Unexplained Gastrointestinal Symptoms Research Articles

Joint Hypermobility, Autonomic Dysfunction, Gastrointestinal Dysfunction and Autoimmune markers (JAG-A): Clinical Associations and Response to Intravenous Immunoglobulin Therapy.

We examined autoimmunity markers (AIM) and autonomic dysfunction in patients with chronic neurogastroenterological symptoms and their relationship to joint hypermobility/hypermobility spectrum disorder (JH/HSD). AIM positivity was defined as a diagnosis of known autoimmune/autoinflammatory disorder (AIDX) with at least one positive seromarker of autoimmunity or at least two positive seromarkers by themselves. Three cohorts were studied: (a) Retrospective (n = 300); (b) Prospective validation cohort (n =133); and (c) Treatment cohort (n=40), administered open-label intravenous immunoglobulin (IVIG). AIM positivity was found in 40% and 29% of the retrospective and prospective cohorts, the majority of whom (71% and 69%, respectively) had AIDX. Significantly more patients with AIM had elevations of C-reactive protein (31% versus 15%, p<0.001) along with an increased proportion of cardiovascular autonomic dysfunction (48% versus 29%; p<.001), small fiber neuropathy (20% versus 9%; p=.002).8) and HLADQ8 positivity (24% versus 13%, p=.01). JH/HSD patients were more likely to have AIM (43% versus 15%, p=.001) along with more severe autonomic and gastrointestinal symptom scores. IVIG treatment was associated with robust improvement in pain, gastrointestinal and autonomic symptoms but adverse events were experienced by 62% patients. Autoimmune markers and autonomic dysfunction are common in patients with unexplained gastrointestinal symptoms, especially in those with JH/HSD. Many patients seem to respond to IVIG treatment but this needs to be confirmed by controlled trials. These results highlight the need for vigilance for autoimmune and autonomic factors and JH/HSD in patients with neurogastroenterological disorders. Clinicaltrials.gov, NCT04859829.

When the Stomach Pain Is Literally “In Your Head”

Abdominal epilepsy (AE) is an extremely rare condition, classified as temporal lobe epilepsy, and is usually a diagnosis of exclusion. Temporal lobe epilepsy often has no clear cause, although it may be associated with diseases such as temporal lobe sclerosis, dysembryoplastic neuroepithelial tumours, and other benign tumours, as well as arterio-venous malformations, gliomas, defects in neuronal migration, or lesions of the cortex caused by encephalitis. AE is more common in children but has been reported in adults. AEs are characterised by recurrent and unexplained gastrointestinal symptoms such as seizure pain, nausea, bloating and diarrhoea, which improve with antiepileptic treatment. Given the vague nature of these symptoms, patients are at high risk of misdiagnosis. An electroencephalogram and neuroimaging of the brain are needed to confirm the diagnosis.&#x0D; We present the clinical case of a 67-year-old female patient who was investigated at the Gastroenterology Department for a sharp pain in the left side of the abdomen, frequent abdominal distension and gurgles, diarrhoeal episodes, weight loss, paroxysmal hallucinations, and headaches. After a thorough gastroenterological examination, consultations with a psychiatrist and a neurologist, an MRI and an EEG were performed and the patient was diagnosed with focal temporal lobe epilepsy.

The spectrum of gastrointestinal functional bowel disorders in joint hypermobility syndrome and in an academic referral center.

