Postprandial Pain Research Articles

Relationship Between Gastric Emptying Rate and Simultaneously Assessed Symptoms in Functional Dyspepsia

During a GE test (breath test with 13C-octanoic acid labelled 250 kcal solid meal), the severity of 6 symptoms (postprandial fullness, epigastric pain and burning, bloating, nausea and belching) was assessed, every 15 min, before meal-intake and 4h postprandially. The sum of individual symptom scores generated the meal-related symptoms score; the sum of all symptoms generated overall meal-related symptom severity (OSS). Data were compared in patients with normal and delayed GE (cut-off T1/2≥ 109 min). Data are shown as mean±SEM. 504 patients were included, of which 382 patients (67% female, age 43.8±0.8 years, BMI 23.3±0.2 kg/m2) had normal and 122 patients (77% female, age 42.7±1.5 years, BMI 23.2±0.6 kg/m2) had delayed GE. OSS tended to be higher in patients with delayed GE (81.8±3.4 vs. 99.5±7.1, p=.05). Only nausea was significantly higher in patients with delayed GE (11±0.8 vs. 16±1.6, p=.01). No correlations were observed between GE rate and any of the symptoms (OSS: r=0.06, p=.2; nausea: r=0.06, p=.1). The symptom severity time course showed a significant difference only for nausea, with increased severity ratings 90 min after the meal (p<.01) in delayed GE compared to normal GE patients. The severity of symptoms in functional dyspepsia and idiopathic gastroparesis, even when assessed during the GE test meal, is not correlated to gastric emptying rate. (Ethics committee University Hospital of Leuven study number S55426).

Topical Mastic Oil for Treatment of Functional Dyspepsia: A Randomized , Triple-Blind Controlled Trial

Background: The main goal of the present study was to evaluate the effect of topical mastic oil, compared to placebo on treatment of functional dyspepsia (FD). Materials and Methods: Sixty-three patients with FD were included. Thirty-two subjects received the topical mastic oil (10 drops/TDS after meal) with massage and 31 patients received topical sesame oil with massage. Both groups received pantoprazole (40 mg daily) along with oil and massage. The severity of early satiation, postprandial fullness, epigastric pain and epigastric burning was assessed after 4 weeks using the Visual Analogue Scale (VAS) as well as frequency of symptoms. Satisfaction with the treatment was also assessed using a researcher-made questionnaire. Changes in the severity of symptoms were evaluated by Friedman’s test. Results: Mean and standard deviation of age of the subjects were equal to 36.95±13.64 and 50 (79.4%) patients were female. Both groups experienced a significant decrease in the severity of all the four symptoms (P&lt;0.001). The percentage of decrease in the severity of early satiation was significantly higher in the mastic group than the control group (76.03±34.91% vs. 37.24±38.86%, P=0.003). No significant differences were found in the percentage of decrease in the severity of postprandial fullness, epigastric pain and burning between the study groups (P=0.05, 0.06, and 0.13, respectively). The frequency of symptoms was decreased similarly in both groups. Satisfaction with the treatment was reported to be significantly higher in the mastic group than the sesame group (P=0.01). There were no intolerable side effects in both groups. Conclusion: Mastic oil reduced early satiation better than the placebo. In addition, satisfaction with the treatment was higher in the mastic group than the sesame group. [GMJ.2021;10:e1965]

Topical Mastic Oil for Treatment of Functional Dyspepsia: A Randomized , Triple-Blind Controlled Trial

Background: The main goal of the present study was to evaluate the effect of topical mastic oil, compared to placebo on treatment of functional dyspepsia (FD). Materials and Methods: Sixty-three patients with FD were included. Thirty-two subjects received the topical mastic oil (10 drops/TDS after meal) with massage and 31 patients received topical sesame oil with massage. Both groups received pantoprazole (40 mg daily) along with oil and massage. The severity of early satiation, postprandial fullness, epigastric pain and epigastric burning was assessed after 4 weeks using the Visual Analogue Scale (VAS) as well as frequency of symptoms. Satisfaction with the treatment was also assessed using a researcher-made questionnaire. Changes in the severity of symptoms were evaluated by Friedman’s test. Results: Mean and standard deviation of age of the subjects were equal to 36.95±13.64 and 50 (79.4%) patients were female. Both groups experienced a significant decrease in the severity of all the four symptoms (P&lt;0.001). The percentage of decrease in the severity of early satiation was significantly higher in the mastic group than the control group (76.03±34.91% vs. 37.24±38.86%, P=0.003). No significant differences were found in the percentage of decrease in the severity of postprandial fullness, epigastric pain and burning between the study groups (P=0.05, 0.06, and 0.13, respectively). The frequency of symptoms was decreased similarly in both groups. Satisfaction with the treatment was reported to be significantly higher in the mastic group than the sesame group (P=0.01). There were no intolerable side effects in both groups. Conclusion: Mastic oil reduced early satiation better than the placebo. In addition, satisfaction with the treatment was higher in the mastic group than the sesame group. [GMJ.2021;10:e1965]

Evaluation of main functional dyspepsia symptoms after probiotic administration in patients receiving conventional pharmacological therapies.

