index of suspicion. The varied symptoms presented by the patient often mimic other less severe, but more common conditions and may cause a misdiagnosis. We report a 79-year-old male known hypertensive patient who presented a day before demise with a 4 h history of severe epigastric pain. He was managed for acute exacerbation of peptic ulcer disease to rule out pancreatitis. However, all investigations done were within normal limits. His clinical condition deteriorated, and he died 18 h after admission. An autopsy revealed massive left hemothorax and a tear in the descending aortic aneurysm. Microscopic examination confirmed complicated atherosclerosis in the descending thoracic aorta. The misdiagnosis, in this case, leads to wrong management with the patient receiving treatment for severe peptic ulcer. There is a need to consider this disease in patients who present with severe nonspecific abdominal symptoms.

Inflammatory and infectious abdominal peritoneal and mesenterial processes

Mesenterial and peritoneal inflammation represents amajor clinical challenge regarding differential diagnosis. In this review article, asystematic overview of the most common causes such as autoimmune reaction, infarction with consecutive necrosis and infection caused by protozoa or bacteria is provided. The common clinical features of all inflammatory peritoneal and mesenterial diseases are the nonspecific abdominal symptoms. Even in radiological imaging an overlap of imaging features such as lymphadenopathy and nodular mesenteric structures is typical. Frequently the radiologist can narrow the differential diagnosis based on clinical information and anamnesis resulting in an optimized clinical outcome. Having ahuge spectrum of etiologies for inflammatory peritoneal and mesenterial conditions the radiologist has to consider autoimmune diseases (IgG4-associated disease), acute infarction with necrosis and bacterial or protozoan infection.

Safe surgical approach to extrahepatic pseudocyst, a rare shunt complication: 2 case reports

BackgroundHepatic pseudocysts are not a common complication and “extrahepatic” pseudocysts are rarer complications but may occur in every ventriculo-peritoneal shunt patient.Case presentationWe present two patients with ventriculo peritoneal shunt induced extrahepatic pseudocysts, who underwent shunt surgery for different etiologies. Etiology, treatment strategies and our choice of treatment have been discussed.ConclusionsWhen a ventriculoperitoneal shunt patient is presented with non-specific abdominal symptoms, the possibility of this complication should always be considered. In the treatment of this complication, it is shown that repositioning the catheter is sufficient for cyst regression.

Pancreatic fracture: a rare complication following scoliosis surgery.

Grand Round case report. We report a pancreatic fracture associated with Wirsung duct disruption, following a scoliosis surgery in a cerebral palsy adolescent. Spinal fusion surgery is the standard treatment for severe neuromuscular scoliosis. Many complications such as digestive ones account for its complexity. Postoperative acute pancreatitis is well described, although its pathophysiology remains unclear. To our knowledge, pancreatic fracture following scoliosis correction has never been described to date. Clinical presentation is not specific, and management is not consensual. A 14-year-old adolescent had posterior spinal fusion for neuromuscular scoliosis due to cerebral palsy. During the postoperative course, she developed progressive nonspecific abdominal symptoms. The abdominal CT scan demonstrated a pancreatic fracture and a surgical exploration was decided as perforations of the bowel were highly suspected. Drains were placed around the pancreatic area as the retrogastric region was out of reach due to local inflammation. Conservative management led to the occurrence of a pseudocyst in the following weeks as the pancreatic leakage progressively dropped. Two hypotheses have been proposed: direct iatrogenic trauma from lumbar pedicle screws and pancreatic rupture related to the correction of the spinal deformity. As the latter seems the most likely, spinal surgeons should be aware of this occurrence following severe scoliosis correction. Spinal fusion for severe neuromuscular scoliosis is a difficult procedure, with a high rate of complications. Among them, pancreatic fracture should be considered when abdominal pain persists in the postoperative period. Conservative management is advocated especially in case of a poor general condition.

Laparoscopic Spleen-Preserving Distal Pancreatectomy in Children

Abstract Introduction: Pancreatic tumors are rare in children. They cause less than 0.2% of pediatric malignancy deaths.1 Ductal adenocarcinomas account for 85% of exocrine pancreatic neoplasms. The other main histologic types only account for 1%–2% prevalence each: intraductal papillary mucinous neoplasms, mucinous cystic neoplasms, solid pseudopapillary epithelial neoplasms (SPENs or SPNs or papillary cystic neoplasms), acinar cell carcinoma, pancreatoblastoma, and serous cystadenoma.2 SPENs are usually located in the body and tail of the pancreas, and are often seen in young (mean age in the 20s), non-Caucasian females 90% of the time.3 In general, these tumors have low malignancy potential and patients generally have a favorable prognosis after surgical resection, which is considered the standard treatment. The difficulty of this condition lies in its diagnosis, as patients tend to present with vague and nonspecific abdominal symptoms.4,5 Materials and Methods: A 12-year-old girl presented with an abd...

