Unexplained Chronic Abdominal Pain Research Articles

Lessons from Korean Capsule Endoscopy Multicenter Studies

Since its development, video capsule endoscopy (VCE) introduced a new area in the study of small bowel disease. We reviewed and discussed current issues from Korean capsule endoscopy multicenter studies. Main results are as follows: First, there was no significant difference in diagnostic yield according to the method of bowel preparation. Second, VCE represents a reliable and influential screening measure in patients with chronic unexplained abdominal pain and this technique could successfully alter the clinical course especially for patients with small bowel tumor. Third, the inter-observer variation in the expert group was lower than that in trainee group. Fourth, studies about the spontaneous capsule passage after retention showed 2.5% of retention rate and the size of lumen was an important factor of spontaneous passage. We need larger scale studies on the effect of bowel preparation methods on the diagnostic yield and further studies about the learning curve or unique capsule endoscopic findings for small intestinal diseases in Korean patients.

Body Mass Index in Children with Fructose Intolerance on Low-Fructose Diet, An Unexpected Finding

Purpose: The purpose of this study was to ascertain if pediatric patients with chronic abdominal pain has concurrent fructose intolerance, as determined by breath hydrogen test (BHT) using a standardized dose, and whether symptoms and body mass index (BMI) would improve with low-fructose diet. Methods: breath hydrogen test was administered to patients evaluated in clinic with unexplained chronic abdominal pain alone or associated with constipation, gas or bloating, and/or diarrhea. Patients were given a standard dose of 1g/kg fructose to a maximum of 25g. A microlyzer self-correcting model SC Quintron machine was used to measure Hydrogen (H2) and methane (CH4) at points 30 min, 60 min, and 90 min. Test was presumed positive if breath hydrogen exceeded 20 ppm above baseline. If positive, subjects were diagnosed with fructose intolerance, and started on a low-fructose diet as prescribed by a staff registered dietitian. Subjects that tested negative were considered the control group. Both patient and control groups were assessed for BMI and symptom improvement at the time of diagnosis, and then one and two years from low-fructose diet initiation. Results: Retrospectively, a total of 208 subjects participated in this study (57% BHT positive and 43% controls). Ages ranged between 2-18 years (mean = 11); 62% of children were female. On low-fructose diet, 69.2% of patients reported improvement of symptoms, as did 73.6% controls without a low-fructose diet. Mean BMI values for patients with fructose intolerance on low fructose diet, at the time of diagnosis, at 1year, and 2 years were 19.49, 19.69, and 20.82 kg/m2, respectively. The change in BMI was more significant from baseline to 2 years than from baseline to 1 year (p=.000 and p=.051, respectively). On the other hand[SL1], the BMI in controls showed significant increase over time; from baseline to 1 year p=.015, and from baseline to 2 years p=.000 (means over time = 21.70, 22.14, and 22.84). Conclusion: In children with fructose intolerance, long term compliance with low-fructose diet contributed to a slower increase in BMI overtime.

Abdominal Pain in Children Between Fructose Intolerance and Small Bowel Bacterial Overgrowth, Another Factor to Treat

Purpose: The purpose of this study is to ascertain if pediatric patients with fructose intolerance, who has had concurrent small bowel bacterial overgrowth (SBBO) showed better improvement of symptoms after SBBO treatment compared to low fructose diet alone. Methods: Breath hydrogen test was administered to patients evaluated in the pediatric gastroenterology clinic for unexplained chronic abdominal pain alone or associated with constipation, gas or bloating, and/or diarrhea. Patients were given a standard dose of 1g/kg fructose to a maximum of 25g. A microlyzer self-correcting model SC Quintron machine was used to measure Hydrogen (H2) and methane (CH4) at points 30 min, 60 min, 90 min and 120 min. Test was presumed positive for SBBO if breath hydrogen exceeded 20ppm above baseline within the first 45 min of BHT. All patients were started on a low-fructose diet as prescribed by a staff registered dietitian, In addition, all patients with SBBO were also treated. Results: Retrospectively, a total of 117 patients participated in this study. Ages ranged between 2-18 years (mean = 11); 59.83% of children were females. There was 39/117 (33.33%) patients with SBBO. After treatment for SBBO and on low fructose diet, 31/39 patients (79.5%) showed improvement or resolution of symptoms, compared to 50/78 (64.1%) on low fructose diet alone, that is a χ2 value (2.89) and an associated p value (0.089). Conclusion: Treatment of SBBO further enhanced the improvement or resolution of symptoms in children with fructose intolerance.