ObjectivePostprandial distress syndrome (PDS) and epigastric pain syndrome (EPS) are the two main forms of functional dyspepsia (FD). Probiotics are a promising therapy for FD, but current data remains heterogeneous. This work aims to evaluate a probiotic combination of Lacticaseibacillus rhamnosus LR04 (DSM 16605), Lactiplantibacillus pentosus LPS01 (DSM 21980), Lactiplantibacillus plantarum LP01 (LMG P-21021), and Lactobacillus delbrueckii subsp. delbruekii LDD01 (DMS 22106), alone or together with other pharmacological therapies, for clinical improvement of symptoms associated with FD.MethodsPatients with FD were enrolled and divided into two groups: PDS and EPS. Probiotic alone or combined with prokinetics, antacids, or proton-pump-inhibitors were administered for 30 days. A progressive-score scale was used to evaluate symptoms in all patients at the beginning of the trial and at 15 days after the end of treatment.ResultsA cohort of 2676 patients were enrolled (1 357 with PDS; 1 319 with EPS). All patients showed significant improvements in dyspeptic symptoms following treatment. In patients with PDS, probiotic alone resulted in the lowest prevalence of symptoms following treatment, while patients with EPS showed no clear between-treatment differences.ConclusionsDyspeptic symptoms were reduced following treatment in all patients.

Comparison of a Novel Herbal Medicine and Omeprazole in the Treatment of Functional Dyspepsia: A Randomized Double-Blinded Clinical Trial.

Background The Trachyspermum ammi L. (TA), Anethum graveolens L. (AG), and Zataria multiflora Boiss (ZM) herbal oils are among the most used herbal products in traditional medicine as the antiseptic, anesthetic, carminative, and antispasmodic. However, there are no clinical studies to evaluate the efficacy of the herbs mentioned in the treatment of functional dyspepsia (FD). This study was designed to appraise the efficacy and safety of a novel herbal medicine consisting of ZM, AG, and TA essential oils compared to omeprazole in FD treatment. Methods The present study was a randomized double-blind clinical trial with parallel groups in Iran. Patients in control and intervention arms received omeprazole 20 mg once a day and 250 mg soft-gel capsules containing 180 mg of essential oils of ZM, AG, and TA twice a day for two weeks, respectively. The primary outcome was the sufficient response rate in the postprandial distress syndrome (PDS) and/or epigastric pain syndrome (EPS) at the end of the intervention. Secondary outcomes were the improvement rate in the PDS, EPS, Gastrointestinal Symptom Rating Scale (GSRS), and quality of life scores. Also, safety and tolerability were assessed. Results The within-group comparison of EPS, PDS, total GSRS, GSRS Pain, and GSRS Dyspepsia scores with that at the end of the treatment indicated a significant reduction in both control and intervention groups (p < 0.001). However, after two weeks of treatment, the herbal medication and omeprazole arms were significantly different in the sufficient response rate based on PDS (p < 0.01) and EPS (p < 0.05) scores (78.3% (18/23) and 73.7% (14/19) in the intervention group vs. 36.4% (8/22) and 40.9% (9/22) in the control group). Also, the mean reduction in EPS (p < 0.05), PDS (p < 0.01), and GSRS (p < 0.001) scores after treatment was significantly higher in the intervention group than control group. Conclusion Based on the study findings, this herbal medicine can be considered as an appropriate treatment of FD. However, a larger multicenter trial is needed to confirm the results of the trial.

