Nonspecific Gastrointestinal Complaints Research Articles

Applicability of the Pancreatic Exocrine Insufficiency Test (PEI-TEST) in Pediatric Patients.

In mild cases, it is difficult to diagnose pancreatic exocrine insufficiency (PEI). There is no gold standard method for the diagnosis of PEI. A reliable method is needed for preliminary diagnosis of PEI. The PEI-TEST was applied to the patients with nonspecific gastrointestinal complaints. Serum amylase, lipase, serum trypsinogen, and fecal elastase 1 (FE-1) were analyzed from each patient. According to the PEI-TEST, PEI was present in 42 (47.7%) and PEI was not present in 46 (52.3%) patients. No significant difference was observed between the 2 groups with regard to age, gender and amylase, lipase, serum trypsinogen, and FE-1. When an FE-1 value of <200 µg/dL was considered as indicating PEI, the sensitivity and specificity of the test were found to be 47.4% and 52.2%, respectively. Although it is promising that PEI-TEST is a validated test in our country and suitable for our society, it is not suitable for pediatric patients.

Chronic midgut volvulus - A challenging diagnosis

Chronic midgut volvulus is a rare condition and the diagnosis can pose a serious challenge. We present the case of an 8 year old girl, with a long-standing history of atypical gastrointestinal symptoms. Although extensive evaluation was performed, the diagnosis of intestinal malrotation with chronic volvulus was only established after 5 years. Her symptoms resolved after corrective surgery. This case report underlines the importance of considering malrotation in the differential diagnosis of patients that present beyond infancy with vague nonspecific gastrointestinal complaints, as a misdiagnosis can result in a catastrophic outcome.

S1616 A Nonspecific Gastrointestinal Symptom Leads to a Rare Colonic Metastasis in a Patient With Remote History of Breast Cancer

INTRODUCTION: Breast cancer is the second most common malignancy in women and can metastasize to the lungs, bone, and liver; colonic metastases are exceedingly rare. We discuss a breast cancer survivor who presented with non-specific GI symptoms and was found to have metastatic breast cancer in the colon. CASE DESCRIPTION/METHODS: This is a 74-year-old female with a remote history of localized right breast cancer initially managed with breast-conserving surgery and radiation in the late 1980s, then maintained on an estrogen receptor (ER) antagonist before receiving a mastectomy in the late 1990s. She adhered to mammogram surveillance that confirmed her remission for the following two decades. At our clinic, she complained of decreased stool caliber and constipation refractory to over-the-counter laxatives. Symptoms were present for four weeks, associated with nausea, and without weight loss, abdominal pain, or blood in stool. She was up-to-date with colonoscopies. Exam revealed a soft abdomen with a firm focus near the umbilicus without tenderness on palpation. Colonoscopy revealed a region of erythematous friable mucosa with ulcerations at the transverse colon measuring 3 cm wide (Figure 1A). Pathology revealed a poorly differentiated carcinoma and GATA3, a breast carcinoma marker, was strongly positive (Figure 1B/D). E-cadherin was negative indicating this is most likely lobular carcinoma and ER, progesterone receptor, and HER-2 were all negative. Subsequent imaging confirmed metastases to the colon and retroperitoneum. She established care with oncology and has since been initiated on chemotherapy. DISCUSSION: Breast cancer metastases to the colon are a rare finding. The frequency at which metastases occur and the time at which they present depends on histologic subtype and hormone receptor status, respectively. Lobular carcinomas, as in our patient, tend to metastasize more than other subtypes. Also, hormone receptor-negative disease tends to metastasize earlier than hormone receptor-positive disease, with the former typically appearing within five years after initial diagnosis and the latter presenting well beyond that. Although our patient has lobular carcinoma, she also has triple-negative disease confirming exceptions to these rules. We present this case not only to highlight an atypical presentation of a common malignancy but to emphasize that providers should maintain a high index of suspicion for cancer recurrence when evaluating nonspecific gastrointestinal complaints in cancer survivors.Figure 1.: A. Endoscopic view of transverse colon demonstrating erythematous friable mucosa with ulceration. Ulcer measures three centimeters wide. B. Hematoxylin and Eosin stain: Ulcerated mucosa with underlying dense infiltrate of poorly differentiated neoplastic cells in the lamina propria. Of note, non-neoplastic colonic mucosa with unremarkable colonic glands/crypts are seen on the left of the dotted red line (arrow). C. Immunohistochemistry for CDX2. The neoplastic cells are negative for CDX-2, ruling out the possibility of adenocarcinoma of the GI tract. D. Immunohistochemistry for GATA 3. The neoplastic cells are positive for GATA3, suggesting breast origin of these neoplastic cells.