Diagnostic Yield of Small Bowel Capsule Endoscopy in Patients With Unexplained Chronic Abdominal Pain

Diagnostic Yield of Small Bowel Capsule Endoscopy in Patients With Unexplained Chronic Abdominal Pain

Fructose Intolerance/Malabsorption and Recurrent Abdominal Pain in Children

Purpose: The purpose of this study was to ascertain if pediatric patients with chronic abdominal pain had concurrent fructose intolerance as determined by breath hydrogen test (BHT) using a standardized dose, and whether symptoms would improve with low-fructose diet. Methods: BHT-fructose test was administered to patients evaluated in clinic with unexplained chronic abdominal pain alone or associated with constipation, gas or bloating and/or diarrhea. Patients were given a standard dose of 1 g/kg fructose to maximum of 25 g. A microlyzer self-correcting model SC QuinTron machine was used to measure hydrogen (H2) and methane (CH4) at time points 30 min, 60 min, and 90 min. Test was presumed positive if breath hydrogen exceeded 20 ppm above baseline. If positive, patients were started on a low-fructose diet as prescribed by a staff registered dietician. Results: Total of 245 patients. One hundred and fifty females (62.1%) were part of the study. Ages ranging from 2 to 18 years with a mean age of 11. Breath hydrogen test for fructose was performed in all patients and it was positive for fructose intolerance in 132/245 patients (53.9%). A total of 113/245 (46.1%) patients had negative BHT for fructose intolerance. The entire 132 patients with a positive BHT for fructose had a nutrition consult with a registered dietitian and were placed on a low-fructose diet. Using a standard pain scale for children, Eighty-eight of the 132 patients (67.7%) reported resolution of symptoms on a low-fructose diet. Furthermore 54/113 patients (47.8%) with negative BHT for fructose reported resolution of symptoms without a low-fructose diet. Conclusion: Fructose intolerance/malabsorption is common in children with recurrent/functional abdominal pain and a low-fructose diet is an effective treatment.

Indications, Diagnostic Findings, and Completion Rate of Small Bowel Capsule Endoscopy: A Single Center Experience

Purpose: To report our experience with small bowel capsule endoscopy (SCE) performed over the past 7½ years. Methods: We retrospectively reviewed 882 SCE cases (January 2003-May 2010) that were performed for evaluation of obscure gastrointestinal bleeding (OGIB), suspected Crohn's disease (17.3%), suspected small bowel tumor (5.4%), abnormal radiological findings (1.7%), chronic unexplained abdominal pain (1.36%), chronic diarrhea (1.6%), and others (3.3%). See Table 1. All SCE cases were reviewed by one trained SCE technician and three experienced gastroenterologists/capsule endoscopists (> 500 SCE cases). Demographic data, indications for referral, endoscopic findings, diagnostic yield, and the number of incomplete studies were evaluated using frequency tables, cross tabulations, and Pearson Chi-square tests.Table 1: Indications and age group distributionResults: See Table 2: The most common SCE findings were angiodysplasia (56.8%), ulcer/erosion (32.5%), lymphangiectasia (26%), and mass lesion (20.9%). In the subgroup analyses, the age group of older than 50 years old had significantly higher prevalence of angiodysplasia (63% vs. 50%, p < 0.05) and lymphangiectasia (34.2% vs. 18.2%, p <0.05) than in younger population. There were 127 cases (14.3%) of incomplete SCE studies defined as the capsules did not enter the cecum (n=101, 79.5%) or did not leave the stomach (n=26, 20.5%). No complications of acute bowel obstruction or perforation occurred in this series.Table 2: Prevalence of endoscopic findings by age groupConclusion: SCE is a safe & useful diagnostic tool for detecting small bowel pathology including OGIB, suspected Crohn's disease, and small bowel tumor. Angiodysplasia is the most common SCE finding and is more common in patients over the age of 50.

