Symptoms Of Recurrent Abdominal Pain Research Articles

Choledococele as a cause of recurrent abdominal pain and biliary sepsis.

We report the case of a 91-year-old female with acute cholangitis and long-standing symptoms of recurrent colic- related abdominal pain after cholecystectomy. She was diagnosed by abdominal CT of saccular dilation of the intramural bile duct in the duodenum suggesting choledococele. ERCP was performed in which the presumptive diagnosis was confirmed, and choledochotomy and choledochoplasty were done with excellent subsequent progress. Choledococele is the least common type of biliary cyst. It consists of a cystic dilation of the intramural portion of the common bile duct that protrudes into the duodenal lumen and causes symptoms of recurrent abdominal pain and biliary events. ERCP is a key test in both diagnosis and treatment except when they cannot be approached by this technique or malignancy is suspected.

The efficacy of the traditional Korean herbal medicine Tongsayobang for the treatment of irritable bowel syndrome: A protocol for a systematic review and meta-analysis.

Background:Irritable bowel syndrome (IBS) is a functional bowel disorder with symptoms of recurrent abdominal pain associated with a change in stool frequency or appearance that decreases patient quality of life. Conventional Western medicine has limited efficacy in treating IBS. Tongsayobang (TSYB) is a traditional Korean medicine that has been used to treat lower intestinal problems. This study provides a procedure for conducting a systematic review of the efficacy and safety of TSYB for IBS.Methods and analysis:The main electronic databases will be searched up to May 2021 for randomized controlled trials and quasi-randomized controlled trials evaluating the effect of TSYB or modified TSYB on patients with IBS. The primary outcome will be the overall efficacy rate. The secondary outcome will be data such as IBS-related quality of life, global symptom scores, and adverse events. This study will adopt the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, and will involve a meta-analysis, if possible. The methodological quality of the included studies will be assessed using the Risk of Bias tool from the Cochrane Handbook, version 6.1.0.Ethics and dissemination:Ethical approval is not required because this study does not include any participants’ personal information.OSF registration number:DOI 10.17605/OSF.IO/M32BK (https://osf.io/m32bk)

Zespół jelita nadwrażliwego – czynniki ryzyka i znaczenie leków spazmolitycznych. Punkt widzenia gastroenterologa i psychologa

Irritable bowel syndrome (IBS) is a highly prevalent, chronic disorder that significantly reduces patients’ quality of life. In clinical practice, IBS is characterized by symptoms of recurrent ab-dominal pain and disordered defecation. Rome IV criteria, derived by consensus from a multi-national group of experts, can be used to diagnose IBS. The pathophysiology of IBS is multi-factorial in nature, and it is thought to include contributions from factors such as gut microbiota dysbiosis, altered intestinal and colonic permeability, GI immune cell activation, visceral hyper sensitivity, and abnormal gut-brain interactions. The first line therapeutic approach is directed towards education, reassurance and lifestyle modification. In case of an unsatisfactory response, an appropriate pharmacologic therapy can be suggested on the basis of digestive symptoms and/or psychological disturbances. Antispasmodic agents reduce the abdominal pain associated with IBS by inhibiting the postprandial contractility pathways in the gut wall and improve bow-el habits by increasing the colonic transit time, which reduces the frequency of stool passage, particularly in diarrhea-dominant IBS.

Short-term and long-term outcomes after Roux-en-Y hepaticojejunostomy versus hepaticoduodenostomy following laparoscopic excision of choledochal cyst in children.