Adalimumab-Inducing Reactivation of Tuberculosis With Previously Negative QuantiFERON Test

Intestinal tuberculosis (TB) is a very rare disease in the 21st Century. This case highlights the necessity of including TB enteritis as a differential diagnosis in patients who had previously negative interferon-gamma release assay (Quantiferron) who presents with non-specific abdominal symptoms while on immunosuppressive therapy. A 37 year old Bangladeshi male with a remote history of treated pulmonary TB and Psoriasis, presented with fever and loose stools for one month. Fever was intermittent, associated with night sweats and mild RLQ discomfort. He denied sick contacts or recent travel history. Three months prior to admission, dermatology had initiated Adalimumab (ADA) for refractory Psoriasis. Prior to starting ADA, sputum and interferon-gamma release assay was negative. Physical exam was notable for temperature of 103 degrees F and mild RLQ tenderness without a discrete mass. CBC, serum transaminases, lipase, viral hepatitis panel, and HIV assay were all negative. ESR was elevated at 110 and CRP at 220. Sputum culture for AFB, stool culture and blood culture were negative. Chest x-ray and CT chest was unremarkable. CT abdomen and pelvis showed short segment mural thickening of the terminal ileum with bowel distention, right retroperitoneal lymphadenopathy and 4.2 cm right retroperitoneal lymph node conglomerate. Pt underwent CT guided biopsy of mesenteric lymph node which showed patchy necrosis, multinucleated giant cells, few granulomas and rare acid fast bacilli. Pt was started on TB therapy with improvement in symptoms. Extra-pulmonary TB (EPTB) is found in approximately 20% of the patients with TB in the U.S. The 6th most common extra pulmonary site is the ileocecal region. Clinical and radiological findings of GI TB often mimic diseases such as Crohn's disease and malignancy. Therefore, this can lead to delays in accurate diagnosis and treatment. This is particularly true for a case like ours, where a prior negative Quantiferron may ‘rule-out' TB as a diagnostic possibility. Our case points out that under circumstances where a high index of suspicion for EPTB exists, particularly in patients with negative PPD, Quantiferron, and sputum, lymph node biopsy can be a very important supplement to our diagnostic armamentarium. An algorithm of these diagnostic methods leads to considerably higher precision in the diagnosis of this insidious disease which primarily necessitates a clinical awareness of this serious health problem.FigureFigure

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.

Acute gall bladder perforation: case series over three years

Background: Acute perforation of gall bladder is a life threatening condition. It is a complication of acute cholecystitis. This is not an uncommon condition and resembles acute cholecystitis in its presentation. If there is delay in diagnosis and management there is high morbidity and mortality. It should be diagnosed as early as possible for better prognosis.Methods: This is a retrospective study wherein data of cholelithiasis, acute and chronic cholecystitis and perforated gall bladder from our hospital for the last three years 2014-2016 was collected. The clinical presentation, investigations routine and radiological, surgical and medical management was analysed.Results: Total numbers of patients with chronic cholelithiasis were 3534, patients with acute cholecystitis were 133, and numbers of patients with gall bladder perforations were 22, making it 0.6% of gall bladder disease patients and 16.5% among patients with acute cholecystitis. TLC was invariably raised in all the cases. 12 out of 22 cases were managed conservatively while others underwent surgery. There was no mortality in the series.Conclusions: Gall bladder perforation occurs in about two weeks or several weeks after episode of acute cholecystitis, the incidence of occurrence of perforation increases to four folds if there is delay in proper management of acute cholecystitis more than two days after the onset of symptoms. Clinical presentation varies from an acute generalized peritonitis to nonspecific abdominal symptoms and thus requires prompt diagnosis for better prognosis.

Adult gastric duplication: an unknown condition within the spectrum of gastric submucosal lesions

Gastric duplication is an uncommon condition in adults representing only 4-8% of all gastrointestinal duplications. It develops as a cystic growth within the thick gastric wall that is surrounded by a layer of smooth muscle and lined with gastric mucosa. It is usually asymptomatic but may present with nonspecific abdominal symptoms as well as cyst-related complications such as gastrointestinal (GI) bleeding, ulceration and even pancreatitis. They are difficult to distinguish from other gastric submucosal lesions and may also mimic a gastrointestinal tumor (GIST) or mucinous cyst of the pancreas. Endoscopic ultrasound (EUS) is the most widely used diagnostic procedure and histology provides a definitive diagnosis. We report the case of a 36-year-old female patient with a history of a "contained" perforated gastric ulcer that was managed conservatively. The patient was diagnosed with a gastric GIST which prompted a laparoscopic subtotal gastrectomy and Roux-en-Y reconstruction with a good postoperative outcome. The definitive histological diagnosis was gastric duplication. Thus, the previous diagnosis of a "contained" perforated gastric ulcer was in fact a complication of the gastric duplication itself.