Altered rectal sensory response induced by balloon distention in patients with functional abdominal pain syndrome

BackgroundFunctional abdominal pain syndrome (FAPS) has chronic unexplained abdominal pain and is similar to the psychiatric diagnosis of somatoform pain disorder. A patient with irritable bowel syndrome (IBS) also has chronic unexplained abdominal pain, and rectal hypersensitivity is observed in a majority of the patients. However, no reports have evaluated the visceral sensory function of FAPS precisely. We aimed to test the hypothesis that FAPS would show altered visceral sensation compared to healthy controls or IBS. The present study determined the rectal perceptual threshold, intensity of sensation using visual analogue scale (VAS), and rectal compliance in response to rectal balloon distention by a barostat in FAPS, IBS, and healthy controls.MethodsFirst, the ramp distention of 40 ml/min was induced and the thresholds of discomfort, pain, and maximum tolerance (mmHg) were measured. Next, three phasic distentions (60-sec duration separated by 30-sec intervals) of 10, 15 and 20 mmHg were randomly loaded. The subjects were asked to mark the VAS in reference to subjective intensity of sensation immediately after each distention. A pressure-volume relationship was determined by plotting corresponding pressures and volumes during ramp distention, and the compliance was calculated over the linear part of the curve by calculating from the slope of the curve using simple regression.ResultsRectal thresholds were significantly reduced in IBS but not in FAPS. The VAS ratings of intensity induced by phasic distention (around the discomfort threshold of the controls) were increased in IBS but significantly decreased in FAPS. Rectal compliance was reduced in IBS but not in FAPS.ConclusionAn inconsistency of visceral sensitivity between lower and higher pressure distention might be a key feature for understanding the pathogenesis of FAPS.

Rome II Versus Rome III Classification of Functional Gastrointestinal Disorders in Pediatric Chronic Abdominal Pain

The updated Rome III criteria for pediatric functional gastrointestinal disorders (FGIDs) include new FGID categories and changes to the Rome II criteria for various FGIDs. To our knowledge, the implications of these revisions for patient classification have not been identified. The purpose of this study was to compare classification results using Rome II versus Rome III criteria for FGIDs associated with chronic abdominal pain. Participants were 368 pediatric patients whose subspecialty evaluations for chronic abdominal pain yielded no evidence of organic disease. The children's gastrointestinal symptoms were assessed with the parent-report version of the Questionnaire on Pediatric Gastrointestinal Symptoms (QPGS). More patients met the criteria for a pediatric pain-related FGID according to the Rome III criteria (86.6%) than the Rome II criteria (68.0%). In comparison with the results from the Rome II criteria, the Rome III criteria classified a greater percentage of children as meeting criteria for Abdominal Migraine (23.1% vs 5.7%) and Functional Abdominal Pain (11.4% vs 2.7%). Irritable Bowel Syndrome was the most common diagnosis according to both Rome II (44.0%) and Rome III (45.1%). Changes to the Rome criteria make the Rome III criteria more inclusive, allowing classification of 86.6% of pediatric patients with medically unexplained chronic abdominal pain.