Choledochal cysts are congenital dilations of the biliary tree. Complete cyst excision and biliary-enteric reconstruction have been the standard operations. In our center, more than 95% of choledochal cyst excision is now performed laparoscopically. Majority of current studies describe laparoscopic-assisted reconstruction using Roux-en-Y hepaticojejunostomy (HJ). However, only a few have studied laparoscopic hepaticoduodenostomy (HD) as an alternative method of biliary-enteric reconstruction. In this study, we focused on comparing longer-term outcomes between laparoscopic HJ and HD reconstruction following choledochal cyst excision. We performed retrospective analysis of 54 children who had undergone laparoscopic choledochal cyst excision and biliary-enteric reconstruction between October 2004 and April 2018. Short-term outcomes including operative time, complications such as anastomotic leakage and bleeding, and hospital stays were included. Long-term outcomes including contrast reflux into biliary tree, cholangitis, anastomotic strictures, and need of reoperation were analyzed. Of the 54 patients, 21 of them underwent laparoscopic HD and 33 underwent laparoscopic Roux-en-Y HJ anastomosis reconstruction. There were no significant differences in gestation, gender, age at operation, antenatal diagnosis, and Todani type of choledochal cyst between HD and HJ group. Operative time was significantly shortened in HD group (p = 0.001). Median time to enteral feeding was 3days in both groups. Median intensive care unit (p = 0.001) and hospital stay (p = 0.019) were significantly shorter in HD group. There was no perioperative mortality. There was no significant difference in anastomotic leakage requiring reoperation (p = 0.743). There were no significant differences in long-term outcomes including anastomotic stricture (p = 0.097), cholangitis (p = 0.061), symptoms of recurrent abdominal pain or gastritis (p = 0.071), or need of reoperation (p = 0.326). All patients had normal postoperative serum bilirubin level. Laparoscopic excision of choledochal cyst with HD reconstruction is safe and feasible with better short-term outcomes and comparable long-term outcomes compared to Roux-en-Y HJ reconstruction.

Long standing biliary colic masking chylous ascites in laparoscopic roux-en-Y gastric bypass; a case report

BackgroundChylous ascites is considered to be an intra-abdominal collection of creamy colored fluid with triglyceride content of > 110 mg/dL. Chylous ascites is an uncommon but serious complication of numerous surgical interventions. However, it is a rare complication of LRYGB. An internal hernia limb defect is thought to be the underlying etiology, where the hernia will cause lymphatic vessel engorgement and lymphatic extravasation.Case presentationWe report a case of a 29 years old male with a 9 year history of laparoscopic Roux en y gastric bypass (LRGYB), presenting with recurrent abdominal pain for 2 months radiating to the right shoulder. Ultrasound examination revealed gallstones and the patient was subsequently admitted for laparoscopic cholecystectomy. Intraoperatively, whitish colored fluid, high in triglycerides content was aspirated. During exploration, an internal hernia limb defect was found and corrected.ConclusionPost LRGYB patients with symptoms of recurrent abdominal pain should be suspected for chylous ascites reflecting an internal hernia.

Childhood recurrent abdominal pain and Helicobacter pylori infection, Islamic Republic of Iran.

We examined the role of Helicobacter pylori infection as a cause of recurrent abdominal pain (RAP) among Iranian children in a population-based case-control study to determine the association between H. pylori infection and RAP among schoolchildren. A total of 1558 children aged 6-13 years were examined. Children with RAP confirmed by the Apley and Naish criteria were selected; 145 cases were selected for inclusion and were compared with 145 healthy children recruited from the same area. Both groups underwent stool antigen testing. The prevalence of RAP in the children tested was 9.3%. Children with RAP had a higher H. pylori infection rate than the control group (58.6% vs 44.8%) (OR = 1.744; 95% CI: 1.095-2.776). There was no significant difference between the RAP symptoms in children with positive stool test, i.e. infected with H. pylori, and those whose tests were negative. We identified H. pylori infection in more than 55% of the case group. Therefore, H. pylori infection can be considered an important factor for RAP in children.

