Postprandial Abdominal Pain Research Articles

Bacteremia, Liver Injury, and Pneumonitis: Strongyloides Unleashed by a Supplement

A 51-year-old woman presented with 2 weeks of fevers and postprandial abdominal pain. The symptoms began insidiously and were accompanied by nausea, vomiting, headache, and dizziness. Review of systems was also notable for joint pain in her hands and feet for the past year. She had otherwise been well, and had no diarrhea, urinary symptoms, skin complaints, cough, dyspnea, or focal neurologic symptoms. She had hypertension and diabetes and took metformin and lisinopril. She was originally from Mexico but had lived in Houston, Texas for years without traveling.

Associations between postprandial symptoms, hydrogen and methane production, and transit time in irritable bowel syndrome.

Abnormal oroanal transit time (OATT) and visceral hypersensitivity are key pathophysiological factors in irritable bowel syndrome (IBS). The lactulose nutrient challenge test (LNCT) has been developed to assess the postprandial symptoms and gut microbial fermentation. We aimed to investigate associations between OATT, rectal sensitivity, and LNCT in IBS patients. We included 263 IBS patients from two study cohorts, where the link between pathophysiology and symptoms was investigated. During the LNCT, severity of postprandial symptoms was graded, and breath hydrogen/methane concentrations were measured after ingestion of a combined lactulose nutrient drink every 15 min for 4h. The patients underwent rectal sensitivity (rectal barostat) and OATT (radiopaque markers) investigations. Comorbid conditions (functional dyspepsia, anxiety, depression, and somatization) were assessed with questionnaires. After controlling for comorbid conditions, rectal sensitivity was associated with abdominal pain (p < 0.05), and more rapid OATT was associated with higher severity of abdominal discomfort, rumbling, nausea, and urgency (p < 0.05 for all) both pre- and post-prandially. Postprandial nausea, urgency, and abdominal pain changed differently over time depending on OATT (p < 0.05 for all). OATT, but not rectal sensitivity, was associated with hydrogen and methane concentrations (p=0.002 for both). Trajectories over time of postprandial symptoms and exhaled hydrogen/methane concentrations were correlated with different correlations depending on OATT. This study highlights the importance of oroanal transit and hydrogen and methane production in the pathophysiology of IBS and increases our understanding of pathophysiological factors involved in postprandial symptom generation. Treatments targeting oroanal transit and hydrogen and methane production may improve specific postprandial symptoms.

S2469 The Big Stretch: A Report of Three Cases of Gastroparesis as an Uncommon Complication of Hypermobile Ehlers-Danlos Syndrome

Introduction: Ehlers-Danlos syndrome (EDS) is a rare autosomal dominant connective tissue disorder that affects the gastrointestinal system, skin, joints, and vasculature. Hypermobile EDS (hEDS) is a subset of EDS with a prevalence of 1 in 5000 people. Major GI features of hEDS include abdominal pain, nausea, constipation, heartburn, and irritable bowel syndrome-like symptoms. Gastroparesis is a debilitating disorder defined as delayed gastric emptying in the absence of a mechanical obstruction. However, hEDS as a cause of gastroparesis is not well established in the literature. Here we report 3 cases of gastroparesis in patients with hEDS to demonstrate its uncommon and varying presentations. Case Description/Methods: Our first patient is a 20-year-old woman who was diagnosed with hEDS at a young age and then developed severe epigastric postprandial abdominal pain with bloating, intractable nausea, early satiety, and unintentional weight loss. She had multiple ER admissions over the past few years for similar symptoms. Physical examination revealed hyperflexible joints, normal bowel sounds with nontender abdomen. Lab values were within normal limits. Esophagogastroduodenoscopy (EGD) and gastric emptying studies both confirmed Grade III gastroparesis. She was initially started on Metoclopramide and Ondansetron without improvement. Patient ultimately achieved symptom control with Azithromycin, Ondansetron, Promethazine as needed and diet modifications. The second patient is a 24-year-old man who was also diagnosed with hEDS at an early age and presented with recurrent postprandial abdominal pain with bloating and heartburn, but no weight loss. He underwent EGD and was found to have gastritis, hiatal hernia and reflux esophagitis. Subsequent gastric emptying scintigraphy later confirmed Grade II gastroparesis and his symptoms improved with diet modifications as well as Metoclopramide. Lastly, our third patient is a 26-year-old woman also with known history of hEDS who presented with mild intermittent postprandial abdominal pain and abdominal bloating. Prior work-up with EGD and gastric emptying scans confirmed the diagnosis of Grade I gastroparesis. Fortunately, her symptoms clinically resolved with regular cannabis use. Discussion: Gastroparesis should be considered in patients with hEDS complaining of severe postprandial abdominal pain. Due to its uncommon presentation and multi-system organ involvement, EDS should be considered in patients with idiopathic gastric dysmotility and joint hypermobility.

