Abdominal Weakness Research Articles

This Month in Gastroenterology

This Month in Gastroenterology

The Death of Napoleon, Cancer or Arsenic?

Napoleon Bonaparte died on May 5, 1821, at the age of 51 on the island of Saint Helena, his prison for 5 years. Four autopsy reports, including 2 from the French contingent, revealed the cause of death to be an extensive carcinoma of the stomach complicated by terminal bleeding, the same disease that took his father and several close relatives, including a purported illegitimate son (1). Napoleon was reasonably well until the autumn of 1820, when he developed recurrent abdominal pain, weakness, and stubborn constipation, and toward the end intractable vomiting, hiccupping, and possibly thrombophlebitis-migrans. In the 1960s, when neutron and other activation techniques became available to measure trace elements in individual hairs, a series of articles appeared reporting that increased arsenic concentrations had been found in Napoleon’s hair, leading to claims that he had been deliberately poisoned while on Saint Helena (2)(3). However, the increased concentrations were measured in hair samples dating back to 1805, including samples taken while he was on Elba in 1814. Indeed, an Italian group has recently reported concentrations of 8 ppm (μg/g) and 6 ppm (modern normal concentration <1 ppm) from 1770 when Napoleon was a baby on Corsica (4). Also, samples of equal provenance have shown both normal and increased arsenic concentrations from hair samples culled on the same day as samples with increased concentrations (5)(6). This confusing situation exemplifies the unreliability of trace-element values measured in individual hair samples; concentrations vary enormously from hair to hair on the same head. Thus, to improve reliability it is necessary …

Case 20-2008: Abdominal Pain and Weakness after Gastric Bypass Surgery

Case 20-2008: Abdominal Pain and Weakness after Gastric Bypass Surgery

Reliability Of Kraus-Weber Exercise Test As An Evaluation Tool In Low Back Pain Susceptibility Among Apparently Healthy University Students

The purpose of this study was to determine strength and flexibility of the spinal and hamstring muscles among University of Ibadan students and the reliability of Kraus-Weber (K-W) exercise test. The Kraus-Weber test, involves a series of exercises that measure minimum strength and flexibility of the back, abdominal, psoas and hamstring muscles. Two hundred subjects (100 males and 100 females); ages ranging between 18 and 30 years, with no previous or present complaints of injury to the back and lower limbs were selected for the study using the non-probability sampling technique of sample of convenience. The Kraus-Weber test was carried out on the subjects whose age, gender, height, total body weight and responses to prepared questions had earlier been recorded, on two occasions with a day\'s interval. Many of the subjects (52%) failed the K-W test aimed at evaluating minimum abdominal, psoas, upper and lower back muscle strength and the back and hamstring muscle flexibility. Body mass index, weight, height and previous history of low back pain had low and negative correlation with performance in Kraus-Weber test while recreational/physical exercise had positive but low correlations with the test. It was concluded that K-W test is reliable and an easy to administer exercise test. It was recommended that individuals with weak abdominal and back muscles should be taken through remedial exercises. It was also suggested that all individuals without low back pain should make a habit of recreational exercise especially those subjects who failed the K-W test. Keywords: Kraus-Weber test, low back pain, muscle flexibility, muscle strength. African Journal for Physical, Health Education, Recreation and Dance Vol. 14 (2) 2008: pp. 188-198

Case 20-2008

A 57-year-old woman was admitted to the hospital because of abdominal pain and weakness, 1 month after gastric bypass surgery. In the month after the operation, episodes of tachycardia, bradycardia, diarrhea, dark urine, and abdominal pain occurred, with urine cultures that were positive for bacteria. After admission, weakness and numbness in the legs and arms developed and progressed to flaccid quadriparesis. A diagnostic test was performed.