Lactose malabsorption based on breath hydrogen test in children with recurrent abdominal pain

Background Recurrent abdominal pain (RAP) is common amongschool-age children. Previous studies found that lactose malab-sorption has an important role in RAP in children. Up to date, dataon the prevalence of lactose malabsorption in children with RAPin Indonesia has not been available.Objective To elicit the prevalence of RAP and lactose malabsorption inchildren with RAP, and to determine associated foods that cause RAPin children with and without lactose malabsorption, the frequency oflactose intolerance during breath hydrogen test (BHT), and also theonset and duration of the symptoms after a lactose load.Methods This was a cross-sectional study conducted on juniorhigh school students who suffered from recurrent abdominal pain.Results Of 1054 students screened, 157 (14.9%) fulfilled the Apley’scriteria for RAP. Of 157, 85 children were enrolled and underwentBHT. Fifty five of them (65%) were girls. Lactose malabsorptionwas found in 68 (80%) subjects. Milk and yogurt were the mostfrequent products that cause symptoms of RAP in our subjectswho mostly (80%) were malabsorber. Lactose intolerance duringBHT was found in 69 (81%) children. Symptoms appeared in 30minutes after lactose ingestion, and the most frequent symptomwas abdominal pain (44%). Lactose intolerance symptoms disap-peared in about 15 hours.Conclusions The prevalence of RAP in children aged 12-14 yearswas 14.9%. The prevalence of lactose malabsorption in childrenwith RAP was 80%. Milk and yogurt were the most frequent productsthat cause symptoms of RAP in our subjects who mostly weremalabsorbers. The frequency of lactose intolerance during BHTwas 81%, and the symptoms lasted within approximately 15 hours

PTU-132 Increased duodenal intra epithelial lymphocytes (IELS) are associated with recurrent abdominal pain and parasite infection but not Helicobacter pylori in a paediatric Chilean cohort

IntroductionFunctional Recurrent Abdominal Pain (RAP) is a paediatric functional gastrointestinal disorder with poorly investigated pathophysiology. Proposed aetiology varies and the diagnosis is characterised by Rome III criteria. Some studies consider...

Sa2003 Increased Duodenal Intra Epithelial Lymphocytes (IELs) are Associated With Recurrent Abdominal Pain and Parasite Infection but Not Helicobacter pylori in a Paediatric Chilean Cohort

Introduction Functional Recurrent Abdominal Pain (RAP) is a paediatric functional gastrointestinal disorder with poorly investigated pathophysiology. Proposed aetiology varies and the diagnosis is characterised by Rome III criteria. Some studies consider Helicobacter pylori to be a cause of RAP, while others disagree. The aim of this study was to investigate upper gastrointestinal pathology in a cohort of 123 children in Chile with respect to RAP, H pylori infection and other concurrent infection. Methods This blinded retrospective and IRB-approved study analysed biopsies taken from the gastric antrum and body and the duodenum in 123 Chilean children referred to endoscopy (with informed parental consent). Histopathology was evaluated against a clinical database which included symptoms, symptom duration and endoscopy findings. Rome III criteria were used to assign RAP to the relevant cases. All patients had stool microbiology and parasitology. H pylori infection was assessed by serology and histology. In the duodenum, routine histopathology and also eosinophil counts (in 5HPF ×40 magnification), were performed by microscopy. IELs/100 enterocytes were counted. Independently those patients with IELs >25 had serology performed for coeliac disease. Results Overall 105 patients were diagnosed with RAP and 12 patients were able to act as controls, having no symptoms of RAP or concurrent infection. The Rome III diagnosis of RAP was significantly associated with higher IEL counts (>20 in 74 patients) compared to controls (p=0.04). Furthermore, a higher IEL count was also positively associated with parasitic infection (nine with parasites) (p=0.02). Of 16 patients with lymphocytic duodenosis, (>25 IELs per 100 enterocytes) only three were infected by H pylori . One had coeliac disease with positive serology. Antral nodularity was observed in association with lymphoid follicles (p≤0.01) and H pylori infection (p H pylori but infection was not significantly associated with RAP (p=0.55) or parasite infection, as concurrent infection was present in only 2 patients (p=0.24). Conclusion From this study, low grade inflammation, manifest by increased IELs, may be associated with RAP and also parasitic infection. H pylori is not associated with parasite infection. However, as eosinophilia was not significantly associated with the condition further investigation is required to elucidate the potential involvement of innate immunity, including mast cells. Furthermore, there is no association between H pylori infection and RAP. Funded by EU CONTENT Project (INCO-CT-2006-032136), CONICYT/BM (RUE #29) and Fondecyt #1100654 (Chile). Competing interests None declared.