S586 Prevalence and Significance of Restrictive Eating Habits Among Patients Presenting to a Tertiary Care Gastroenterology Clinic

Introduction: Complaints of gastrointestinal (GI) symptoms, such as postprandial fullness, abdominal distention, abdominal pain, gastric distention, early satiety, constipation, vomiting, flatulence, decreased appetite, borborygmi, and nausea, are frequent among patient with eating disorders, including anorexia nervosa and bulimia nervosa. In addition, there is a significant correlation between GI symptoms and hypochondriasis. Despite potential overlap of eating disorders and gastrointestinal disorders, it is unknown how many of these patients have restrictive eating habits and hence may benefit from further therapy including counseling by a specialist in eating disorders. The purpose of this study is to investigate the prevalence of restrictive eating habits in the patients seen an Ohio State University Gastroenterology clinic by conducting a retrospective review of the electronic medical records of patients in clinic. Methods: This is an observational and retrospective IRB approved chart review study. Patients seen in Ohio State University Gastroenterology clinic between August 1, 2021 and March 31, 2022 were screened for eligibility. Those who have completed the SCOFF questionnaire, are 18 years an older, speak English, and attended an appointment during the study time frame were included. Chart review included demographic information, past medical history, current medication use, eating habits, digestive symptoms, stress, and quality of life. Data was entered in RedCap and analyzed using t-tests. Results: A preliminary analysis of 20 patients found 20% screened positive for eating disorder using the SCOFF questionnaire, despite none having a prior established eating disorder diagnosis. Those with positive SCOFF screening had a diagnosis of anxiety more commonly than those with a negative SCOFF (p=0.02). All patients with a positive SCOFF had gastroesophageal reflux, type 2 diabetes mellitus, and prescription for a non-SSRI antidepressant. No significant difference in quality of life, perceived stress, dysphagia, or swallowing was identified in this group. Conclusion: The prevalence of positive eating disorder screen in patients with gastrointestinal disease is more than double the prevalence of eating disorders in the United States. Screening for eating disorders in gastrointestinal patients may be an important, previously unrecognized aspect of care for these patients.

Challenges in the diagnosis of marginal zone lymphoma with symptoms of small intestinal disease: a case report and scoping review of the literature.

Marginal zone lymphoma can be accompanied by symptoms of small intestinal disease including abdominal pain and malabsorption. However, the best diagnostic approach for suspected marginal zone lymphoma is unknown and intestinal biopsies are frequently negative. We describe the case of a patient with symptoms of small bowel involvement where marginal zone lymphoma could only be detected upon peripheral lymph node resection. To assess the clinical variability of intestinal marginal zone lymphoma as a rare clinical entity, a scoping review with systematic literature research was performed. A 57-year-old man presented with a 10-year history of postprandial abdominal pain, systemic inflammation and recent weight loss. Endoscopies and a surgical small bowel specimen revealed non-specific findings. Flow cytometry from the bone marrow was highly suspicious for marginal zone lymphoma. A 2-18F-fluorodeoxyglucose-positron emission tomography/computed tomography (2-18F-FDG-PET/CT) showed hypermetabolic lymph nodes on both sides of the diaphragm. Cervical lymph node dissection finally confirmed marginal zone lymphoma. Immunochemotherapy yielded lasting oncological remission and resolved symptoms. We searched PubMed, Embase and Ovid MEDLINE® for additional case reports limited to the last 25 years. Five primary search terms combined using "AND" were used freely and as controlled vocabulary. Additional studies were identified by reviewing the reference lists of included articles. Our review revealed 52 cases of marginal zone lymphoma with small intestinal manifestation. Patients presented with abdominal pain, bowel obstruction, weight loss or gastrointestinal bleeding. Diagnosis was mainly established by surgery (73%). The most frequent endoscopic findings were mucosal erosions and ulcerations. A 2-18F-FDG-PET/CT was positive in 9/15 patients. Treatment included rituximab, chemotherapy, surgery and/or radiation resulting in clinical remission in 82% of cases. Diagnostic workup for suspected small intestinal marginal zone lymphoma is challenging, necessitating a multidisciplinary approach. Endoscopy, imaging including 2-18F-FDG-PET/CT and small bowel resection or dissection of hypermetabolic lymph nodes can be useful. If marginal zone lymphoma is suspected vigorous diagnostic efforts are justified since remission can be achieved in most patients. Our review highlights the variable clinical presentation of this underdiagnosed disease and adds systematic data to the literature.