Gastric cancer following pancreaticoduodenectomy: Experience from a high-volume center and review of existing literature

BackgroundProlonged survival of patients after pancreaticoduodenectomy can be associated with late complications due to altered gastrointestinal anatomy. The incidence of gastric cancer is increasingly reported. We set out to examine our experience with gastric cancer as a late complication after pancreaticoduodenectomy with a focus on incidence, risk factors, and outcomes. MethodsWe queried our prospectively collected institutional database for patients that developed gastric cancer after pancreaticoduodenectomy and conducted a systematic review of the literature. ResultsOur database revealed 6 patients who developed gastric cancer following pancreaticoduodenectomy, presenting with a mean age of 62.2 years and an even sex distribution. All of those patients underwent pancreaticoduodenectomy for malignant indications with an average time to development of metachronous gastric cancer of 8.3 years. Four patients complained of gastrointestinal discomfort prior to diagnosis of secondary malignancy. All of these cancers were poorly differentiated and were discovered at an advanced T stage (≥3). Only half developed at the gastrointestinal anastomosis. Four underwent surgery with a curative intent, and 2 patients are currently alive (mean postgastrectomy survival = 25.5 months). In accordance with previous literature, biliopancreatic reflux from pancreaticoduodenectomy reconstruction, underlying genetic susceptibility, and adjuvant therapy may play a causative role in later development of gastric cancer. ConclusionLong-term survivors after pancreaticoduodenectomy who develop nonspecific gastrointestinal complaints should be evaluated carefully for complications including gastric malignancy. This may serve as an opportunity to intervene on tumors that typically present at an advanced stage and with aggressive histology.

Giant Fecaloma Causing Large Bowel Obstruction: A Case Report

Fecalomas are masses of hardened stool that are typically impacted in the sigmoid colon and rectum. Fecalomas are commonly associated with chronic constipation, Hirschsprung’s disease, Chagas disease, and multiple psychiatric conditions. We present a case of a giant fecaloma resulting in complete large bowel obstruction and suggest a five-year abdominal ultrasound monitoring of adults presenting with chronic constipation and/or chronic nonspecific gastrointestinal (GI) complaints.

Postoperative Gastrointestinal Complaints After Laparoscopic Nissen Fundoplication.

To investigate the postoperative gastrointestinal complaints and their effects on the satisfaction level of patients after laparoscopic Nissen fundoplication (LNF). Over a 7-year period, 553 patients who underwent "floppy" LNF were evaluated for preoperative and postoperative complaints. For this purpose, a set of questions derived from gastroesophageal reflux disease-health-related quality-of-life questionnaire (GERD-HRQL) was used. A P-value of <0.05 was considered to show a statistically significant result. The present study included 215 patients with a mean follow-up of 60 months. Reflux-related symptoms [regurgitation (17.7%), heartburn (17.2%), and vomiting (3.7%)] and nonspecific symptoms [bloating (50.2%), abdominal pain (15.3%), and belching (27%)] showed a significant decrease (P<0.001) after the surgery. Inability to belch (25.1%) and early satiety (29.3%) were the newly emerged symptoms. The percentage of patients with flatulence increased from 23.3% to 38.1% after LNF. There was no significant difference for dysphagia (25.6%) and diarrhea (15.3%) in the postoperative period. Of the patients, 15.3% had recurrent preoperative complaints and 9.8% were using drugs for that condition. Satisfaction level and preference for surgery were 82.8% and 91.6%, respectively. There was no significant difference in GERD-HRQL score according to body mass index. This is the first study in which postoperative reflux-related and nonspecific gastrointestinal complaints are analyzed together for a long follow-up period. We found a significant decrease in many reflux-related and nonspecific symptoms. Although some disturbing complaints like inability to belch, early satiety, and flatulence emerged, the preference for surgery did not change.