Wilkie’s Weight Loss Wonder: A Case Series

INTRODUCTIONWilkie’s Syndrome, also known as Superior Mesenteric Artery Syndrome (SMAS), is a rare cause of bowel obstruction that can contribute to vague abdominal symptoms on clinical presentation. This syndrome occurs when the aortomesenteric angle decreases, compressing the third portion of the duodenum between the aorta and the superior mesenteric artery. An acute decrease in the mesenteric fat pad cushion between these two blood vessels is the primary etiology, although other causes (e.g., anatomical, postoperative, functional, and pubescent etiologies) have also been described.CASE PRESENTATIONIn the present cases, 2 females with a common history of recent weight loss presented to our institution with similar symptoms of abdominal pain, nausea and vomiting. Each patient was subsequently diagnosed with SMAS following imaging studies. Both patients experienced successful resolution of symptoms with conservative nutritional management.DISCUSSIONCommon presenting complaints of SMAS include nausea, vomiting, early satiety and postprandial pain. These symptoms overlap with other gastrointestinal disorders (i.e., mesenteric ischemia, intestinal volvulus, peptic ulcer disease) making diagnosis difficult. SMAS can be identified through imaging modalities including barium studies and computer tomography. First line therapies typically include conservative nutritional support and promotion of weight gain. If conservative therapies fail, various surgical procedures can be pursued. Delayed diagnosis can lead to further pathological sequelae, including duodenal compromise, ischemia and necrosis. As the syndrome progresses, success of conservative nutritional support is less likely, and surgical correction becomes increasingly necessary.CONCLUSIONTherefore, a clinical goal for SMAS should include as swift a recognition and diagnosis as possible.

Botulinum Toxin Injection for Chronic Parotitis: A Multi-Center and Prospective Trial.

When conservative therapy fails for chronic parotitis, sialendoscopic treatment or surgical excision can be considered. However, these are financially costly or invasive. Thus, this study aimed to evaluate the clinical efficacy and safety of botulinum toxin (BTX) injection and to further analyze its effect on parotid gland function and volume using salivary single-photon emission computed tomography (SPECT)-computed tomography (CT). This clinical trial has been registered in the Clinical Research Information Service, Republic of Korea. Fourteen patients with chronic parotitis received BTX injections into the parotid glands. Pain, postprandial pain, swelling, aesthetic discomfort, and salivary flow rate were assessed before injection, at 2 weeks, and at 1, 3, and 6 months. Salivary SPECT-CT was performed before injection and again 3 and 6 months after to assess the volume and uptake changes. All subjective symptoms decreased significantly until 1 month and then increased. However, at 6 months, all subjective symptoms were determined to be better than before injection. The unstimulated and stimulated salivary flow rate did not show a significant difference over time. No significant difference was noted in parotid gland volume or uptake on salivary SPECT-CT over time. BTX injection can be an alternative treatment option for chronic parotitis. 4 Laryngoscope, 131:E1903-E1909, 2021.

S1801 Got It From My Mama: Case Report of Mesenteric Adenocarcinoma

INTRODUCTION: Mesenteric tumors are uncommon. They arise from peritoneum, lymphatic, fat, and connective tissue. Generally, consist of nonneoplastic or neoplastic tumors. We report a case of an unusual mesenteric adenocarcinoma. CASE DESCRIPTION/METHODS: A 83-year-old female presented for a routine surveillance colonoscopy. She had undergone right hemicolectomy (2015) for stage II colon cancer (T3N0M0). She had a strong family history of cancer: colon and pancreatic cancer ( mother), rectal cancer (brother) and lung cancer (sister). She had previously undergone TAH BSO (1999). She presented with vague epigastric discomfort and post prandial pain but had no nausea, vomiting or weight loss. CT scan revealed a focal mass with rim enhancement near the inferior aspect of the pancreatic body measuring 4 cm × 3.7 cm and wall thickening of the gastric antrum. On EGD 4 nonbleeding antral ulcers were seen. EUS demonstrated a 5.2 × 3.6 cm irregular mass near the pancreatic neck, heterogenous and cystic but separate from the pancreas. FNA positive for adenocarcinoma. On PET scan a centrally necrotic neoplasm of the right mid abdomen was identified. CEA and CA19-9 were not elevated, HGB and LFTs were normal. At the time of this abstract the patient was receiving neoadjuvant chemotherapy. DISCUSSION: Mesenteric tumors consist of peritoneal cysts, enteric cysts, mesenteric mesotheliomas, mesenteric lipodystrophy, lymphangiomas, desmoid tumors (associated with FAP & Gardner syndrome), mesenteric lymphoma, mesenteric Carcinoid tumors & metastatic tumors. Medical evaluation consists of clinical examination, imagery and histopathology. Therapeutic management vary from observation, medical therapy to surgery: (Dufray et al. 239).This case underscores the importance of a thorough post-operative surveillance in patients with colo-rectal cancer. Implementation of postoperative surveillance guideline recommendations will potentially aide with early detection of metachronous colorectal lesions and other primary neoplasm in other organ systems.