Experience with Two Cases of Intestinal Tuberculosis: Utility of the QuantiFERON-TB Gold Test for Diagnosis

Intestinal tuberculosis is rare in Western countries, with incidence rates of 35.7 and 0.43 per 100,000 per year for the immigrant and native populations, respectively. Despite a clear increase in the frequency of extrapulmonary tuberculosis in immunosuppressed patients, the clinical features of intestinal tuberculosis are seen rarely. A typical clinical presentation includes abdominal pain, weight loss, fever, weakness, nausea, vomiting, obstruction, and bleeding. Intestinal tuberculosis often mimics inflammatory bowel disease or malignant neoplasia, and its preoperative diagnosis is a challenge. Microbiologic diagnosis often is difficult because the causative microorganism requires a long incubation period. Two case reports and review of the pertinent literature. We report two cases of colonic tuberculosis mimicking cecal carcinoma in one patient and periappendiceal abscess in the other. A 75 year-old man underwent right hemicolectomy for a right colon mass. Preoperative laboratory, radiologic, and endoscopic evaluations were negative for tuberculosis and carcinoma. The QuantiFERON-TB Gold test was positive. Surgical specimen histologic review showed non-caseating granulomas and rare Ziehl-Neelsen-positive bacilli. A 35 year-old man, born in Sri Lanka but living in Italy for 10 years, came to our attention for a periappendiceal abscess. Multiple peritoneal micro-nodules were found at laparotomy. Their extemporaneous histologic examination showed granulomas and giant-cell inflammation. A right hemicolectomy was performed. The QuantiFERON-TB Gold test, performed on peritoneal fluid and blood, was positive in both. The QuantiFERON-TB Gold test may hold promise for use in intestinal inflammatory diseases when tuberculosis is suspected but conventional workup is not diagnostic.

A case of vanishing bile duct syndrome and IBD secondary to Hodgkin's lymphoma

A 39-year-old man presented with a 2-month history of abdominal pain, jaundice, non-bloody diarrhea, weakness, and weight loss. Initial evaluation revealed intrahepatic ductopenia consistent with vanishing bile duct syndrome and IBD, type unclassified. Although treatment with budesonide improved his symptoms, they worsened several months later. On repeat evaluation, he was found to have extensive lymphadenopathy and an elevated white blood cell count. Physical examination, laboratory investigations, abdominal ultrasound, CT scans, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, colonoscopies with biopsies, hepatic biopsy, axillary lymph node biopsy. Hodgkin's lymphoma with secondary vanishing bile duct syndrome and IBD, type unclassified. The initial symptoms were managed with budesonide, but following recurrence, the patient's underlying lymphoma was treated with nitrogen mustard and dexamethasone.

Management of abdominal scars in the event of DIEP-flap breast reconstruction

Introduction and aims: The deep inferior epigastric perforator (DIEP)-flap continues to be the standard treatment in microsurgical breast reconstruction. However, previous abdominal operations with resulting scars limit the use of this flap due to possible severe complications such as fat necrosis or wound break down at the donor site in subcostal scars or hemiflap failure in lower abdominal midline scars. Such circumstances reduces the surgeons' enthusiasm for such procedures. A strategy to avoid such troubles is introduced. Material and methods: Cholecystectomy scar: After harvesting the DIEP-flap the cranial abdominal flap has to be prepared for direct closure. During the undermining of this cranial skin edge much care is taken to identify a perforator supplying the overlaying skin. Then this perforator is dissected through the muscle and traced caudally to the point where the perforator will be positioned after closing the abdominal wall without any tension. Lower Midline scar: After raising the DIEP-flap in a traditional manner on one side with harvesting of a considerate length of the inferior epigastric vessels, a segment of the superior epigastric vessels is left attached to the main pedicle. This stump of the superior epigastric vessels is now anastomosed under the microscope to a paraumbilical perforator on the contralateral side of the flap for in-flap microvascular augmentation. The above-mentioned technique was applied in five patients who presented with an infraumbilical vertical scar and were reconstructed with a DIEP-flap because of breast cancer. Results: This technique was used for abdominal closure in three subcostal scar patients and five lower midline scar patients without any complication. No abdominal weakness or hernia was encountered due to the additional manipulation of the rectus muscle and rectus sheath The above-mentioned technique was applied in five patients who presented with an infraumbilical vertical scar and were reconstructed with a DIEP-flap because of breast cancer. In three of the five patients there was an additional risk factor present such as smoking or diabetes mellitus. In all five patients no major complication due to marginal perfusion of the contralateral side of the flap was encountered. In two patients there was minor breakdown of fatty tissue that was managed conservatively in both cases. Conclusion: In-flap microvascular augmentation of DIEP-flaps is a valuable tool for the plastic surgeon in microvascular breast reconstruction. It permits usage of the lower abdominal tissue even if perfusion is compromised due to midline scarring. We recommend this technique as a safe alternative in patients seeking autologous breast reconstruction in the presence of a midline abdominal scar. With this technique, the DIEP-flap can be harvested safely even in the presence of abdominal scars and, thus, is not contraindicated under these circumstances any longer.