Gut reactions: emerging mechanisms of abdominal pain from food intake.

Abdominal pain, which is a form of visceral pain, is a highly prevalent symptom worldwide frequently occurring following food ingestion. Its pathophysiology is complex, and many factors, including intestinal environmental cues, the immune system, or the molecular composition of foods, can influence the development of postprandial abdominal pain. Because of the poor efficacy of drug treatments, current strategies are often limited to the exclusion of culprit food(s) from the diet. However, there are two important limitations to this approach. First, patients suffering from food-induced abdominal pain usually recognize several food items as the cause of their gastrointestinal symptoms. Second, not all offending foods can always be identified by these patients. Newly identified mechanisms involving neuroimmune interactions and their communication with the intestinal microbiota shed light on the development of new therapeutic strategies. In this Mini-Review, these novel mechanisms and relevance of such findings are highlighted.

Robotic median arcuate ligament release: management algorithm and clinical outcomes from a large minimally invasive series.

Median arcuate ligament syndrome (MALS) is a rare and debilitating condition that remains difficult to diagnose. Proper patient selection remains key to achieving favorable outcomes for those undergoing MALR. The robotic technique facilitates a minimally invasive MALR approach given the fine precision of the instrumentation and stability of visualization. Here we describe our management algorithm and clinical outcomes for a large series of robotic MALR patients. This retrospective cohort study analyzed adult patients who underwent robotic MALR performed by a single surgeon at a tertiary academic hospital from 2014 to 2021. The diagnosis of MALS was made using objective criteria from celiac artery duplex ultrasound with a peak systolic velocity of > 350cm/s combined with a right upper quadrant abdominal ultrasound, esophagogastroduodenoscopy, and computer tomography or magnetic resonance angiography to exclude other diagnoses. Information on patient demographics, perioperative factors, and patient reported symptoms up to 1-year post-operatively were collected. A total of 74 patients underwent robotic MALR during the study period. The mean age was 27.3 ± 7.9years and the majority of patients were female (n = 60/74, 81.1%). The most common presenting symptom was post-prandial abdominal pain (n = 65/74, 87.7%). The mean operative time was 52.6 ± 18.1min. There were no conversions to open surgery and minimal blood loss (mean = 13.9 ± 8.4mL). At 3-months, 12% (n = 9/74) of patients had persistent abdominal pain and underwent additional imaging. 5 of these 9 patients had persistently elevated DUS expiratory PSV and were referred for angioplasty. 3 of these 5 referred patients had resolution of abdominal pain after angioplasty. At 1-year follow up, 90.3% (n = 56/62) continued to have no abdominal pain. Through this series, the largest set of minimally invasive (laparoscopic or robotic) MALR procedures published to date, we show that with strict adherence to a management algorithm, the robotic approach to MALR is safe and feasible, with good patient outcomes.