S2896 A Rare Case of Proximal Intestinal Obstruction from Superior Mesenteric Artery Syndrome

INTRODUCTION: Superior mesenteric artery (SMA) syndrome is a rare disorder that is characterized by compression of the third portion of the duodenum due to narrowing of the angle between the SMA and the aorta. Patients typically present with intermittent postprandial epigastric pain, nausea, and bilious vomiting. We report a case of a 25-year-old female who presents with symptoms of intestinal obstruction, diagnostic evaluation revealing SMA syndrome, and successful duodeno-jejunostomy procedure. CASE DESCRIPTION/METHODS: A 25-year-old female history of cholecystectomy presented with worsening symptoms of nausea, intractable vomiting, postprandial epigastric pain, and twenty pound weight loss for 2 years. She had multiple hospitalizations and extensive gastrointestinal work-up in the past without any identifiable cause of her symptoms. Physical exam, labs, CT abdomen and pelvis, EGD, colonoscopy, and PillCam endoscopy were benign. CT angiography of abdomen and pelvis demonstrated a decreased aorta-superior mesenteric artery angle of 9.1 degrees (normal 38 degrees to 65 degrees) with aorta- superior mesenteric distance of 5.1 mm (normal 10 to 28 mm), and compression of the third part of duodenum, confirming the diagnoses of SMA syndrome. She was initially managed conservatively with duodenal and gastric decompression via NG tube, fluid and electrolyte correction, body positioning, proton pump inhibitors, and nutritional support. Unfortunately, the patient had no improvement in her symptoms and subsequently required duodeno-jejunostomy. Upon completion of the procedure, the patient had complete resolution of her presenting symptoms. DISCUSSION: The diagnosis of SMA syndrome requires a high clinical suspicion in order to obtain abdominal angiography in patients with persistent symptoms despite negative endoscopic and conventional radiographic findings. Diagnosis requires an aorto-mesenteric angle between 6-22 degrees and an aorto-mesenteric distance between 2-8 mm on CT angiography. Patients should initially be managed with conservative therapy. However, if symptoms fail to improve or increase in severity, surgery is the definitive treatment. Surgical options include duodeno-jejunostomy, gastro-jejunostomy, and Strong’s procedure. Duodeno-jejunostomy is the procedure of choice, as it carries a 90% success rate.

The role of intraoperative endoscopic guidance during laparoscopic repair of esophageal achalasia

Purpose The aim was to assess the advantage of using intraoperative endoscopic guidance during laparoscopic repair of esophageal achalasia. Materials and methods This was a retrospective study conducted at Ain Shams Specialized Hospitals that included 84 patients. A total of 42 patients had Heller cardiomyotomy procedure with dor fundoplication and another 42 patients had the same procedure with intraoperative endoscopic guidance. Results Preoperative symptoms included dysphagia in 80 (95%) patients, regurgitation and vomiting in 60 (71.5%) patients, heartburn in 56 (66%) patients, and postprandial chest pain in 40 (49%) patients. Weight loss occurred in 42 (50%) patients. Overall, 72 (85%) patients had tried 2–3 pneumatic dilation. Mean lower esophageal sphincter pressure preoperatively was 33 and was 13.3 mmHg postoperatively (4.1–28.4). The operative time was 45±20 min in the endoscopic group and was 40±10 in the nonendoscopic guidance. Overall, 5 patients of the nonendoscopic group had perforation and one case of bleeding. Postoperatively, dysphagia was seen in one (2.25%) patient of the endoscopic group and four (9.5%) patients of the nonendoscopic group. Postprandial heart pain was seen in two (4.6%) patients of the endoscopic group and four (9.2%) patients of the nonendoscopic group. Moreover, 2 (4.6%) patients of the endoscopic group and four (9.5%) patients of the nonendoscopic group had postoperative regurgitation. Weight regain was seen in 19 (90%) patients of the endoscopic group and 17 (80%) patients of the patients of nonendoscopic group after 12-month follow-up. Conclusion Heller cardiomyotomy with endoscopic guidance is very important not only as a guide to ensure adequate myotomy but also to limit the extent of the myotomy, thereby minimizing the postoperative reflux symptoms.

S1479 Cystic Duct Stump Stone: A Diagnostic Dilemma of Post Cholecystectomy Syndrome