Need for a comprehensive medical approach to the neuro-immuno-gastroenterology of irritable bowel syndrome.

Irritable bowel syndrome (IBS) is defined by the Rome III criteria as symptoms of recurrent abdominal pain or discomfort with the onset of a marked change in bowel habits with no evidence of an inflammatory, anatomic, metabolic, or neoplastic process. As such, many clinicians regard IBS as a central nervous system problem of altered pain perception. Here, we review the recent literature and discuss the evidence that supports an organic based model, which views IBS as a complex, heterogeneous, inter-dependent, and multi-variable inflammatory process along the neuronal-gut axis. We delineate the organic pathophysiology of IBS, demonstrate the role of inflammation in IBS, review the possible differences between adult and pediatric IBS, discuss the merits of a comprehensive treatment model as taught by the Institute of Functional Medicine, and describe the potential for future research for this syndrome.

Helicobacter pylori Infection in Pediatrics

The diagnosis of Helicobacter pylori infection continues to challenge practicing physicians around the world. In the last year, several reports from Africa tried to examine the epidemiology of H. pylori infection in nursing babies, while others investigated the association between recurrent abdominal pain symptoms and H. pylori. In the diagnostic arena, attempts were made to improve diagnostic accuracy, mainly by using a new monoclonal version of the stool antigen test, and by applying the urea breath test in smaller children. In the current report, the most important studies on H. pylori infection in children published in the last year are also reviewed.

Paramesocolic hernias: consequences of delayed diagnosis. Report of three new cases

Background If internal hernias account for less than 1% of the causes of intestinal obstruction, the paraduodenal or paramesocolic hernias (PMH) represent 50% of the 500 published as of the year 2000. Despite their congenital character, they are diagnosed more frequently in adulthood, with a mean age of 38 years at diagnosis. In the last few years, diagnoses are being made earlier. With the goal of increased early diagnosis and decreased mortality associated with these internal hernias, the authors report on 3 young patients with PMH. Methods Three cases of paramesocolic hernias are reported, 2 right (RPMH) and 1 left (LPMH). They all had a history of symptoms of recurrent abdominal pain of variable frequency and intensity but of sufficient importance to justify previous diagnostic studies. The 2 patients with RPMH, a 3-year-old boy and a 17-year-old woman, presented symptoms of intestinal obstruction and had necrosis of the small intestine leading to short-bowel syndrome. The LPMH patient, a 13-year-old boy, suffered recurrent abdominal pain from the age of 3. Gastroesophageal reflux was diagnosed, and surgery was performed at the age of 4 years. A laparoscopy at 13 years of age found no pathology. A new upper gastrointestinal tract series found retroperitoneal and paraduodenal jejunum incarceration, partially obstructing the duodenum. During surgery, the adhered jejunal section was restored intraperitoneally, and the open Treitz arch was closed. The authors have not found the anatomic characteristics of this case in the literature. Conclusions Delays and errors in PMH diagnosis may result in irreparable damage. Differential diagnosis workups of patients with recurrent abdominal pain syndrome should always include PMH.