Lady's mantle (Alchemilla vulgaris L., Rosaceae): A review of traditional uses, phytochemical profile, and biological properties

Lady's mantle (Alchemilla vulgaris L. syn. Alchemilla xanthochlora Rothm., Rosaceae) has been commonly used in folk medicine to heal inflammations in the mouth, bleeding of the nose, furuncules, gynaecological (menorrhagia and dysmenorrhoea), and gastrointestinal disorders. Although therapeutic indications for lady's mantle are non-specific diarrhoea and gastrointestinal complaints, it has been reported to exert, as well, a variety of biological activities, including wound healing, antimicrobial, neuroprotective, gastroprotective, cytotoxic, and antioxidant. Lady's mantle presents a valuable source of natural bioactive compounds, mostly phenolic compounds - a large amount of tannins, phenolcarboxylic acids, and flavonoids, being responsible for the abovementioned effects. In this work, a literature review of biological properties, investigated in in vitro and in vivo experiments in regard to the determined chemical profile is presented. In addition, the data reported are discussed, and the directions for further investigations are proposed.

The gastroenterologist's guide to management of the post-liver transplant patient.

The management of the post-liver transplant patient is complex and involves a large interdisciplinary team. After referral to a transplant center, evaluation and listing, and eventual transplantation, the patient is cared for closely by the transplant center. Once deemed ready for discharge, the patient returns to the primary care provider for ongoing management of the various issues that increase in incidence post transplant such as osteoporosis, cardiovascular, and renal diseases, as well as metabolic syndrome. The role of the gastroenterologist is not well defined, but certainly, he or she may be called upon for the initial evaluation and ongoing management of gastrointestinal as well as hepatobiliary issues. This includes but is not limited to the investigation of abnormal liver tests, non-specific gastrointestinal complaints such as nausea, vomiting, or diarrhea, biliary complications, and even recurrent hepatic disease. Having familiarity with post-transplant immunosuppressive agents, drug interactions, and potential infectious and malignancy-related complications of transplant is essential, as the primary gastroenterologist may be expected in some situations to field the initial work-up, if patient access to the transplant center is limited. The aim of this review is to summarize the gastroenterologist's role in the management of the post-liver transplant patient.

Mitochondrial dysfunction in the gastrointestinal mucosa of children with autism: A blinded case-control study.

Gastrointestinal (GI) symptoms are prevalent in autism spectrum disorder (ASD) but the pathophysiology is poorly understood. Imbalances in the enteric microbiome have been associated with ASD and can cause GI dysfunction potentially through disruption of mitochondrial function as microbiome metabolites modulate mitochondrial function and mitochondrial dysfunction is highly associated with GI symptoms. In this study, we compared mitochondrial function in rectal and cecum biopsies under the assumption that certain microbiome metabolites, such as butyrate and propionic acid, are more abundant in the cecum as compared to the rectum. Rectal and cecum mucosal biopsies were collected during elective diagnostic colonoscopy. Using a single-blind case-control design, complex I and IV and citrate synthase activities and complex I-V protein quantity from 10 children with ASD, 10 children with Crohn’s disease and 10 neurotypical children with nonspecific GI complaints were measured. The protein for all complexes, except complex II, in the cecum as compared to the rectum was significantly higher in ASD samples as compared to other groups. For both rectal and cecum biopsies, ASD samples demonstrated higher complex I activity, but not complex IV or citrate synthase activity, compared to other groups. Mitochondrial function in the gut mucosa from children with ASD was found to be significantly different than other groups who manifested similar GI symptomatology suggesting a unique pathophysiology for GI symptoms in children with ASD. Abnormalities localized to the cecum suggest a role for imbalances in the microbiome, potentially in the production of butyrate, in children with ASD.

Syndrome of Inappropriate Anti-Diuretic Hormone Secretion Secondary to Strongyloides stercoralis Infection in an Allogeneic Stem Cell Transplant Patient: A Case Report and Literature Review