Abdominal wall pain – classification, diagnosis and treatment suggestions

Abdominal pain is generally believed to be a symptom of intra-abdominal disease. When no pathological findings are evident, abdominal pain is considered functional. Abdominal pain, however, may also originate in the abdominal wall. Consecutive patients with unexplained abdominal pain were enrolled in a prospective observational study in a gastroenterologic clinic during a period of three years. The following criteria were tested: Can abdominal pain be elicited by physical movement? Is the source of pain localized to a circumscribed site in the abdominal wall? Can pain be provoked by digital palpation in this area and does pain increase when the abdominal muscles are tensed? Clinical examination of 55 patients revealed small painful pits in the abdominal wall with varying intensity of pain when the abdominal muscles were contracted: in 39 patients the painful area was located in the semilunar line, in seven patients the pain originated in the linea alba between xiphoid and umbilicus, in five cases the painful spots were situated within the rectus muscle, and in four patients the pain was localized along the costal arch. Of the 39 patients with pain in the semilunar line, 16 had a BMI > 30, 12 presented with anxiety and depression, and 10 reported bloating and straining during defecation. Pain in the rectus muscle was associated with exercise. The patients with pain in the linea alba and at the costal arch suffered from obesity, anxiety or depression. These findings suggest that repeated forceful contractions of the abdominal wall muscles during exercise and straining, as well as chronic inflation of the abdominal wall by fat pads and by bloating, may cause strain and pain in the abdominal wall at sites predestined by anatomy. Symptom-specific anxiety may be a consequence of chronic unexplained abdominal pain. A novel classification of abdominal wall pain is proposed. The correct diagnosis will avoid repeated and costly investigations and relieve the patient's anxiety.

Fever and Sepsis as an Unusual Complication of Erosion of an IVC Filter into the Duodenum

Purpose: Erosion of an inferior vena cava (IVC) filter into the GI tract is rare. Similarly, fever and sepsis is an underappreciated complication of intravascular device migration. We report a patient with an unexpected duodenal-caval fistula detected endscopically as the postulated cause of unexplained recurrent sepsis. Case Report: A 67-year-old presented with one week of confusion. He denied abdominal complaints. He had been discharged 2 weeks earlier with Klebsiella pneumoniae sepsis. Past medical history was significant for multiple pulmonary emboli with placement of a non-retrievable IVC filter 2 years previously. Two months prior to the current admission, UGI endoscopy for Barrett's esophagitis screening lead to the seemingly incidental discovery of a thin, metallic foreign body protruding into the duodenum. On exam, temp. = 101.6°F, blood pressure = 140/80 without postural change, pulse = 74/min. Cardiac, pulmonary and abdominal exams were normal. WBC count = 16,000; 4 out of 4 blood cultures were positive for Staphylococcus aureas. Progressive dysphagia due to Parkinson's disease required percutaneous endoscopic gastrostomy tube placement. At UGI endoscopy, a thin metal wire was protruding through the wall of the second portion of the duodenum. A clean-based, non-bleeding ulcer was on the opposite wall. The finding was consistent with migration or erosion of a non-retrievable IVC filter through the duodenal wall. CT scan confirmed this finding. He declined further treatment. Discussion: Perforation of an IVC filter into the GI tract is rare. Other potential mechanisms of IVC-duodenal fistula are penetrating injury; erosion of tumor, abcess or pseudocyst. Clinical manifestations of filter migration into the duodenum are diverse, including chronic abdominal pain, GI bleeding of any magnitude, fever or sepsis. Clinical signs of infection, such as confusion in our patient, may be non-specific and misleading, mimicking more common disorders. Delay in diagnosis is common. We postulate that duodenal ulceration and sepsis were complications of an IVC filter. Fever and bacteremia are rare, reported complications of duodenal migration or perforation of these devices. Filter erosion should be considered in any patient with a history of filter placement and unexplained chronic abdominal pain, GI bleeding, fever or sepsis.