INTRODUCTION: Post-cholecystectomy syndrome (PCS) is defined as persistent dyspepsia, upper abdominal pain, pancreatitis, or jaundice after cholecystectomy. The symptoms of PCS can be caused by a wide variety of conditions, including biliary, pancreatic, or hepatic, while the rest are extra-intestinal. PCS can be described as early: occurring in the postoperative period or late: occurring months to years later. Here we will focus on endoscopic management of retained biliary stones within the cystic duct stump. CASE DESCRIPTION/METHODS: We present a 72-year-old male with new post-prandial epigastric pain with mild tenderness on deep palpation. Cholecystectomy completed six months prior. Lipase: 82, AST: 72, ALT: 47, Total Bilirubin: 0.7, Direct bilirubin: 0.2. CT Abdomen Pelvis with Contrast: Calculus in the remnant cystic duct stump without any intra or extrahepatic biliary dilation. Endoscopic retrograde cholangiopancreatography (ERCP) and fluoroscopy were performed, without visualization of stone. Therefore, Direct Visualization Cholangioscopy was performed, where an impacted stone was noted in the proximal tip of the cystic duct stump. Electrohydraulic Lithotripsy (EHL) was completed, and fragments of the stone were flushed with biliary plastic stent placement. On a three-month follow-up, the patient remained asymptomatic with the removal of the plastic stent. DISCUSSION: It has been demonstrated that ERCP is an adequate alternative to laparoscopic therapy for the diagnosis and treatment of cystic duct stump stones, causing PCS. However, without any head-to-head trials comparing surgical versus endoscopic therapies, selection of therapy becomes anecdotal and based on institutional expertise. We demonstrate a case whereby traditional fluoroscopy with ERCP could not visualize the impacted stone at the proximal tip of the cystic duct stump. Therefore, we question whether the accuracy of diagnostic biliary fluoroscopy decreases in the setting of cystic duct stump. Without cholangioscopy and lithotripsy, the stone likely would have remained, and the patient symptomatic. Therefore, gastroenterologists should recognize the difficulty of fluoroscopic diagnosis of remnant cystic duct stump stones. Additionally, cholangioscopy facilitates selective cannulation of the cystic duct in comparison to contrast fluoroscopy on its own. We are highlighting the importance of the diagnostic and therapeutic role of direct visualization cholangioscopy, in patients with PCS and a suspected cystic duct stump stones.Figure 1.: ERCP and Fluroscopy of cystic duct stump without visualization of cystic duct stump stone.Figure 2.: Direct Visualization Cholangioscopy of impacted stone at the proximal tip of the cystic duct stump.Figure 3.: Clearance of impacted cystic duct stump stone after use of Electrohydraulic Lithotripsy.

S2043 Anxiolytic - A Gastric Fundus Relaxing Agent for Epigastric Pain Syndrome

INTRODUCTION: Functional dyspepsia (FD) is characterized by upper gastrointestinal symptoms such as early satiety, postprandial fullness, and epigastric pain or burning sensations. FD is commonly reported in women. According to the Rome III criteria, FD has two subtypes: postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS). In current clinical practice, the two subtypes often overlap in their presentation. Here, we present the case of a female patient who presented with symptoms of epigastric pain syndrome and achieved symptom relief with the anxiolytic gastric fundus relaxing agent buspirone. CASE DESCRIPTION/METHODS: A 71-year-old female with PMH of GERD, IBS, and anxiety that was well controlled with medications presented to the ED with complaints of non-radiating epigastric pain at a 7/10 intensity level intermittent since many months, and she reported no known aggravating or relieving factors. She denied any associated symptoms of nausea, vomiting, or diarrhea. In the past, she had been prescribed multiple medications such as antacids, PPI, and an anti-spasmodic agent for epigastric pain, and was also given antibiotics for possible SIBO. EGD revealed completely normal findings and no evidence of an ulcer or visible bleeding. The patient tested negative for H. pylori. After admission, she was started on a trial of 10 mg buspirone twice daily. She reported partial relief in the hospital and was discharged home. At the 1-month follow up at the GI clinic, the patient reported complete improvement in symptoms. DISCUSSION: EPS is characterized by symptoms such as an intermittent, non-generalized epigastric burning sensation, and a lack of relief with defecation or passage of flatus. Diagnosis of EPS remains exclusionary after all structural causes have been ruled out and according to the Rome III criteria, patients should have had symptoms for the past 3 months, and symptom onset should have occurred at least 6 months before the diagnosis. Reassurance and counseling have major roles. Other available agents such as antacids, PPIs, and prokinetics were reported in the treatment of EPS. Buspirone use for EPS has rarely been reported in the literature. Buspirone acts by activating 5 HT1A receptors on the presynaptic nerve endings of cholinergic neurons, thus inducing smooth muscle relaxation. Limited data are currently available on the efficacy of buspirone compared with other drugs used in the treatment of EPS. In the future, more research is needed to validate this use of buspirone.