Syndrome of inappropriate anti-diuretic hormone (SIADH) has been reported to be associated with systemic Strongyloides stercoralis. Here, we report a case of a stem cell transplant (SCT) recipient who developed severe SIADH secondary to systemic S Stercoralis. The SIADH resolved quickly after treating the systemic S Stercoralis with ivermectin. A systematic review of the literature was performed by PubMed, Scopus, and Cochrane database search. Only eight cases of S Stercoralis in allogeneic SCT recipients have been previously reported. To our knowledge, ours is the first reported case of SIADH secondary to S Stercoralis infection in an allogeneic SCT recipient. Prior to transplantation, even if asymptomatic, patients from endemic regions should be screened with strongyloides immunoglobulin (Ig)G serology. Pretransplantation eosinophilia should be evaluated by screening multiple stool samples for ova and parasites. Transplant candidates with positive serology or stool tests can be treated pretransplantation to eradicate infection. Patients at risk for S Stercoralis who develop nonspecific gastrointestinal complaints, rash, pulmonary infiltrates, or gram-negative bacteremia or meningitis may have S Stercoralis hyperinfection syndrome. Our case indicates that the development of SIADH may be an additional clue to this diagnosis. Appropriate diagnostic studies, including repeat stool and other body fluid sampling, should be expedited and ivermectin therapy initiated rapidly to prevent significant morbidity and mortality.

Color Doppler—An effective tool for diagnosing midgut volvulus with malrotation

Malrotation with midgut volvulus is a common surgical emergency in children. A diagnostic tool for malrotation with characteristics ideal in emergency settings such as non-invasiveness and rapidity remains a keenly debated issue among surgeons and radiologists alike. Fifty-two pediatric patients of suspected malrotation with midgut volvulus were studied between 1998 and 2016. All patients underwent plain abdominal X-ray and Color Doppler; contrast upper gastrointestinal (GI) studywas done in some patients. All cases were operated and diagnosis was confirmed. A subset of 60 pediatric patients with nonspecific GI complaints were also examined to see relative position of superior mesenteric vein (SMV)/superior mesenteric artery (SMA) in control population. A total of 52 suspected cases of malrotation were admitted from May 1998 to November 2015, 43 had inversion of SMA/SMV and nine had SMV anterior of SMA in Color Doppler. All 43 cases of inversion of SMA/SMV were cases of malrotation after surgical confirmation; while five out of nine cases of SMV anterior to SMA had malrotation. In appropriate clinical settings, Color Doppler documenting the reversal or aberrant SMV/SMA axis is not only predictive but also diagnostic of malrotation of gut.

Predictors of dietary gluten avoidance in adults without a prior diagnosis of celiac disease

ObjectivePrior studies have shown that dietary gluten avoidance (DGA) is relatively common in children without previously diagnosed celiac disease (CD), and several clinical predictors of DGA have been found. However, available data on predictors of DGA in adults without diagnosed CD are limited. The aim of this study was to determine the independent predictors of DGA in this population. MethodsWe performed a structured medical record review of 376 patients, ages ≥20 y, who had never been formally diagnosed with CD, presenting for an initial CD evaluation (ICD-9-CM 579.0) between January 2000 and December 2010 at two large Boston teaching hospitals. We collected data including demographic characteristics, medical history, history of CD serology before referral, and self-reported DGA. Predictors of DGA were determined using multivariable logistic regression. ResultsMean age was 47 (SD = 17) years. We found that 41 patients (10.9%; 95% confidence interval [CI], 7.9–14.5) had avoided gluten at some time in their lives. Most patients had subjective abdominal complaints or bowel movement changes. History of CD seropositivity before referral was noted in 14%. Independent predictors of DGA (P < 0.05) were lactose intolerance (odds ratio [OR], 2.8; 95% CI, 1.1–7.5), food allergy (OR, 3.8; 95% CI, 1.04–13.7), and history of positive serology of less-specific CD markers before the referral (OR, 3.2; 95% CI, 1.3–7.9). ConclusionsGluten avoidance is common in a clinic population of adults without prior CD diagnosis. The recognized predictors suggest that DGA may associate with conditions presenting with nonspecific gastrointestinal complaints and perhaps with the perceived benefits of DGA among patients with prior history of positive CD serology.

Brain sensitization to external and internal stimuli

Sensitization is defined as a non-associative learning process occurring when repeated administrations of a stimulus result in a progressive amplification of a response (Shettleworth, 2010). The purpose of this review paper is to discuss whether brain sensitization is helpful in common health problems in man. The paper reviews data on brain sensitization covering increased behavioral, physiological, cognitive, and emotional responses in man and animals. The paper concludes that brain sensitization may be a helpful concept to understand subjective and "unexplained" health complaints (nonspecific muscle pain, mood changes, fatigue, and gastrointestinal complaints), and, therefore, relevant for evidence based treatment and prevention of these common health problems.