Joint hypermobility syndrome (JHS) is a non-inflammatory hereditary disorder of connective tissue with varied clinical presentations, including frequent joint dislocations, hyperextensible skin, easy bruising, and abnormal paper-thin scar formation. Many of these patients have unexplained gastrointestinal (GI) symptoms. Our aim was to evaluate the prevalence of JHS in a tertiary gastroenterology motility clinic and the spectrum of functional bowel disorders in JHS patients. In this retrospective case series, we screened the medical records of 277 patients seen over 4 years at an academic GI Motility Center. The patients who met the criteria for JHS by Beighton hypermobility score were evaluated for the presence of functional GI disorders by Rome IV criteria. They also underwent gastric emptying study and glucose breath testing for small intestinal bacterial overgrowth. The prevalence of JHS in the study population was 9.7%. The mean age was 27 years, and 92.5% were female. The symptoms experienced by these patients include nausea/vomiting (89%), abdominal pain (70%), constipation (48%), and bloating (18.5%). The disorders associated with JHS include gastroparesis (52%), irritable bowel syndrome (55.5%), and gastroesophageal reflux disease (30%). Also, 10 patients (37%) were diagnosed with postural hypotension tachycardia syndrome secondary to autonomic dysfunction. Approximately 10% of patients with suspected functional bowel disorders have hypermobility syndrome. Hence, it is crucial to familiarize gastrointestinal practitioners with the criteria utilized to diagnose JHS and the methods to identify physical examination findings related to this condition.

S1806 Prevalence and Symptoms of Disaccharidase Enzyme Deficiency in Adult Patients With Unexplained Gastrointestinal Symptoms

S1806 Prevalence and Symptoms of Disaccharidase Enzyme Deficiency in Adult Patients With Unexplained Gastrointestinal Symptoms

Genetic screening for hereditary transthyretin amyloidosis with polyneuropathy in western Sicily: Two years of experience in a neurological clinic.

Hereditary transthyretin amyloidosis with polyneuropathy (ATTRv-PN) is caused by mutations in the TTR gene, leading to misfolded monomers that aggregate generating amyloid fibrils. A prospective systematic genetic screening for ATTRv-PN was proposed in patients presenting with a sensory-motor idiopathic polyneuropathy and two or more "red flags" among the following: family history of polyneuropathy or cardiopathy, bilateral carpal tunnel syndrome, cardiac insufficiency, renal amyloidosis, lumbar tract stenosis, autonomic dysfunction, idiopathic gastrointestinal disease, amyloid deposits on biopsy, and vitreous opacities. The detection rate was calculated, and nonparametric analyses were carried out to underline differences among screened positive versus negative patients. In the first step, 145 suspected patients underwent genetic testing, revealing a diagnosis of ATTRv-PN in 14 patients (10%). Then, cascade screening allowed early recognition of 33 additional individuals (seven symptomatic ATTRv-PN patients and 26 presymptomatic carriers) among 84 first-degree relatives. Patients with a positive genetic test presented a higher frequency of unexplained weight loss, gastrointestinal symptoms, and family history of cardiopathy. A systematic screening for ATTRv-PN yielded an increased recognition of the disease in our neurological clinic. Unexplained weight loss associated with axonal polyneuropathy had the highest predictive value in the guidance of clinical suspicion. A focused approach for the screening of ATTRv-PN could lead to an earlier diagnosis and identification of asymptomatic carriers, who will be promptly treated after a strict follow-up at the clinical onset.

Idiopathic Isolated Adrenocorticotropic Hormone Deficiency: A Single-Center Retrospective Study.

Idiopathic isolated adrenocorticotrophic hormone deficiency (IIAD) is rare, with high clinical omission and misdiagnosis rates. This study retrospectively collected information on clinical presentation, laboratory findings, and treatment response of 17 patients with IIAD at Jining No. 1 People's Hospital from January 2014 to December 2022. The clinical characteristics were summarized, and the pertinent data were analyzed. As a result, most of the patients with IIAD were male (94.12%), with age at onset ranging from 13 to 80 years. The primary manifestations were anorexia (88.24%), nausea (70.59%), vomiting (47.06%), fatigue (64.71%), and neurological or psychiatric symptoms (88.24%). The median time to diagnosis was 2 months and the longest was 10 years. Laboratory tests mostly showed hyponatremia (88.24%) and hypoglycemia (70.59%). The symptoms and laboratory indicators returned to normal after supplementing patients with glucocorticoids. IIAD has an insidious onset and atypical symptoms; it was often misdiagnosed as gastrointestinal, neurological, or psychiatric disease. The aim of this study was to improve clinicians' understanding of IIAD, patients with unexplained gastrointestinal symptoms, neurological and psychiatric symptoms, hyponatremia, or hypoglycemia should be evaluated for IIAD and ensure early diagnosis and treatment.