Frequency and Clinical Outcomes of Retention and Factors Predicting Spontaneous Delayed Passage After Retention During Capsule Endoscopy: A Korean Nationwide Multicenter Study

Background and aims: Although capsule endoscopy (CE) allows direct examination of the entire length of small bowel in a noninvasive manner, retention remains a major concern for physicians. The rates of retention, however, have been reported to vary widely from 0% to 21% because of the dissimilarity of indication for CE and study populations among investigations, and most of them were relatively small single center studies. Moreover, the predicting factors affecting the outcomes after retention remain unknown. The aims of this study were to investigate the frequency and clinical outcomes of capsule retention for various small bowel diseases, and to determine the predicting factors for the favorable outcomes after retention by a Korean multicenter study. Methods: By nationwide multi-center survey, we retrospectively reviewed the records of 1291 cases performed at institutions equipped with CE between February 2002 and July 2006 in Korea. For cases with capsule retention, clinical and procedural characteristics, and post-procedural outcomes were analyzed. Results: Capsule retention occurred in 2.8% of total cases (36/1291). The major causes of retention were Crohn's disease (47.2%), malignant tumors (13.9%), and intestinal tuberculosis (8.3%) in decreasing order in Korea. The retention rates for specific indications of disorders are as follows; 11.7% (7/60) in known or suspected Crohn's disease, 2.4% (15/629) in obscure gastrointestinal bleeding, 3.9% (9/229) in chronic unexplained abdominal pain, 1.7% (1/58) in chronic unexplained diarrhea, and 3.6% (1/28) in polyposis. Most of cases with retention (83.3%) were free from complications, but surgical or endoscopic interventions were performed for two thirds of the cases (21/36) to treat underlying diseases or retrieve caspule. In 11 (30.5%) of retention cases, capsule left patients spontaneously or with medical treatments of underlying diseases after retention. Regarding the predicting factors that affect clinical outcomes after retention, larger diameter of stricture area, and changing retention site on x-ray during follow-up were associated with spontaneous delayed passage without complications after retention. Conclusions: We identified the specific retention rates according to various indications of CE and small bowel diseases. Patients and physicians should be aware of the potential risks of retention when using CE in Crohn's disease, malignant tumors, or tuberculosis particularly in Korea. Outcomes of most retention cases were favorable and, moreover, we firstly documented some endoscopic and radiologic features which might predict spontaneous delayed passage after capsule retention.

Comparative Analysis of Direct Pancreatic Function Testing Versus Morphological Assessment by Endoscopic Ultrasonography for the Evaluation of Chronic Unexplained Abdominal Pain of Presumed Pancreatic Origin

The diagnosis of "minimal change" chronic pancreatitis (MCCP) is often considered when conventional imaging studies are unrevealing in a patient population with abdominal pain of presumed pancreatic origin. Direct pancreatic function testing using secretin as a secretagogue (ST) has been considered the most sensitive method to diagnose MCCP but is not widely available to clinicians. Endoscopic ultrasound (EUS) allows detailed imaging of pancreatic architecture, but the sensitivity and specificity for MCCP remain to be determined. We sought to compare the accuracy of EUS and ST in patients with presumed MCCP. Seventy-four patients referred to our pancreas clinic with unexplained abdominal pain and previously negative imaging studies underwent an ST for evaluation of possible MCCP. Twenty-one of these also underwent EUS. EUS images were read by 1 of 2 experts blinded to ST results. Using ST as the "gold standard," EUS had a maximum sensitivity of 71% when the cut-off for diagnosis was set at at least 3 EUS features. Conversely, maximum specificity (92%) was seen when the cut-off value was set at at least 6 EUS criteria. Diagnostic certainty was only 50% (positive predictive value = 0.5) when at least 6 criteria were used as the cut-off. MCCP was excluded with greater than 70% certainty when less than 3 criteria were present. At the best cut-off value of at least 4 features, EUS had a sensitivity of 57% and a specificity of 64%. In this patient population with abdominal pain of presumed pancreatic origin, EUS and standard pancreatic function testing are often discordant. If ST is assumed to be the reference against which other tests are compared, EUS is less accurate than ST in diagnosing MCCP.