Breath Test Using A Single 50‐mg Dose of 13C‐Urea to Detect Helicobacter pylori Infection in Children

ABSTRACTBackgroundThe 13C‐urea breath test is an accurate, noninvasive method for the diagnosis of Helicobacter pylori in adults. A dose of 75 to 100 mg of urea is generally used, especially in adults, but the optimal dose in children is still unknown. Our aim was to determine whether urea breath test performed with a single 50‐mg dose of 13C‐urea was sufficient and accurate for diagnosing H. pylori infection in children.MethodsConsecutive children 4 to 14 years of age undergoing upper intestinal endoscopy to evaluate symptoms of recurrent abdominal pain were prospectively included. Exclusion criteria included use of antibiotics or proton pump inhibitors during the last month, gastric surgery, and previous H. pylori eradication therapy. Reference criteria for diagnosis of infection were based on histology, culture, and serology. Urea breath test (TAU‐KIT; Isomed, S.L., Madrid, Spain) was performed as follows: citric acid (Citral pylori) dissolved in 100 mL of water was initially given. Ten minutes later, a baseline exhaled breath sample was collected, and thereafter 50 mg of 13C‐urea dissolved in 50 mL of water was given. A second breath sample was obtained 30 minutes later. Breath samples were analyzed by isotope ratio mass spectrometry. The endoscopist, the pathologist, the microbiologist, and the person responsible for reading the serology and the urea breath test were all unaware of H. pylori status by the other diagnostic methods.ResultsOne hundred children were included (40% males; mean age, 9.2 ± 2 years; mean weight, 33.9 ± 12 kg). Based on the reference criteria, 45% were infected, 37% were not infected, and 18% were indeterminate. Sensitivity, specificity, positive predictive value, and negative predictive value were, respectively, 91% (95% confidence interval [CI], 79%–96%), 97% (95% CI, 86%–99%), 98% (95% CI, 87%–91%), and 90% (95% CI, 76%–96%). Positive and negative likelihood ratios were of 33 and 0.09. Any cutoff point between 2 and 14 δ units had the same high diagnostic accuracy. The area under the receiver operating characteristic curve was 0.94. No adverse effects were reported.ConclusionUrea breath test using 50 mg of urea is sufficient and accurate for the diagnosis of H. pylori infection in children. Use of a small test dose significantly lowers the cost of the test.

Breath test using a single 50-mg dose of 13C-urea to detect Helicobacter pylori infection in children.

The 13C-urea breath test is an accurate, noninvasive method for the diagnosis of in adults. A dose of 75 to 100 mg of urea is generally used, especially in adults, but the optimal dose in children is still unknown. Our aim was to determine whether urea breath test performed with a single 50-mg dose of 13C-urea was sufficient and accurate for diagnosing infection in children. Consecutive children 4 to 14 years of age undergoing upper intestinal endoscopy to evaluate symptoms of recurrent abdominal pain were prospectively included. Exclusion criteria included use of antibiotics or proton pump inhibitors during the last month, gastric surgery, and previous eradication therapy. Reference criteria for diagnosis of infection were based on histology, culture, and serology. Urea breath test (TAU-KIT; Isomed, S.L., Madrid, Spain) was performed as follows: citric acid (Citral pylori) dissolved in 100 mL of water was initially given. Ten minutes later, a baseline exhaled breath sample was collected, and thereafter 50 mg of 13C-urea dissolved in 50 mL of water was given. A second breath sample was obtained 30 minutes later. Breath samples were analyzed by isotope ratio mass spectrometry. The endoscopist, the pathologist, the microbiologist, and the person responsible for reading the serology and the urea breath test were all unaware of status by the other diagnostic methods. One hundred children were included (40% males; mean age, 9.2 +/- 2 years; mean weight, 33.9 +/- 12 kg). Based on the reference criteria, 45% were infected, 37% were not infected, and 18% were indeterminate. Sensitivity, specificity, positive predictive value, and negative predictive value were, respectively, 91% (95% confidence interval [CI], 79%-96%), 97% (95% CI, 86%-99%), 98% (95% CI, 87%-91%), and 90% (95% CI, 76%-96%). Positive and negative likelihood ratios were of 33 and 0.09. Any cutoff point between 2 and 14 delta units had the same high diagnostic accuracy. The area under the receiver operating characteristic curve was 0.94. No adverse effects were reported. Urea breath test using 50 mg of urea is sufficient and accurate for the diagnosis of infection in children. Use of a small test dose significantly lowers the cost of the test.