Case Report: Primary small bowel adenocarcinoma with peritoneal metastasis responded well to a CapeOX + bevacizumab regimen

BackgroundSmall bowel adenocarcinoma (SBA) is a rare condition often presenting with various non-specific gastrointestinal symptoms, making its diagnosis challenging. Delayed diagnosis is common, as patients may not receive the correct diagnosis until complications arise, necessitating further investigations. Furthermore, the management of SBA patients poses difficulties due to the scarcity of high-quality evidence.Case presentationIn this report, we present the case of an elderly man with SBA in the ileum who arrived at our emergency room with acute abdominal pain. The diagnosis was not made until the SBA caused a perforation, leading to acute abdominal pain. An emergent exploratory laparotomy revealed a 3 cm × 3 cm perforated tumor in the ileum, along with widespread metastatic nodules on the omentum, ascending colon, descending colon, and rectum. Postoperative pathological evaluation confirmed the diagnosis of SBA with peritoneal metastasis (pT4N2M1, stage IV). Following surgery, the patient received palliative systemic chemotherapy, which included the CapeOX regimen and the anti-VEGF monoclonal antibody bevacizumab. Remarkably, the patient responded well to this therapy, displaying good tolerance, and we observed no signs of disease progression. As of now, the patient is in good health and continuing with regular follow-up.ConclusionThe early diagnosis of small bowel adenocarcinoma remains a challenge. Delayed diagnosis can lead to a poor prognosis, underscoring the importance of considering SBA as a potential diagnosis for patients with unexplained abdominal pain and gastrointestinal symptoms. This case also highlights the efficacy of palliative chemotherapy with the CapeOX regimen combined with bevacizumab in controlling SBA.

Gastrointestinal amyloidosis: an often unexpected finding with systemic implications

The gastrointestinal (GI) tract is a common site of amyloidosis, but the incidence, clinicopathologic features, and systemic implications of different types of GI amyloidosis are not well understood. GI amyloid specimens (N = 2,511) typed using a proteomics-based method between 2008-2021 were identified. Clinical and morphologic features were reviewed in a subset of cases. Twelve amyloid types were identified, including AL (77.9%), ATTR (11.3%), AA (6.6%), AH (1.1%), AApoAIV (1.1%), AEFEMP1 (0.7%), ALys (0.4%), AApoAI (0.4%), ALECT2 (0.2%), Aβ2M (0.1%), AGel (0.1%), and AFib (<0.1%). Amino acid abnormalities indicative of known amyloidogenic mutations were detected in 24.4% ATTR cases. AL, ATTR, and AA types all commonly involved submucosal vessels. They also showed some characteristic patterns of involvement of more superficial anatomic compartments, although there was significant overlap. Common indications for biopsy were diarrhea, GI bleed, abdominal pain, or weight loss. Amyloidosis was usually an unexpected finding, but most AL and ATTR patients were ultimately found to have cardiac involvement (83.5% of AL; 100% of ATTR). Although most GI amyloid is of AL type, over 10% are ATTR, over 5% are AA, and twelve different types were identified in total. GI amyloid is often unexpected but usually signals systemic amyloidosis, thus there should be a low threshold to perform biopsy with Congo red stain in patients with unexplained GI symptoms. Clinical and histologic features are nonspecific, and typing should be performed via a robust method such as proteomics as treatment hinges on correctly identifying the amyloid type.

Machine Learning for Early Diagnosis of ATTRv Amyloidosis in Non-Endemic Areas: A Multicenter Study from Italy.