Late-presenting congenital diaphragmatic hernia.

This study was undertaken to highlight the clinical profile, misdiagnosis, surgical treatment,and prognosis of late-presenting congenital diaphragmatic hernia (CDH) cases in a tertiary level hospital. This retrospective study included all the babies and children >1 month of age with CDH who were admitted in our Hospital (Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India) during the period between January 2008 and December 2013. Babies with age <1 month were excluded from the study. Data regarding clinical profile, operative records, and follow-up was reviewed and analysed statistically. A total of 20 patients were included in this study. The clinical picture ranged from respiratory distress (13 patients) to non-specific gastrointestinal complaints (5 patients). In two patients, CDH was misdiagnosed as pneumothorax and had got chest tube inserted in other hospitals before referral to this tertiary care centre. In 14 patients chest, X-ray revealed the diagnosis of CDH and in remaining five patients (including the two patients with misdiagnosis) further investigations were undertaken to establish the diagnosis. Age ranged from 45 days to 17 years with an average age of 58.9 months. There were 12 male and 8 female patients. In all the 20 patients, surgical procedures were undertaken with the retrieval of herniated contents from the thoracic cavity and repair of the diaphragmatic defect. There was no mortality in our series. All the 20 patients were followed-up for a period ranging from 6 months to 5 years (median 3.1 years). Late-presenting CDH can have diverse clinical presentation. Late diagnosis and misdiagnosis can result in significant morbidity and potential mortality if these cases are not managed properly at an appropriate stage. Outcome is favourable if these patients are expeditiously identified and surgically repaired.

Eosinophilic gastroenteritis, complicated with Esonophilic ascites, acute pancreatitis and chronic diarrhea: A rare presentation of hyper eosinophillic syndrome.

Eosinophilic gastrointestinal disorders (EGID) are one ofrare causes of chronic diarrhea. The disorders are characterizedby inflammation rich in eosinophilic infiltration in the gastrointestinal(GI) tract without evidence of known causes foreosinophilia such as parasitic infection, drug reaction, or malignancy (1). It was originally described by Kaijserin 1937.EGID can involve one or multiple segments of the GI tractfrom the esophagus to the rectum (mainly in the antrum of the stomach and small intestine) and can also occupy various sitesthrough the depth of the wall (2). Clinical manifestations range from non-specific gastrointestinal complaints to more specific symptoms such as protein-losing enteropathy, malabsorption, luminal obstruction and eosinophilic ascites. Thus it is an easily missed condition that needs more awareness from the gastroenterologists and general internists. We report the case of a 30-year-old woman with chronic diarroheea and ascites presenting as acute pancreatitis, a rare documented presentation of Esonophillic gastroenteritis.

Profile of Pediatric Poisoning at District Hospital Gulbarga

Introduction: Children are curious and explore their world with all their senses, including taste. As a result, the home and its surroundings can be a dangerous place when poisonous substances are inadvertently ingested. Methods: This study was done to know the profile of poisoning cases in pediatric age group in district hospital Gulbarga. It is a retrospective study of Pediatric poisoning between August 2011 and July 2013. Results: Poisoning constituted 0.73% of all Pediatric admissions. Distribution of cases among boys and girls were equal. Majority (68%) of these cases were from rural areas. Only one case of poisoning happened by inhalation / dermal absorption during farming activity, rest 36 (97%) were by oral ingestion. Most (81%) of these poisoning happened in the home environment. Out of the 7 (19%) outdoor poisoning 6 were plant poisons, which were eaten out of curiosity by children. Pesticide was the most common poison found in the study followed by lice powder and kerosene. Nonspecific gastrointestinal complaints like vomiting (75.7%), pain abdomen (40.5%) and loose stools (21.6%) were the most common symptoms with which children with poisoning presented to hospital. Conclusions: Poisoning in children remains one of the causes of emergency admissions to hospital. It is target population regarding proper storage of potential poisonous substances away from the reach of children.

A Toddler With Vomiting, Abdominal Pain, and Alopecia

A previously healthy toddler presented to the emergency department with nonspecific gastrointestinal complaints. Laboratory studies were consistent with pancreatitis, and imaging studies demonstrated a pancreatic transection. Alopecia felt to be related to traction was also noted. There was no history of any witnessed trauma, and nonaccidental trauma was diagnosed.

Is it an eating disorder, gastrointestinal disorder, or both?