S1441 Emphysematous Pancreatitis Complicated by Gastroduodenal Artery Pseudoaneurysm and Extra-Pancreatic Involvement

INTRODUCTION: Emphysematous pancreatitis (EP) is a rare form of necrotizing pancreatitis associated with gas-forming bacteria and a high mortality rate. Extra-pancreatic complications include pleural effusion, ascites, vascular and gastrointestinal involvement. Disruption of the pancreatic duct can cause pancreatic ascites and pleural effusion. Gastroduodenal artery (GDA) pseudoaneurysms are rare complications of EP caused by release of proteolytic enzymes leading to weakening and ballooning of the vessel wall. CASE DESCRIPTION/METHODS: We present a case of an 82-year-old male ex-smoker with a history of hyperlipidemia, peptic ulcer disease, and noninsulin-dependent diabetes mellitus, who presented with postprandial epigastric pain. During the first 24 hours of onset, he met three out of the five Ranson criteria: age greater than 55, LDH above 350, glucose of 393 mg/dl, with additional findings of AST 46 IU/L, WBC 14.64, amylase 2,378, and lipase greater than 600. CT revealed pancreatic gas, bilateral pleural effusions, and cholelithiasis, the latter of which was determined to be the cause of acute EP (Figure 1). The patient required surgical debridement and ERCP with stenting of biliary and pancreatic ducts (Figure 2). Intraoperative cultures were negative for enteric, fungal, or anaerobic organisms. One month later, the patient presented with septic shock and leukocytosis. Abdominal CT revealed sequelae of necrotizing pancreatitis with increased extent of fluid collection. Upper endoscopic ultrasound identified a 35 mm fluid-filled lesion in the pancreatic head positive for gram-negative rods and Streptococcus anginosus. The following week, the patient presented with melena and painless bleeding from his Davol drain. Abdominal CT angiography showed a pseudoaneurysm arising from the distal GDA and endovascular coil embolization was performed (Figure 3). One year later, the patient presented with weight loss. Abdominal CT identified a 7.0 cm pancreatic pseudocyst causing extrinsic compression in the gastric body and antrum leading to LA Grade C stasis esophagitis. A 15 mm cystgastrostomy metal stent was placed across the posterior gastric wall to relieve gastric outlet obstruction. DISCUSSION: Our case offers a unique sequela of EP causing GDA pseudoaneurysm with delayed formation of a pancreatic pseudocyst leading to severe esophagitis and gastric outlet obstruction. Effective diagnostic and therapeutic management helped this patient survive his multiple, life-threatening complications associated with EP.Figure 1.: Figure 1. Abdominal CTs in coronal view performed 6 hours apart. (A) Initial abdominal CT without contrast showed extensive inflammatory and air (white arrow) around the pancreatic head concerning for emphysematous pancreatitis versus duodenal perforation. (B) Subsequent same-day CT examination with oral contrast only demonstrated marked increase in pancreatic gas and inflammatory changes (white arrow) concerning for rapid progression. There was no extravasation of oral contrast (dashed white arrows) thereby ruling out perforated viscus as a cause for the air.Figure 2.: Figure 2. ERCP and sphincterotomy were performed given the known pancreatic head necrosis. The main pancreatic duct (A) and common bile duct (B) were cannulated, and temporary pancreatic and biliary stents were placed.Figure 3.: Figure 3. (A) Abdominal CT angiography showed pseudoaneurysm (white arrow) arising from a branch of the gastroduodenal artery in the region of peripancreatic inflammatory changes. (B) The gastroduodenal artery was embolized with multiple coils (dashed white arrow) endovascularly to treat the pseudoaneurysm.

The Role of Ultrasound in Dunbar Syndrome: Lessons Based on a Case Report

Patient: Male, 55-year-oldFinal Diagnosis: Dunbar syndromeSymptoms: Epigastric pain • weight lossMedication: —Clinical Procedure: NoneSpecialty: Gastroenterology and Hepatology • RadiologyObjective:Rare diseaseBackground:Dunbar syndrome is a rare vascular alteration caused by the abnormal course of the median arcuate ligament of the diaphragm, which in some patients causes chronic compression of the celiac artery and can cause non-specific symptoms such as diarrhea, retro-sternal pain, vomiting, swelling, and nausea, or a typical symptomatic triad with weight loss, post-prandial abdominal pain, and epigastric murmur. Color Doppler ultrasound and duplex Doppler ultrasound provide a complete diagnostic framework of this disease.Case Report:We describe a case of 55-year-old man with post-prandial epigastric pain, significant weight loss, and several episodes of retro-sternal pain. He underwent multidetector computed tomography of the abdomen and color duplex Doppler ultrasound examination of the celiac artery that highlighted stenosis of the celiac artery, more severe in expiratory apnea. The computed tomography showed the typical aspect of the celiac artery, with the “hook sign”. A duplex Doppler ultrasound examination showed a significant increase in peak speed (226 cm/s) due to severe stenosis of the celiac artery by the median arched ligament of the diaphragm.Conclusions:This case is unique due to the severity of the celiac artery stenosis and the unusual clinical presentation of the patient who had frequent episodes of retro-sternal pain. The significant increase in peak velocity in the celiac artery in expiratory apnea, if associated with the typical symptomatology in the absence of other alterations of the splanchnic vessels, can be considered, in our opinion, sufficient for the diagnosis of Dunbar syndrome.