Hereditary transthyretin amyloidosis with polyneuropathy (ATTRv) is an adult-onset multisystemic disease, affecting the peripheral nerves, heart, gastrointestinal tract, eyes, and kidneys. Nowadays, several treatment options are available; thus, avoiding misdiagnosis is crucial to starting therapy in early disease stages. However, clinical diagnosis may be difficult, as the disease may present with unspecific symptoms and signs. We hypothesize that the diagnostic process may benefit from the use of machine learning (ML). 397 patients referring to neuromuscular clinics in 4 centers from the south of Italy with neuropathy and at least 1 more red flag, as well as undergoing genetic testing for ATTRv, were considered. Then, only probands were considered for analysis. Hence, a cohort of 184 patients, 93 with positive and 91 (age- and sex-matched) with negative genetics, was considered for the classification task. The XGBoost (XGB) algorithm was trained to classify positive and negative TTR mutation patients. The SHAP method was used as an explainable artificial intelligence algorithm to interpret the model findings. diabetes, gender, unexplained weight loss, cardiomyopathy, bilateral carpal tunnel syndrome (CTS), ocular symptoms, autonomic symptoms, ataxia, renal dysfunction, lumbar canal stenosis, and history of autoimmunity were used for the model training. The XGB model showed an accuracy of 0.707 ± 0.101, a sensitivity of 0.712 ± 0.147, a specificity of 0.704 ± 0.150, and an AUC-ROC of 0.752 ± 0.107. Using the SHAP explanation, it was confirmed that unexplained weight loss, gastrointestinal symptoms, and cardiomyopathy showed a significant association with the genetic diagnosis of ATTRv, while bilateral CTS, diabetes, autoimmunity, and ocular and renal involvement were associated with a negative genetic test. Our data show that ML might potentially be a useful instrument to identify patients with neuropathy that should undergo genetic testing for ATTRv. Unexplained weight loss and cardiomyopathy are relevant red flags in ATTRv in the south of Italy. Further studies are needed to confirm these findings.

Is Irritable Bowel Syndrome out of date and misleading as a diagnosis?

This study aimed at assessing the efficacy of targeted interventions addressing common food sensitivities and lifestyle factors that commonly contribute to the presentation of gastrointestinal problems identified as Irritable bowel syndrome (IBS). IBS has served to cover the expression of multifactorial disorders with variable aetiology and pathophysiology. Food antigens implicated in the modern lifestyle, acting as strong epigenetic factors is strongly implicated in pathophysiology of conditions under IBS. Identifying and addressing food sensitivities in patients presenting with IBS like symptoms are currently underemphasised in clinical guidelines yet have the potential to provide major benefits for patients. Information was collected from the medical records of patients that were referred to the Gastroenterology Unit of Palmerston North DHB with unexplained gastrointestinal (GI) symptoms with or without other GI comorbidities between September 2018 and November 2021. The main management option offered to the 121 patients included in this study, was lifestyle adjustment and/or a trial of 6 weeks, eliminating gluten and lactose from the diet. The most prevalent symptoms were abdominal pain 96/121 (79%), diarrhoea 83/121 (69%), followed by bloating and constipation. Seventy-eight patients had the outcomes of their improvement available. A total of 42 out of 78 patients (54%) were treated exclusively with gluten and lactose-free diet, in this group of patients 86% (36/42) reported a significant improvement in their symptoms with a score in the range of 40-100%. Our study illustrates the importance of focusing on triggering factors when assessing patients with IBS. We suggest that careful identifying and eliminating the triggering food antigens as monotherapy or in addition to the lifestyle adjustment where appropriate should be the main objective in symptomatic patients fulfilling the IBS diagnostic criteria. These combinations and holistic approach in treating IBS' patients' symptoms are less expensive, non-toxic, and highly effective in achieving optimal outcomes and improving these patient's quality of life.

A pain fired from brain: Abdominal Epilepsy

Introduction: Abdominal pain is a nonspecific symptom which can be caused by a constellation of pathologies. It can be related sometimes to pathologies that affect the brain and mind. Among pathological conditions that can cause paroxysmal gastrointestinal symptoms are porphyria, abdominal migraine, cyclical vomiting, intestinal malrotation and peritoneal bands. Among them, rare, but important to recognize is abdominal epilepsy. Abdominal epilepsy is more a diagnosis of exclusion, and it is considered to be part of the group of temporal lobe epilepsies, which usually occur in children. However rare, there is recorded documentation of its occurrence even in adults. Method: We present two adult case reports with abdominal symptoms who have undergone several investigations before the diagnosis. Results: In these patients the pellicular combination of the irregular paroxysm of abdominal pain, combined with symptoms involving the central nervous system and the exclusion of pathologies that can produce similar symptoms can guide the physician to the diagnosis of abdominal epilepsy. Discussion: It should be suspected abdominal epilepsy when we encounter unexplained and recurrent gastrointestinal symptoms such as severe paroxysmal pain, hunger, flatulence, nausea and sometimes diarrhea. Symptoms are associated with central nervous system symptoms such as lethargy, confusion or alteration of consciousness and are improved with antiepileptic therapy. This diagnosis is usually associated with electroencephalography changes. The symptoms are quite vague and for this reason, it is difficult to make a diagnosis. Keywords: abdominal epilepsy, unexplained abdominal pain, EEG, adults, antiepilepsy drug therapy, case report