The authors examine the differential diagnosis for gastrointestinal disorders that should be considered in individuals who present with nonspecific gastrointestinal and nutritional complaints suggestive of an eating disorder. This review first identifies diseases with which eating disorders are often confused and then explores features in the history, physical examination, and laboratory studies, which can provide clues to the cause of the patient's symptoms. In addition, it discusses the recommended evaluation and treatments for the gastrointestinal diseases that most commonly mimic the presentation of eating disorders including Crohn disease (CrD), celiac disease, gastroesophageal reflux disease (GERD), and eosinophilic esophagitis (EoE). The ubiquitous nature of the gastrointestinal complaints requires the clinician to consider a broad differential diagnosis when evaluating a patient for an eating disorder.

Predictors of Gluten Avoidance and Implementation of a Gluten-Free Diet in Children and Adolescents without Confirmed Celiac Disease

To determine independent predictors of gluten avoidance and of a physician's decision to initiate a gluten-free diet (GFD) in children and adolescents without confirmed celiac disease. We performed a structured medical record review of 579 patients aged 1-19 years presenting for evaluation of celiac disease between January 2000 and December 2010 at a large Boston teaching hospital. We collected data including demographic information, medical history, serology, small intestinal biopsy, history of gluten avoidance, and the postworkup recommendation of implementation of a GFD. Predictors of gluten-related issues were identified by multivariate logistic regression. Among 579 children without a previous diagnosis of celiac disease (mean age, 8.7 years), 43 (7.4%) had ever avoided gluten. Independent predictors of gluten avoidance were irritability or poor temper (OR, 3.2), diarrhea (OR, 2.5), weight issues (OR, 0.4), pervasive developmental disorder (OR, 5.3), and family history of celiac disease (OR, 2.2). Among 143 children without confirmed celiac disease who underwent diagnostic evaluation, several predictive factors were associated with a physician- recommended/parent-initiated GFD: irritability (OR, 6.4), diarrhea (OR, 3.4), pervasive developmental disorder (OR, 7.9), and positive serology before the referral (OR, 4.3). Gluten avoidance among children and adolescents without a previous diagnosis of celiac disease is relatively common. The identified predictors suggest that gluten avoidance is associated with nonspecific behavioral and gastrointestinal complaints and perhaps with the perceived dietary responses in another family member thought to have celiac disease.

Acute Appendicitis: Radiological or Clinical Diagnosis?

Purpose: The purpose of our paper is to conduct a retrospective case review of several accounts of acute appendicitis diagnosed in the emergency room, and to establish the degree of correlation between the clinician's diagnostic acumen and radiological findings on computed tomography. In an era of constantly emerging diagnostic procedures, and because several other gastrointestinal maladies mimic appendicitis, is the clinical exam still the golden rule? This paper serves to discount or support the axiom that acute appendicitis is a clinical diagnosis, and also includes a review of the current literature. Methods: A retrospective case review was conducted of over one hundred cases of acute appendicitis diagnosed by computed tomography and compared with pre-procedure clinician diagnosis in the emergency room setting to establish the percent of matching diagnoses. Individual cases were chosen at random over a 6 month period from two neighboring community hospitals. Specific radiological criteria were used for CT diagnosis of acute appendicitis. A review of the current literature was also performed. Results: Of the over one hundred cases of acute appendicitis per CT criteria reviewed, approximately eight percent of clinicians had matching clinical diagnoses, with another twenty percent with alternate diagnoses such as gastroenteritis or colitis, and the remaining cases with nonspecific gastrointestinal complaints such as nausea, diarrhea, or abdominal pain. The current literature postulates a significant decrease in the negative appendectomy rate, both after the advent of the age of computed tomography, and also when CT is used in conjunction with clinical judgment. Conclusion: In our experience, acute appendicitis has become more of a radiological diagnosis than previously thought. The advent of computed tomography has significantly decreased the negative appendectomy rate per the recent medical literature. In addition, our study included several patients who were given an incorrect presumptive diagnosis with other gastrointestinal maladies, when in fact they had an atypical presentation of acute appendicitis determined by CT. Therefor, one cannot ignore the value of computed tomography in the diagnosis of acute appendicitis, not just as an adjunct, but as a necessity in its diagnosis and thus obviating the need for surgery in patients with benign gastrointestinal illness that may present similarly.