CT-Guided Celiac Ganglion Block for Neurogenic Gastrointestinal Dysmotility

PurposeTo determine whether celiac ganglion block can serve as a diagnostic test for dysautonomia as the cause of gastrointestinal dysmotility–related symptoms. Materials and MethodsThis was an institutional review board–approved, prospective, single-arm, registered study, from January 2020 to May 2021, and included patients aged 14–85 years with gastrointestinal symptoms of food intolerance, abdominal pain, or angina. Patients with nonneurogenic causes (ie, chronic cholecystitis, peptic ulcer disease, gastroesophageal reflux, and malabsorption syndrome) were excluded. All 15 patients underwent computed tomography–guided celiac ganglion block with 100 mg of liposomal bupivacaine. Patients filled out the dysautonomia-validated questionnaire Composite Autonomic Symptom Score 31 (COMPASS-31) before and after intervention. Differences (before vs after) were compared with the exact permutation method. ResultsFifteen women (median age, 17 years; range, 14–41 years) were included. Average COMPASS-31 score improved significantly, from baseline 11 (SD ± 2.8) to 4 (SD ± 1.9) (improvement, 7 points ± 2.8; P < .001). All patients reported significant reduction in abdominal angina. Fourteen of the 15 patients (93%) reported complete resolution, and 14 of 15 (93%) reported a significant reduction in non–postprandial abdominal pain (P < .01). Only 1 patient reported no improvement. Eight of those 14 patients (57%) reported complete resolution of abdominal pain. There was a significant improvement in functional scores (vomiting, P = .01; constipation frequency, P = .02; constipation severity, P < .01; and nausea, P < .01). The rate of minor and major adverse events was 13% and 0%, respectively, per the Society of Interventional Radiology adverse event classification. ConclusionsCeliac ganglion block is a safe diagnostic tool for confirming dysautonomia as the underlying condition in patients with gastrointestinal dysmotility–related symptoms. It could provide early diagnosis, lead to definitive treatment (ganglionectomy) earlier, or obviate unnecessary surgery.

Coeliac Artery Release or Sham Operation in Patients Suspected of Having Median Arcuate Ligament Syndrome: The CARoSO study

In patients with median arcuate ligament (MAL) syndrome (MALS), external compression of the coeliac artery (CA) by the MAL causes chronic disabling postprandial abdominal pain, weight loss, and, consequently, lethargy and social deprivation.1,2 The majority of patients with MALS will experience a long medical journey before a diagnosis of MALS is considered, resulting in a substantial burden of disease and high healthcare and societal costs.

Cholangioscopic diagnosis of biliary amyloidosis presenting as bile duct obstruction with cholangitis (with video)

A 73-year-old woman with a history of cardiac amyloidosis presented with obstructive jaundice and upper right postprandial abdominal pain. Computed tomography yielded findings suggestive of common bile duct stones with acute cholangitis. A cholangiogram demonstrated 2 oval filling defects in the common bile duct (A). Intraductal US revealed hypoechoic, homogenous submucosal mass lesions (B). Single-operator cholangioscopy (SpyGlass DS II, Boston Scientific, Marlborough, Mass, USA) showed a protruding mass lesion with tortuous and dilated vessels and central ulceration (C) (Video 1, available online at www.giejournal.org). SpyBite Max forceps biopsy was performed to confirm the pathologic diagnosis. Analysis of the biopsy specimen revealed pink-red deposits in the area of eosinophilic material, consistent with amyloidosis (D, Congo red stain, orig. mag. ×200).

Autonomic dysfunction and gastroparesis in Gulf War veterans

Over 25% of veterans with Gulf War illness developed chronic gastrointestinal (GI) symptoms of unknown etiology after they returned from deployment to the Persian Gulf. To determine the prevalence of...

Gabapentin as a Symptomatic Modifier in Median Arcuate Ligament Syndrome: A Case Report and Assessment of Treatment Modalities

Median arcuate ligament syndrome (MALS) is a rare constellation of neurogenic gastrointestinal (GI) symptoms resulting from compression of the celiac trunk and celiac plexus by the median arcuate ligament. MALS is characterized by nonspecific symptoms including nausea, vomiting, diarrhea, bloating, unintentional weight loss due to food aversion, and postprandial epigastric abdominal pain. We present a case of atypical, chronic MALS that confounded clinicians for over a decade and led to various misdiagnoses, including early-onset Parkinson’s disease. Of the constellation of symptoms that MALS may present with, postprandial epigastric pain is a classic symptom and increases the index of suspicion for the diagnosis; however, the absence of the classic symptom of postprandial epigastric pain and the predomination of nonspecific GI symptoms and syncope in our patient further clouded clinicians’ ability to diagnose MALS. Upon further investigation, we elucidated a link between gabapentin, which our patient was chronically prescribed, and its efficacy in decreasing neurogenic hypersensitivity in the GI tract. Our case and the implications of gabapentin use to decrease neurogenic pain from MALS represents a novel addition to the literature on MALS treatment modalities and elucidates new avenues for continued research in the use of gabapentin as a symptom-modifying agent in the nonoperative and preoperative treatment of MALS.