Quantitative gastrointestinal function and corresponding symptom profiles in autonomic neuropathy.

Peripheral neuropathies with autonomic nervous system involvement are a recognized cause of gastrointestinal dysmotility for a wide spectrum of diseases. Recent advances in wireless motility capsule testing allow improved sampling of regional and whole gut motility to aid in the diagnosis of gastrointestinal motility disorders and may provide additional insight into segment-specific enteric involvement of peripheral neuropathies affecting autonomic nervous system function. We utilized standardized autonomic nervous system (ANS) reflex assessment and wireless motility capsule testing to evaluate 20 individuals with idiopathic autonomic neuropathy and unexplained gastrointestinal symptoms. Additionally, we examined the relationship between quantifiable autonomic neuropathy and gastrointestinal dysmotility at specific neuroanatomical levels. Symptom profiles were evaluated using the 31-item Composite Autonomic Symptom Score questionnaire (COMPASS-31) and compared to wireless motility capsule data. We found that transit times were predominately abnormal (delayed) in the foregut (10 of 20; 50%), while contractility abnormalities were far more prominent in the hindgut (17 of 20; 85%), and that motility and symptom patterns, as assessed by the COMPASS-31 GI domain items, generally corresponded. Finally, we also found that there was neuroanatomical overlap in the presence of autonomic reflex abnormalities and WMC-based transit and/or contractility abnormalities. We found that transit times were predominately abnormal in the foregut and midgut, while contractility abnormalities were far more prominent in the hindgut in individuals with idiopathic autonomic neuropathy. There was a high rate of agreement in segmental wireless motility capsule data with neuroanatomically corresponding standardized ANS function measures (e.g., cardiovagal, sudomotor, adrenergic). Expanded sudomotor testing, including additional neuroanatomical segments, could provide additional indirect assessment of visceral involvement in ANS dysfunction.

S3505 A Case of Invasive Gastrointestinal Mold Infection

IntroductionL: Invasive mold infections can be devastating and are mostly seen in patients with hematologic malignancies, profound neutropenia, solid organ or hematopoietic cell transplantation, and poorly controlled diabetes mellitus. Mucormycosis is caused by a group of ubiquitous molds called Mucormycetes and characterized by tissue infarction and necrosis that results from invasion of the vasculature by hyphae. We present a rare case of a patient with invasive gastrointestinal mold infection. Case Description/Methods: A 40-year-old male with chronic inflammatory demyelinating polyneuropathy (CIDP) was admitted for autologous stem cell transplantation (ASCT). Initial hospitalization was complicated by neutropenic fever and C. difficile enteritis treated with Fidaxomicin. He was admitted one month later for nausea, vomiting and push enteroscopy revealed two circumferential deep small bowel ulcerations and a jejunal stricture too distal to be reached. Ulcer biopsies showed granulation tissue and was positive for Cytomegalovirus. He was treated with Valganciclovir and initiated on TPN. One week later, he had a third admission for intractable nausea and vomiting due to a small bowel obstruction. He failed conservative management and underwent diagnostic laparoscopy that revealed five strictures in the distal small bowel which were all resected with two small bowel resections and re-anastomosed. Histopathology of resected jejunum showed necrotizing granulomatous inflammation with aseptated fungal hyphae concerning for Mucormycosis, which was not identified on fungal PCR. He was treated with liposomal Amphotericin B then transitioned to oral Isavuconazole before making a full recovery. (Figure) Discussion: The most common presentation of Mucormycosis is a rhino-orbital-cerebral infection. Gastrointestinal infection is rare in living patients and has been estimated to occur in around 7% of all Mucormycosis cases and carries mortality as high as 85%. Our patient had a history of refractory CIDP and underwent chemotherapy for ASCT that was complicated by development of C. difficile and CMV gastrointestinal infections and small bowel obstruction necessitating endoscopic intervention which led to exploratory laparoscopy for surgical resection and the diagnosis of invasive Mucormycosis. Although invasive GI Mucormycosis is rare, in severely immunocompromised patients with unexplained gastrointestinal symptoms and multiple risk factors as presented in our patient, this infectious organism can be considered in the differential.Figure 1.: (A, B) Circumferential ulcerations seen in the small bowel on push enteroscopy. (C) Mucosal ulceration with underlying necrotizing granulomatous inflammation in the deep muscularis propria/pericolonic adipose tissue with non-septated fungal hyphae present.