Helicobacter pylori infection and childhood recurrent abdominal pain: lack of evidence for a cause and effect relationship.

Recurrent abdominal pain is a common complaint among children and adolescents. Apley's criteria - at least three discrete episodes of abdominal pain of sufficient severity to interrupt normal activities that occur over a period of three or more months - are often used to define this chronic pain syndrome. To summarize the extent and quality of the published evidence for a cause-and-effect relationship between Helicobacter pylori infection and childhood recurrent abdominal pain. The MEDLINE bibliographic database (January 1983 to July 1998) was searched to identify pertinent (English language) studies. The search was restricted to prospective, controlled studies reporting empirical data on children up to 18 years of age. Six studies were identified. Five of the six were case-control studies, while the remaining study assessed the effectiveness of antibiotic therapy. Only one study was community based, with the remaining studies conducted in the tertiary hospital setting. The evidence for a causal relationship was inconsistent; of the five case-control studies reviewed, the odds ratios ranged from 0.32 to 1.80. Two studies demonstrated statistically significant results; however, the findings were conflicting. The only treatment trial was limited because of methodological flaws. Current evidence suggests no association between H pylori infection and recurrent abdominal pain in children. The evidence to date indicates that routine investigation for H pylori infection in children who present with the classical symptoms of recurrent abdominal pain based on Apley's criteria is not warranted.

13 Dyspepsia in infants and children

Pathological processes and diseases of the upper gastrointestinal tract have become increasingly recognized over recent years as childhood entities responsible for a variety of upper gastrointestinal symptoms previously labelled as functional or non-organic. The term ‘dyspepsia’ is an adult one whose definition requires clarification before use in the paediatric context, but it encompasses age-dependent symptoms such as feedassociated irritability in the infant, peri-umbilical pain in the younger child, and heartburn, nausea, and indigestion in the older child as in adults. The possible organic conditions giving rise to such symptoms are multiple and multiorgan and include: gastro-oesophageal reflux; peptic ulcer disease; upper gastrointestinal Crohn's disease; antroduodenal motility disorders; pancreatitis; cholecystitis; cholelithiasis; biliary dyskinesia; and abdominal migraine. However, Munchausen syndrome by proxy must not be forgotten. Non-ulcer dyspepsia, it is now clear, has a basis in altered gastroduodenal motility and may be amenable to propulsion agents. In many individuals the dyspeptic symptoms of recurrent abdominal pain may be altered by psychotherapeutic intervention. Indeed there remains a proportion of children who undoubtedly have a behavioural or psychological base to their complaint. Nevertheless, with the recent increase in diagnostic yield from improved technical investigative aids available to paediatrics in the last 5–10 years, it is clear that the responsibility of the paediatrician to the child to find a cause of their symptoms is paramount. The variety of presenting features, possible causes of these symptoms, and appropriate investigation and treatment will be discussed, and management algorithms based on published literature and personal practice will be offered.

Helicobacter pylori Infection in Recurrent Abdominal Pain in Childhood: Comparison of Diagnostic Tests and Therapy