P186 Peritoneal mesothelioma as a rare cause of chronic unexplained abdominal pain in a young patient

P186 Peritoneal mesothelioma as a rare cause of chronic unexplained abdominal pain in a young patient

Comparative analysis of pancreatic function testing versus morphological assessment (by EUS) for the evaluation of chronic unexplained abdominal pain (UAP)

Comparative analysis of pancreatic function testing versus morphological assessment (by EUS) for the evaluation of chronic unexplained abdominal pain (UAP)

Comparative analysis of pancreatic function testing versus morphological assessment (by EUS) for the evaluation of chronic unexplained abdominal pain (UAP)

Comparative analysis of pancreatic function testing versus morphological assessment (by EUS) for the evaluation of chronic unexplained abdominal pain (UAP)

7023 Enteroclysis in the evaluation of unexplained chronic abdominal pain.

Purpose: The purpose of this study was to evaluate the utility of enteroclysis (dedicated small bowel radiography) in the evaluation of chronic abdominal pain. Methods:A retrospective review of 34 consecutive patients was done at Temple University Hospital (mean age of 42 years, 17 males and 17 females) who had undergone enteroclysis for evaluation of chronic abdominal pain. All patients were initially worked up with EGD and colonoscopy, and when these tests did not reveal a source for the chronic abdominal pain an enteroclysis was performed. Results:4/34(12%) of the patients had an abnormal enteroclysis study. These patients included 2 with small bowel patterns consistant with adhesions, 1 with dilitation of the proximal duodenum consistant with superior mesenteric artery syndrome and 1 with ulceration in the ileum consistant with Crohns ileitis. Conclusions: In patients completely worked up with endoscopic procedures (i.e. colonoscopy and upper endoscopy) in which an explanation for chronic abdominal pain is not apparent, 12% of patients had an abnormal enteroclysis finding which could have explained the chronic abdominal pain. Whether or not these findings actually contributed to the abdominal pain remains unclear.Enteroclysis is an relatively insensitive test for the evaluation of chronic abdominal pain but may be useful in a small percentage of patients after endoscopic evaluation if the source of chronic pain is not clear. In this study enteroclysis was most useful for defining adhesions 2/4(50%) which were not picked up by endoscopic diagnostic tests. 1/4(25%) of the positive enteroclysis findings in this study was due to Crohn's ileitis, and 1/4(25%) was due to a possible superior mesenteric artery syndrome.

Neuromuscular diseases of the gastrointestinal tract.

Preview When traditional testing fails to identify a cause of common gastrointestinal problems such as abdominal pain, bloating, and diarrhea, the symptoms are sometimes lumped under a general diagnosis of functional or irritable bowel disease. However, the cause may be a well-defined organic condition, recognizable by its signs and symptoms and by results of more specialized testing. The authors describe mechanisms and characteristics of five neuromuscular diseases, as well as promising therapeutic agents.

Association of Pancreas Divisum and Pan reatitis and Its Treatment by Sphincteroplasty of the Accessory Ampulla

All 519 endoscopic pancreatograms performed in the Massachusetts General Hospital Endoscopy Unit from 1973 to 1980 were reviewed. Patients who underwent pancreatograms for documented pancreatitis were more likely (p less than 0.005) to have the duct anomaly pancreas divisum (12%) than those patients who had pancreatograms incidental to cholangiography (2.9%), or for unexplained chronic abdominal pain (3.3%). When compared with patients with pancreatitis and normal duct development, patients with pancreatitis associated with pancreas divisum tended to be younger and to have a clinical pattern of recurrent acute attacks of pancreatitis. Nine patients with recurrent pancreatitis or severe chronic abdominal pain and pancreas divisum were treated by surgical sphincteroplasty of the accessory ampulla. Five of the 6 patients with documented acute attacks of pancreatitis received good to excellent pain relief and had no further attacks of acute pancreatitis. None of the 3 patients with severe chronic abdominal pain without objective evidence of pancreatitis derived significant benefit. Accessory ampulla sphincteroplasty seems to relieve pain and prevent further attacks of acute pancreatitis in patients with pancreas divisum and recurrent pancreatitis. This response to sphincteroplasty adds further credence to the stated association between pancreas divisum and pancreatitis.