Sucrose intolerance in adults with common functional gastrointestinal symptoms

Sucrose intolerance is a form of carbohydrate malabsorption caused by sucrase-isomaltase deficiency that is more common than recognized. Its symptoms include postprandial cramping, bloating, gas, and diarrhea, which are difficult to distinguish from irritable bowel syndrome. The gold standard test for diagnosing sucrase deficiency is a sucrase enzyme assay of duodenal biopsies obtained by endoscopy. Hydrogen-methane or 13C-sucrose breath tests are noninvasive methods to screen for sucrose malabsorption. This chart review included 258 consecutive adults (47 men and 211 women) with chronic unexplained gastrointestinal symptoms and suspected sucrose intolerance who were screened with a hydrogen-methane or 13C-sucrose breath test. The incidence of sucrose malabsorption with two different hydrogen-methane breath tests was 34.4% (21/61) (Commonwealth Diagnostics International, Inc., Salem, MA) and 40% (20/50) (Aerodiagnostics, Concord, MA). The incidence of sucrose malabsorption with the 13C-sucrose breath test was 26.5% (39/147). In a subgroup of patients with positive breath tests and clinical follow-up, counseling regarding diet and/or enzyme replacement led to symptomatic improvement in 26/43 (60%). In conclusion, sucrose malabsorption may present with irritable bowel syndrome symptoms in a proportion of adult patients, and breath tests may be useful in identifying sucrose malabsorption and differentiating it from other gastrointestinal disorders.

Intestinal Giardiasis in Children Undergoing Upper Endoscopy for Unexplained Gastrointestinal Symptoms: Implication for Diagnosis

Background Giardia lamblia is a flagellated protozoan causing diarrheal outbreaks worldwide. Microscopic stool examination is widely used. We conducted this study to explore intestinal giardiasis in children undergoing upper endoscopy for unexplained gastrointestinal symptoms. Methods The study included 160 children undergoing upper endoscopy for unexplained gastrointestinal symptoms (patients) and 90 children as controls. We collected stool samples for microscopic examination and ELISA coproantigen detection from all participants. We examined duodenal biopsies for patients. Results In patients, stool examination revealed Giardia in 23.8% and coproantigen detection was positive in 37.5%. Endoscopic duodenal biopsies revealed Giardia trophozoites in 5% of patients, in addition to various pathological changes. Conclusion Giardiasis was significantly higher (P = 0.001) in children with unexplained gastrointestinal complaints than the controls. Diagnosis by coproantigen detection was superior to microscopic stool examination, with a sensitivity of 90.9%. Duodenal biopsies examination confirmed the infection in fewer cases but added other diagnostic information.

Gut bless you: The microbiota-gut-brain axis in irritable bowel syndrome.