Herbal medicine Siho-sogan-san for functional dyspepsia: A protocol for a systematic review and meta-analysis.

Background:Functional dyspepsia (FD) is characterized by persistent and recurrent dyspeptic symptoms, such as postprandial fullness and epigastric pain. Although it is rarely severe or life-threatening, it can degrade the quality of life and cause social and economic issues. As symptoms often persist despite the treatment with conventional Western medicine, herbal medicine can be considered as an alternative for treating FD. Siho-sogan-san (SHS) is a traditional herbal formula prescribed for dyspepsia for hundreds of years. This protocol for a systematic review was designed to evaluate the safety and efficacy of SHS for the treatment of FD through a meta-analysis.Methods:Studies will be searched from the following electronic databases up to March 2020: Embase, MEDLINE (via PubMED), Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine Database, Korean Medical Database, KoreaMed, Korean Studies Information Service System, National Digital Science Library, Oriental Medicine Advanced Searching Integrated System, China National Knowledge Infrastructure Database, and Citation Information by Nii. Randomized controlled trials of SHS and herb-added SHS for treating FD will be selected in this review. The control groups of no-treatment, placebo, and conventional Western medicine will be compared with SHS for its efficacy. The synergetic effect of SHS with Western medicine will also be analyzed in comparison with conventional Western medicine alone. Two independent reviewers will collect the data and assess the risk of bias in individual studies. The total clinical effectiveness rate will be synthesized and evaluated as primary outcome.Results:This systematic review will present an adequate clinical evidence of SHS for the treatment of FD based on specific parameters, including dyspepsia-related symptoms, gastric emptying, and adverse events.Conclusion:This study will provide evidence for the safety and efficacy of SHS for the treatment of patients with FD.Review Registry Unique Identifying Number:reviewregistry952.

Predictive value of alarm symptoms in patients with Rome IV dyspepsia: A cross-sectional study.

BACKGROUNDNo studies have evaluated the predictive value of alarm symptoms for organic dyspepsia and organic upper gastrointestinal (GI) diseases based on Rome IV criteria in the Chinese population.AIMTo evaluate the predictive value of alarm symptoms for dyspeptic patients based on Rome IV criteria.METHODSWe performed a cross-sectional study of dyspepsia patients who met the inclusion and exclusion criteria at two academic urban tertiary-care centers from March 2018 to January 2019. Basic demographic data, dyspeptic information, alarm symptoms, lifestyle, examination results, family history and outpatient cost information were collected. Dyspepsia patients with normal findings on upper GI endoscopy, epigastric ultrasound and laboratory examination and without Helicobacter pylori-associated dyspepsia were classified as functional dyspepsia.RESULTSA total of 381 patients were enrolled in the study, including 266 functional dyspepsia patients and 115 organic dyspepsia patients. There were 24 patients with organic upper GI disease among patients with organic dyspepsia. We found that based on the Rome IV criteria, alarm symptoms were of limited value in differentiating organic dyspepsia and organic upper GI diseases from functional dyspepsia. Age (odds ratio (OR) = 1.056, P = 0.012), smoking (OR = 4.714, P = 0.006) and anemia (OR = 88.270, P < 0.001) were independent predictors for organic upper GI diseases. For the comparison of epigastric pain syndrome, postprandial distress syndrome and epigastric pain syndrome combined with postprandial distress syndrome, the results showed that there were statistically significant differences in anorexia (P = 0.021) and previous visits (P = 0.012). The ClinicalTrials.gov number is NCT 03479528.CONCLUSIONMost alarm symptoms had poor predictive value for organic dyspepsia and organic upper GI diseases based on Rome IV criteria. Gastroscopic screening should not be based solely on alarm symptoms.

Reconstruction of superior mesenteric artery by prostheses placement in a case of chronic mesenteric ischemia: A case report and literature review.

Although superior mesenteric artery stenosis is a relatively common situation, it is rarely symptomatic due to the fact that in a significant number of cases an adequate collateral circulation exists. The aim of this study is to report a case in which arterial reconstruction was needed due to the absence of such a patent collateral circulation. The 47-year-old patient was investigated for chronic postprandial pain and was diagnosed with superior mesenteric artery stenosis. Percutaneous treatment was the initial option of choice but the patient rapidly became symptomatic again. Therefore surgery was performed, the segment of arterial stenosis was resected and the arterial continuity was re-established by using a synthetic prosthesis. The postoperative outcome was uneventful, the patient was discharged in the seventh postoperative day under anticoagulant therapy. In conclusion, superior mesenteric artery reconstruction by using a synthetic prosthesis can be useful in cases presenting chronic mesenteric ischemia and failure of percutaneous treatment.