Outcome of Whipple's procedure for Groove pancreatitis: A retrospective cross-sectional study

BackgroundGroove pancreatitis (GP) is a rare form of chronic pancreatitis primarily affecting the pancreatoduodenal groove. Very few studies have been published from India. The aim of the present study is to report our experience with Whipple's procedure for GP. MethodologyIn this cross-sectional study, data of all patients who underwent Whipple's procedure for GP between August 2007 and July 2021 were retrospectively reviewed. ResultsOf the total 504 Whipple's procedures, histopathologically proven GP was identified in 9 patients. All of them were male. Mean age at presentation was 42.66 ± 4.35 years. All of them had history of alcohol abuse. Eight (88.8%) of them had history of smoking. Postprandial abdominal discomfort and pain (n = 9, 100%) was the most common presenting symptom. Three (33.3%) patients had solid variety and six (66.6%) patients had cystic dystrophy of the duodenal wall. Two (22.2%) patients had mass in the head of the pancreas which was thought to be malignant. None of the patients underwent prior endoscopic management (stenting). Duration of surgery and blood loss was 330 (range, 300–379) minutes, and 250 (range, 200–750) ml respectively. There was no postoperative mortality. Postoperative complications developed in 5 (55.5%) patients. All the complications were managed conservatively. Median postoperative hospital stay was 10 (range, 9–16) days. Over a median follow-up of 41 (range, 12–120) months, complete remission of symptoms was achieved in 7 (78%) patients. ConclusionWhipple's procedure is safe with acceptable perioperative outcomes and good long-term symptom control.

A case of a common iliac-mesenteric bypass for chronic mesenteric ischemia with coral reef aorta after common iliac endarterectomy.

Chronic mesenteric ischemia is a clinical diagnosis characterized by weight loss, food fear, and postprandial pain.1 Although retrograde mesenteric bypass is a commonly described technique in the literature, an end-to-end anastomosis directly from the common iliac artery (CIA) concurrent with iliac endarterectomy has not been frequently performed. Combined endarterectomy and bypass approaches have been proved to be durable in regard to patency rates and freedom from restenosis.2 We have described the case of a 75-year-old woman who had presented with a 15-lb weight loss, postprandial abdominal pain, and food fear.

An unusual cause of abdominal pain: Case report of a Superior Mesenteric Artery syndrome.

Introduction and importanceSuperior Mesenteric Artery (SMA) syndrome is an occlusive vascular disease, mainly caused by a severe weight loss that leads to a reduction of the fatty cushion around the SMA. Postprandial abdominal pain, early satiety, vomits, weight loss and malnutrition are the main symptoms of SMA syndrome. Therapy consists of nutritional support, while mini-invasive surgery is indicated when conservative measures are unsuccessful.Case presentationA 39-years old caucasian woman reported the following symptoms: epigastric pain irradiated up to the right hypochondrium, late post-prandial vomiting and severe weight loss. During previous hospitalizations a gastroscopy, a colonoscopy, and radiographic study of food transit were performed, these exams showed a slow gastric emptying. We performed an abdomen CT scan discovering SMA syndrome typical features. A duodenojejunostomy was performed in videolaparoscopy; the procedure was completed easily without complications.Clinical discussionDebilitating conditions with severe weight loss or anatomic abnormalities are the main causes of SMA syndrome. Symptoms are usually unclear and non-specific. The commonest SMA syndrome features are highlighted with contrast CT. This syndrome is often misunderstood and not considered in differential diagnosis of abdominal pain, determining a delay in diagnosis and further weight loss. An early diagnosis is useful to choose the best treatment of the case. For severe cases, surgery represents the best treatment, especially duodenojejunostomy that is usually linked to rapid symptoms' resumptions without post-operative consequences.ConclusionSMA syndrome should be included in differential diagnosis of abdominal pain. Severe cases can be treated with mini-invasive surgery.