To determine the role of Helicobacter pylori infection in children with recurrent abdominal pain and the usefulness of serologic tests in screening H pylori infection and monitoring treatment of H pylori-associated gastritis. During a 3 year period, we investigated the presence of serum immunoglobulin G (IgG) antibody to H pylori in 456 children using the high-molecular-weight cell-associated protein H pylori enzyme immunoassay kit. Among the 456 children studied, 218 (age range, 3 to 18 years; mean age, 9.5 years) had symptoms of recurrent abdominal pain (RAP syndrome) with or without vomiting, and the remaining 238 (age range, 3 to 18 years; mean age, 9.8 years) had no RAP (non-RAP syndrome). We performed upper gastrointestinal endoscopy on 111 consecutive children of the 218 with RAP syndrome and obtained mucosal biopsies for culture, histologic analysis, CLO test (Delta West, Perth, Australia), and H pylori detection by polymerase chain reaction. Thirty-eight (17.4%) of 218 children in the RAP group and 25 (10.5%) of 238 children in the non-RAP group were seropositive for H pylori. Of the 111 children endoscoped, 95 were found to be negative, and 12 were positive by all five assays. Specimens from 2 children were negative by culture and the CLO test but positive by the other three assays. Specimens from 1 child were negative by histologic analysis but positive by all other tests. The remaining child was positive for anti-H pylori IgG but negative by all of the other four assays. Upper gastrointestinal endoscopy detected 14 children with peptic ulcer disease (9 duodenal ulcer and 5 gastric ulcer) and 12 with antral nodular gastritis. Only 4 of the 14 diagnosed with peptic ulcer were H pylori positive by all five assays, whereas all 12 children with antral nodular gastritis were H pylori positive. Nine of the 12 H pylori-positive children were treated with a combination of bismuth subsalicylate, amoxicillin, and metronidazole for 2 weeks. Sera obtained at 2, 4, and 6 months after treatment from all 9 children showed a decrease in anti-H pylori IgG titer. Three H pylori-infected children who did not receive any treatment served as control children, and their IgG levels remained elevated or increased over time. The results from our study indicate that screening for the serum IgG antibody to H pylori is a practical method for diagnosing H pylori infection in children, and that serial measurements of the H pylori IgG antibody are useful for monitoring treatment of H pylori because of its high sensitivity and ease of performance. Only 4 of the 14 children diagnosed with peptic ulcer disease were confirmed to be infected with H pylori, whereas all 12 children with antral nodular gastritis were found to be infected by H pylori. These observations suggest that H pylori infection is more frequently associated with gastritis than with peptic ulcer disease in children, and that H pylori gastritis is a cause of RAP syndrome in children.

Matching treatment with recurrent abdominal pain symptoms: An evaluation of dietary fiber and relaxation treatments

We evaluated whether symptoms of recurrent abdominal pain in children provide a basis for treatment selection. Subjects were assigned to dietary fiber or relaxation treatments based upon whether they presented with symptoms of constipation. Elven subjects were treated in a combined multiple baseline and A-B or A-B-C design. As a control, some subjects recived the alternative treatment first. All four subjects with symptoms of constipation showed reductions in the number of stomachaches during the dietary fiber treatment. Of the seven subjects without symptoms of constipation, one showed reductions in stomachaches during the relaxation treatment, three showed some minimal reduction that was difficult to attribute to the relaxation treatment, two responded to the dietary fiber treatment, and one spontaneously improved during baseline. Results support the effectiveness of a dietary fiber treatment for children with symptoms of constipation. Minimal support was obtained for the effectiveness of a relaxation treatment for children without symptoms of constipation. Implications, limitations, and directions for future research are discussed.

Intestinal Volvulus in Idiopathic Steatorrhea

Volvulus of the intestine has recently been observed in three patients with idiopathic steatorrhea in relapse. Two patients gave a history of intermittent abdominal pain, distension and obstipation. Radiographic studies during these attacks revealed obstruction at the level of the sigmoid colon. Reduction under proctoscopic control was achieved in one instance, spontaneous resolution occurring in the other. The third patient presented as a surgical emergency and underwent operative reduction of a small intestinal volvulus. Persistence of diarrhea and weight loss postoperatively led to further investigation and a diagnosis of idiopathic steatorrhea. In all cases, treatment resulted in clinical remission with a coincident disappearance of obstructive intestinal symptoms. The pathogenesis of volvulus in sprue is poorly understood. Atonicity and dilatation of the bowel and stretching of the mesentery likely represent important factors. The symptoms of recurrent abdominal pain and distension in idiopathic steatorrhea necessitate an increased awareness of intestinal volvulus as a complication of this disease.