Pancreatic solid pseudo-papillary tumours

Pancreatic solid pseudo-papillary tumours can be diagnosed radiologically for non-specific abdominal symptoms, for which the definitive treatment is surgical resection of the pancreas. The malignant or benign nature of the tumour is revealed only during histological evaluation after excision. We present three cases of patients with pancreatic pseudo-papillary tumours. These patients were suspected to have papillary tumours based on radiology findings and the diagnosis was confirmed after histopathology of resected pancreatic specimens. Patients suffering from benign pancreatic pseudo-papillary tumours have an excellent prognosis. This neoplasm usually does not metastasize and is amenable to cure after complete resection. The nature of the tumour is confirmed by histology after pancreatic resection, with adjuvant chemotherapy being instituted in the case of malignant tumours.

Splenic abscess in an immune competent individual: case report and review of the literature

Splenic abscess is a rarity in immune competent individuals. Salmonella, Pasteurella multocida, M. tuberculosis and actinomycosis have been implicated. A 63-year old immune competent female with an arab descent presented with fever, nausea and vomiting. Polymorph leucocytosis, high ESR and markedly high C-reactive protein (CRP) were reported. Chest x-ray and CT scan pointed to the diagnosis. She was managed uneventfully by splenectomy. Enterobacter Spp was grown from operative samples. The patient was well and asymptomatic when seen six months post-operatively. Splenic abscess should be considered even in the absence of co- morbidities in individuals with fever, non-specific abdominal symptoms, polymorphs leucocytosis and high CRP.

Decreased Prevalence of Nonspecific Functional Bowel Disorders and Increased Constipation in Patients after Sleeve Gastrectomy or Gastric Banding

Aim: To examine the effect of laparoscopic adjustable gastric banding (LAGB) and sleeve gastrectomy (SG) on the prevalence of functional gastrointestinal disorders (FGIDs) as defined by the Rome III criteria. Methods: All patients fulfilled the French consensus inclusion criteria for bariatric surgery (BS). Patients eligible for BS, but did not undergo surgery, constituted the control group (n = 124), whereas patients that underwent LAGB (n = 93) and SG (n = 70) formed the two BS groups. Results: The control group was younger (p = 0.041). Dysphagia (22.1% vs. 9.7%; p = 0.005) and constipation (45.4% vs. 28.2%; p < 0.003) were significantly increased in operated patients; however, these factors were not significantly different between the LAGB and SG groups. In the presence of functional defecation disorder, the odds of constipation in the LAGB and SG groups were increased threefold. In operated patients, the number of nonspecific abdominal symptoms was significantly decreased from that in the control patients (16.6% vs. 33.1%; p < 0.001); this factor was not significantly different between the LAGB and SG groups. Conclusions: No differences were found between the LAGB and SG groups regarding the postoperative prevalence of FGIDs. Improved screening for FGIDs before BS may prevent increased prevalence of dysphagia and constipation.

Overuse of proton pump inhibitors and its consequences.

Direct inhibition of H+ ion excretion to the gastric lumen makes proton pump inhibitors (PPI) the most effective drugs against gastric acid-related diseases. Over recent years usage of proton pump inhibitors has increased dramatically. Due to the low costs, high efficacy and rarity of adverse effects, their use is prevalent and often it does not correspond with existing medical guidelines. The literature lists stress ulcer prophylaxis among patients with low risk of bleeding, routine 'gastroprotective' medication during treatment and non-specific abdominal symptoms as the most common patterns of off-label PPI use. This article summarizes the influence of PPI therapy on gastric mucosa, absorption and occurrence of adverse effects. The authors note that their low awareness among physicians contributes to wide and imprudent use of drugs of this group.