Irritable bowel syndrome (IBS) is a common clinical label for medically unexplained gastrointestinal symptoms, recently described as a disturbance of the microbiota-gut-brain axis. Despite decades of research, the pathophysiology of this highly heterogeneous disorder remains elusive. However, a dramatic change in the understanding of the underlying pathophysiological mechanisms surfaced when the importance of gut microbiota protruded the scientific picture. Are we getting any closer to understanding IBS’ etiology, or are we drowning in unspecific, conflicting data because we possess limited tools to unravel the cluster of secrets our gut microbiota is concealing? In this comprehensive review we are discussing some of the major important features of IBS and their interaction with gut microbiota, clinical microbiota-altering treatment such as the low FODMAP diet and fecal microbiota transplantation, neuroimaging and methods in microbiota analyses, and current and future challenges with big data analysis in IBS.

Eosinophilic gastroenteritis - a manifestation of an allergic disease in the gastrointestinal tract? Part 1. Epidemiology and diagnosis.

Eosinophilic gastroenteritis (EGE) is a relatively rare disease, but it should be considered whenever a patient presents with unexplained gastrointestinal symptoms that cannot be explained by parasitic infection or other gastrointestinal diseases characterized by eosinophilic infiltration. A high coexistence of EGE and allergic diseases has been documented. Diagnosis of EGE is based primarily on clinical, endoscopic, and histopathological findings. Glucocorticosteroids and other immunomodulatory drugs are the mainstay of treatment, but currently the greatest hope lies in biological drugs, which are undergoing intensive research. This disease is troublesome for the patient and significantly reduces the quality of life.

Prevalence and Characteristics of Gastrointestinal Symptoms and Hepatic Manifestation in Covid-19 Infection in Tertiary Care Center

Introduction: Although the primary clinical manifestation of COVID-19 is pulmonary disease, but there are increasing data to support the gastrointestinal and hepatic involvement. Aims: We aimed to see the prevalence and characteristics of gastrointestinal symptoms and hepatic manifestation in COVID-19 infection. Methods: This is a hospital based descriptive cross-sectional study which was carried out in medicine department of Nepalgunj Medical College. Consecutive patients of COVID-19 cases confirmed by polymerase chain reaction were included. The presenting complaints, laboratory parameters, clinical events were noted. The primary objective was to determine the prevalence of gastrointestinal manifestation and hepatic dysfunction and their correlation with severity of pneumonia. Results: Total patients enrolled in the study were 205. Majority of patients presented with respiratory symptoms 67.8%. Both respiratory and gastrointestinal symptoms were observed in 29.3% cases. Isolated gastrointestinal symptoms were observed in 2.9% cases. Common gastrointestinal symptoms were anorexia 14.1%, anorexia and nausea in 6.3%, pain abdomen in 3.9% and diarrhea in 2.4% cases. Hepatocellular type hepatic dysfunction reported in 53.2% cases. Rise in alanine aminotransferase (58.2% vs. 23.6%), aspartate aminotransferase (51.6% vs. 20.6%), alkaline phosphatase (44% vs. 15%), total bilirubin (76.6% vs12.5%) found significantly high in severe pneumonias compared with pneumonia only. Both gastrointestinal and hepatic dysfunctions were more common in severe cases (87.9% and 58.7%) than in mild disease (1% and 27%). Conclusion: One third of the patients of COVID-19 can have gastrointestinal symptoms and hepatic dysfunction. Around 3% of patients presented with isolated gastrointestinal symptoms. Thus, unexplained gastrointestinal symptoms in contacts of COVID-19 may demand polymerase chain reaction test to confirm the disease. Both gastrointestinal and hepatic dysfunction was more prevalent in severe pneumonia.

Considering Cannabis Use in Differential Diagnosis

This Teachable Moment describes why patients with unexplained gastrointestinal symptoms should be asked about cannabis use and how considering a diagnosis of cannabis hyperemesis and withdrawal may avoid recurrent emergency visits, imaging, and hospital admissions.

S1434 The 4-Hour Gastric Scintigraphy Emptying Study Identifies a Treatable Diagnosis in Most Patients Being Evaluated for Previously Unexplained Upper Gastrointestinal Post-Prandial Symptoms

S1434 The 4-Hour Gastric Scintigraphy Emptying Study Identifies a Treatable Diagnosis in Most Patients Being Evaluated for Previously Unexplained Upper Gastrointestinal Post-Prandial Symptoms