Primary carcinoid tumor of the ovary: a case report

Carcinoid tumors commonly occur in the gastrointestinal tract and lungs. However, carcinoid tumors of the ovary are rare, primary carcinoid tumors being even rarer, forming 0.3% of all carcinoid tumors. We present a case of a 55-year-old woman presented with symptoms of abdominal discomfort, weakness and fatigue. Pelvic ultrasound revealed a left-sided lobulated ovarian mass, which was solid with occasional internal scattered fluid areas. No other abnormality was detected on pelvic and abdominal ultrasonography. The findings of biochemical investigations were within normal limits. The patient underwent total abdominal hysterectomy and bilateral salphingo-oophorectomy for a clinical suspicion of ovarian tumor. Gross examination revealed a large tumor completely replacing the ovary, which was predominantly solid with few cystic areas and yellowish in color. Microscopically, the tumor was composed of uniform population of polygonal cells with abundant granular cytoplasm, arranged in small acini, solid sheets, ribbons and trabecular pattern. No teratomatous component was seen either grossly or microscopically. The tumor cells showed the strong expression of Chromogranin A and synaptophysin on immunohistochemistry. On the basis of this, a diagnosis of primary ovarian carcinoid was made. We conclude that it is important to be aware of this entity in the pathological diagnosis of ovarian tumors, even in the absence of any clinical indicator of carcinoid tumor/syndrome, as it carries a markedly better prognosis and clinical outcome in comparison with most other malignant ovarian tumors.

A Thoracic Disc Herniation Presenting as an Abdominal Hernia

Thoracic disc herniations (TDHs) occur infrequently, accounting for fewer than 1% of all spinal disc prolapses.1 Although most TDHs present initially with radicular pain, others may demonstrate only myelopathic signs and/or, even less often, ipsilateral abdominal muscle weakness.2,3 A 75-yr-old male who had been successfully treated with intermittent split-table pelvic traction for a T12–L1 disc herniation returned a year later with new, abrupt-onset, severe left-flank and abdominal pain. The physical examination revealed a large abdominal-wall hernia (Fig. 1) involving both the left upper- and lower-abdominal quadrants. The straight-leg raising test was unrestricted. Sensory and motor testing and the deep tendon reflexeswere all normal.FIGURE 1: Large abdominal-wall hernia (arrow) with thoracic disc herniation.However, there was a notable reduction in the motor units of the muscular abdominal wall. No long tract signs were observed, and the bowels and bladder were controlled. Electroneuromyography demonstrated 4+ fibrillationand positive waves in the left paraspinal muscle at the T10–T12 levels, without similar findings in the adjacent abdominal muscle. However, there was a notable reduction in motor units in the abdominal musculature. The peroneal motor nerve conductions were normal. Magnetic resonance imaging revealed a large, left T12–L1 disc herniation (Fig. 2). With persistent pain and associated difficulty in walking, the patient was referred to a spinal surgeon and was restarted on split-table intermittent pelvic traction after thermal therapy.FIGURE 2: Thoracic disc herniation (arrow) at T12–L1.With continuing conservative treatment, the patient’s pain slowly remitted. TDHs account for 0.24–0.75% of all disc herniations, with an overall incidence of 1/1,000,000 patients per year.1 This relative paucity of TDHs has been attributed to the stabilizing influence of the rib cage. When thoracic radicular pain is accompanied by myelopathic signs (i.e., hyperreflexia and Babinski reflexes), they mimic the presence of a spinal cord tumor. Although suggestive, an abdominal hernia in the presence of radicular thoracic pain is not pathognomonic evidence of a TDH. Other sources of thoracic root compromise include, among others, diabetes mellitus and/or viral exanthems (i.e., poliomyelitis), as well as herpes zoster.