A Rare Cause of Abdominal Pain to Consider: Solid Pseudopapillary Tumor of the Pancreas

Solid Pseudopapillary Neoplasm (SPN) of the pancreas also known as Frantz's tumor is an uncommon tumor that mainly occurs in women in their second to fourth decades of life. It accounts for less than 1% of pancreatic tumors and typically arises from the pancreatic tail. It is characterized by low potential for malignancy and a favorable prognosis after resection with 5 year survival rates approaching 85-95%. Diagnosis could be challenging as SPN tend to manifest with nonspecific abdominal symptoms, variable radiological features and inconsistent morphology. The cellular origin of SPN is unclear and might involve ductal, acinar, endocrine, or multipotent stem cells. Specific findings for cellular differentiation are indeterminate; hence accurate diagnosis depends on immunohistochemical staining. We report a rare case of a 27 year-old woman who presented with intermittent abdominal pain, nausea, vomiting and anorexia of 2 weeks duration. Her medical history was significant for recurrent abdominal wall abscesses after abdominoplasty a year ago. Physical examination revealed mild epigastric tenderness. Laboratory tests were unremarkable. Contrast computed tomography (CT) scan of abdomen showed a 2 x 2 cm indeterminate pancreatic tail lesion (Fig 1). An endoscopic ultrasound (EUS) disclosed a 2.1 x 1.8 cm hypoechoic mass in the tail of the pancreas (Fig 2). Trans-gastric fine needle aspiration was obtained to show clusters of uniform neoplastic cells with abundant cytoplasm and oval bean-shaped nuclei. Immunohistochemical stains were positive for CD10, CD56, Ck7, Cyclin D1 and cytoplasmic Beta Catenin but negative for chromogranin and E-Cadherin which was consistent with a pseudopapillary tumor (Fig 3). The patient underwent a robotic assisted en-bloc distal pancreatectomy and splenectomy. There were no intra-abdominal metastases. Despite the increasing number of SPN detected incidentally by imaging, this tumor remains infrequent and the presentation of individual cases can be unique. SPN is characterized by a specific immunohistological pattern, as demonstrated in our case, which makes it highly distinct from other pancreatic neoplasms particularly neuroendocrine tumors, acinar carcinomas and carcinoids. It is important to differentiate SPN from other pancreatic neoplasms because this neoplasm is amenable to cure after complete surgical resection even in cases with capsular invasion and distant metastases, unlike other malignant tumors of the pancreas.Figure 1Figure 2Figure 3

Lobular breast carcinoma with colonic metastases: A synchronous diagnosis in a 4-day period

Lobular breast carcinoma involving the colon is a rare condition. In most cases reported in the literature, metastases are detected after a 20-year latency period after the initial diagnosis. Here we describe a case in which metastatic lobular breast carcinoma and colonic metastasis were simultaneously diagnosed—with only 4 days between the two diagnoses. A 55-year-old woman underwent mammography and colonoscopy in the setting of the National Cancer Screening Program. A malignant nodule in the left breast was detected, and core-biopsy revealed an invasive lobular carcinoma. Simultaneously, numerous intestinal micropolyps were sampled. Histological examination of the latter showed tumor cells growing in cords and presenting signet-ring appearance, thereby confirming metastatic breast carcinoma. In cases such as the one described here, pathological diagnosis can be extremely difficult and deep biopsies are required. Metastatic breast cancer involving the colon can be considerably underestimated because of the unspecificity of the clinical manifestations, the long latency period, and diverse radiological findings that can lead to misdiagnosis. We conclude that clinicians should rule out intestinal metastasis in patients diagnosed with breast cancer, especially the lobular type, and presenting non-specific abdominal symptoms.

Xiphoidectomy: A Surgical Intervention for an Underdocumented Disorder.

Two patients who presented with nonspecific thoracic and upper abdominal symptoms and tenderness of the xiphoid process are discussed. Both patients had undergone extensive examinations, but no source for their symptoms could be found. Plain chest radiographs revealed an anterior displacement of the xiphoid process in both patients. Physical examination confirmed this to be the primary source of discomfort. Anterior displacement of the xiphoid process may be the result of significant weight gain. Repeated trauma of the afflicted area, unaccustomed heavy lifting, exercise, and perichondritis are, amongst other causes, believed to contribute to the development of xiphodynia. Both patients were treated by performing a xiphoidectomy, resulting in disappearance of the symptoms.

Retroperitoneal Sarcoma - A Diagnostic Challenge with Only a Surgical Cure

Sarcomas are solid tumours of mesenchymal cell origin and account for 1% of all adult malignancies. Retroperitoneal sarcomas more commonly affect people in their 50’s who can present to a general surgeon for assessment of non-specific abdominal symptoms. This nature of their presentation and anatomical location provides a diagnostic challenge and initial investigations may be normal. Patients can therefore present late when the tumour is locally advanced. Complete surgical resection with negative macroscopic margins is the treatment of choice and the only proven modality to improve survival and reduce disease recurrence. Extensive resection of multiple organs may be necessary to offer any chance of cure. The benefits of other treatments such as radiotherapy and chemotherapy are less certain. We will present the case of a 63-year-old man who presented with a chronic history of non-specific abdominal symptoms and outline the results of his investigations and subsequent management. We will briefly discuss some of the issue relating to the diagnosis and management of retroperitoneal sarcomas in general.