Ileum Thickening and Biliary Stenosis in a 26-Year-Old Woman From Brazil

Question: A 26-year-old woman presented to the emergency department with diffuse abdominal pain and diarrhea that progressively worsened for the last 3 days. On examination, she had abdominal tenderness with abdominal rebound in the right lower quadrant. The patient had postprandial abdominal pain, malabsorption syndrome, and weight loss for the last 3 months. Laboratory assessment revealed marked elevation of liver enzymes (aspartate aminotransferase 98 U/L and alanine aminotransferase 254 U/L) and biliary canalicular enzymes (gamma glutamyl transferase 288 U/L and alkaline phosphatase 164 U/L).

Severe Post-prandial Pain: A Case Report

Median arcuate ligament syndrome (MALS) is a rare cause of post-prandial abdominal pain due to compression of the celiac artery and celiac plexus. Associated symptoms include nausea, vomiting, diarrhea, and weight loss. The incidence of radiologic compression of the celiac axis is reported to be between 10% and 24%; however, symptomatic compression is noted to be found in about half of the population. MALS is considered a diagnosis of exclusion due to its tendency to present with nonspecific symptoms that mimic other common causes of abdominal pain. Radiologic evidence from angiography with breathing maneuvers is the gold standard for diagnosis. Surgical division of the median arcuate ligament to decompress the celiac artery is an effective treatment proving to provide up to 60-70% of symptomatic relief.

An Uncommon Finding in the Artery

Question: A 56-year-old woman with diabetes mellitus, hypertension, and dyslipidemia presented with 1-day history of severe abdominal pain with diarrhea. She has had intermittent episodes of postprandial crampy abdominal pain 2 weeks before her initial presentation. She denies any fever or any hematochezia. Examination revealed generalized abdominal tenderness, with lactic acidosis. A computed tomography scan of the abdomen was urgently performed.

“MEDIAN ARCUATE LIGAMENT SYNDROME’’ -A RARE CASE REPORT

Background: The median arcuate ligament passes superior to the origin of the celiac artery and is a continuation of the posterior diaphragm that wraps over the aorta. If it lies too low on the aorta or if the origin of celiac artery is higher in location, the ligament may cause symptoms of abdominal pain related to compression of the celiac artery. Case Report: An abdominal ultrasound in a 20-year-old woman with longstanding abdominal pain after eating and Computed tomography angiography of the abdomen showed stenosis of the origin of the celiac artery and conrmed the diagnosis of median arcuate ligament syndrome. Laparoscopic release of the median arcuate ligament resulted in relief of the patient's symptoms. Conclusion: The diagnosis of median arcuate ligament syndrome should be considered in patients with postprandial abdominal pain that does not have a clearly established etiology.

Endoscopic suspect of subacute occlusive mesenteric ischaemia

A 74-year-old patient presented to our emergency department with melena for 24 hours, associated with postprandial abdominal pain, predominantly in the epigastrium, for one month. Urgent gastroscopy showed a pale mucosa with loss of vascular pattern in the gastric antrum, as well as several superficial ulcers, Forrest III, at that level and in the duodenal bulb highly suggestive of ischaemia. An abdominal computed tomography angiography (CTA) revealed a filiform celiac trunk, with calcified atherosclerotic plaques in the ostium, superior mesenteric artery and both renal arteries, with absence of enhancement in a large part of the intestinal wall, suggestive of ischaemia. An exploratory laparoscopy confirmed patchy ischaemia of the small intestine, as well as of the cecum, ascending colon, and portion of the transversus. Atherosclerosis is the most common cause of occlusive chronic mesenteric ischaemia. The 'classic triad' consisting of postprandial pain, weight loss and abdominal bruit, is found in only a minority of patients, with a significant percentage of paucisymptomatic patients due to abundant colateral circulation, making diagnosis difficult. The endoscopic finding of edema, erythema or signs of mucosal atrophy, as well as gastric or duodenal ulcers, not justified by other causes can guide us in the diagnosis. However, more distal sections of the digestive tract which are not accessible with the conventional endoscope can often be affected, and the absence of these findings, does not exclude the diagnosis. Abdominal CTA is the gold-standard imaging test. Early diagnosis of mesenteric ischaemia is a challenge in clinical practice. Recognizing its endoscopic signs can facilitate its early diagnosis and treatment.