Internal Hernia After Laparoscopic Gastric Bypass Without Preventive Closure of Mesenteric Defects: a Single Institution’s Experience

BackgroundInternal herniation (IH) is a well-known complication after laparoscopic gastric bypass (LGB). Diagnosing and managing IH can be challenging. This retrospective cohort study aimed to achieve a greater understanding of symptomatology, diagnostic tools, complications, risk of IH recurrence, and symptom relief in IH patients. MethodsWe included patients who underwent LGB surgery at our institution between 2011 and 2015. Mesenteric defects were not preventively closed during LGB. We focused on LGB patients who underwent surgical intervention(s) for suspected IH during a 7-year study period. We studied patient characteristics, (predictive) symptoms and signs, abdominal imaging, operative findings, post-operative course, and risk of (recurrent) IH. ResultsA total of 1588 patients were included. In total, 243 patients underwent IH-related diagnostic laparoscopy. Radiating pain to the back (OR 2.45, p = .03), post-prandial pain (OR 3.23, p = .00), and leukocytosis (OR 15.53, p = .01) were identified as predictors of IH. The estimated risk of IH-related diagnostic laparoscopy was 16% at 3 years post-LGB, and the risk of confirmed IH was 12%. The estimated risk of diagnostic laparoscopy for suspected recurrent IH was 10% at 5 years post-LGB. In patients who underwent secondary mesenteric defects closure, post-operative symptom relief was reported in 84%. ConclusionThis study demonstrates a considerable risk of developing IH after LGB without preventive closure of the mesenteric defects. We emphasize the value of diagnostic laparoscopy to achieve symptom relief in patients with suspicion of IH. Preoperative diagnosis of IH can be improved by being watchful of specific symptoms and signs which can predict the intra-operative presence of IH.

Effects of Rome IV Definitions of Functional Dyspepsia Subgroups in Secondary Care

Functional dyspepsia (FD) is subdivided into postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS) according to the Rome III consensus. In clinical practice, there is a major overlap between these subgroups. The Rome IV criteria included postprandially occurring symptoms in the PDS subgroup. We aimed to analyze the effects of the Rome IV criteria, compared with Rome III, on FD subgroups in patients recruited from secondary care. Patients with FD (n= 224; mean age, 43 ± 1 y; 77% women) were recruited from secondary-care units in Belgium and filled out symptom questionnaires, allowing subdivision according to Rome III and Rome IV criteria and identification of postprandial symptoms. Symptom patterns and demographics were compared between the subgroups. Statistical analysis was performed using the t test and the Fisher exact test. According to the Rome III criteria, 25% of participants had PDS, 8% had EPS, and 67% had an overlap. Postprandial fullness, early satiation, and bloating were present in significantly more patients in the PDS and overlap groups than the EPS group (P < .0001). A higher proportion of patients in the overlap group showed symptoms such as postprandial epigastric pain and nausea than in the EPS group (both P ≤ .02). With the Rome IV criteria, the overlap group was reduced to 35%; 57% of patients were considered to have PDS and 8% to have EPS. Postprandial pain was significantly more prevalent in the PDS than in the EPS group (P ≤ .002), and postprandial nausea was significantly more prevalent in the PDS group than the overlap group (P= .007). Compared with Rome III criteria, the Rome IV criteria significantly reduces the overlap between PDS and EPS groups. Studies are needed to determine if Rome IV subgroups are associated differently with psychological comorbidities and treatment responses.

Carcinoid of the uncinate process of the pancreas in a child: An unusual case

Carcinoid of the pancreas is rare among children. We treated a debilitating child who complained about post-prandial pain with a mass in upper abdomen, vomiting and weakness for a period of six months. Abdominal examination revealed an immobile, mildly tender, solid mass in the right lumbar region. Ultrasonography of abdomen demonstrated a tumour of head of the pancreas and ultrasonography-guided fine needle aspiration cytology of the mass suggested a malignant small round cell tumour. With Computed Tomogram an enhancing compact big mass was found at the head of the pancreas compressing the duodenum without invasion and metastasis. At exploratory laparotomy, we also detected a well-defined, rounded, big solid mass arising from uncinate process of the pancreas with no metastasis. After the excision of the mass along with a healthy portion of uncinate process, the patient recovered successfully. Histopathology evaluation showed a neoplasm composed of small nests and sheets of a dense cluster of malignant round cells with hyperchromatic nuclei, sometimes forming acini with stromal invasion. Diagnosis was malignant carcinoid of the pancreas, T2 N0 M0. At follow-up of three and a half years, the patient was found symptom-free and there was no evidence of recurrence.&#x0D; Mediscope Vol. 7, No. 1: Jan 2020, Page 58-62