Primary and secondary causes of constipation in older people.

Older people are at risk of constipation because of age-related changes that may weaken intestinal muscles, decrease peristalsis and reduce physical activity. Primary causes of constipation include decrease in fluid intake, decrease in ingestion of high fibre foods which may be associated with reduced ability to chew food, and weak abdominal muscles reducing effective evacuation. Secondary causes include disease processes such as dementia, Parkinson's, hypothryroidism, diverticular disease and prescribed medications, including narcotics, calcium channel blockers, anticholinergics and antidepressants. In this study a mixture was made up consisting of one cup of each of the following.

Abdominal distention due to omental bursitis in a calf

There are many potential causes of abdominal distention in cattle, among which, omental bursitis is a rare condition. Abdominal distention due to omental bursa inflammation was diagnosed in a 6-month-old Holstein calf. Clinical signs included severe abdominal distention, weakness, and diarrhea. Exploratory laparotomy was carried out at the midline and a large quantity of exudate was drained. α-Hemolytic streptococcus was cultured from the exudate. In accordance with the wishes of the owner, the calf was euthanized at an abattoir. At necropsy, ulcers in the abomasum were found together with one metallic foreign body that penetrated to the reticular wall. This report indicates that omental bursitis should be considered in the differential diagnosis for calves with signs of abdominal distention.

Heterotopic Pregnancy In A Low Risk Woman: A Diagnostic Dilemma

Whilst ectopic pregnancy is a relatively common occurrence, (11.1/1000 pregnancies 1), heterotopic pregnancy has traditionally been regarded as an extremely rare event. Recently, with the advent of assisted reproductive techniques the incidence has risen, but in a spontaneous conception cycle however, its incidence is still rare, and estimated to be 1:30,000 2. This case report illustrates that even when a diagnosis of intrauterine miscarriage has been made, coexistence of an ectopic pregnancy cannot be completely excluded. The patient was suspected to have incomplete miscarriage with suspicion of molar pregnancy on scan, however serum B-HCG was not grossly elevated. Suction curettage was done and products of conception were confirmed on histological examination. Couple of week's later patient presented with acute abdomen and was suspected to have ectopic pregnancy. The diagnosis of Interestial Pregnancy was confirmed on laproscopy and partial salpingectomy was done. A 36-year-old primigravida, presented with vaginal bleeding, lower abdominal pain and a positive pregnancy test. There was no history of abdomino-pelvic surgery, sexually transmitted diseases, pelvic inflammatory disease (PID) or intrauterine contraceptive device (IUCD) use or assisted conception techniques. The serum ?-hCG was13650 IU/L and a transvaginal scan identified a 2.5cm intrauterine gestational sac with no fetal pole. Some sonographic features raised suspicions of ‘‘a molar pregnancy'‘ but at evacuation of retained products, only ‘‘normal-looking'‘ tissue was found. Histology confirmed normal “products of conception” with no Arisstella reaction or molar tissue and hence no follow-up was arranged. Three weeks later she presented with sudden lower abdominal pain, weakness, and heavy vaginal bleeding. Her cervix was closed with moderate cervical excitation and severe pain in the left adenexa. The urinary pregnancy test was still positive and transvaginal scanning showed a “7.1 x 5.5 x 5.2 cm mass to the left of uterus”. A diagnostic laparoscopy revealed ruptured ectopic pregnancy in the interstitial portion of the left fallopian tube and a partial salpingectomy was carried out. Histology confirmed ectopic pregnancy and she made an uneventful recovery. DISCUSSION Heterotopic pregnancy, the coexistence of intrauterine and ectopic gestations, was first reported in 1708 3. Its aetiology is multifactorial with anatomical and functional alteration of the fallopian tubes. Factors like PID and gonadotrophins administration are the main predisposing factors4, but IUCD use, endometriosis, or previous abdominal-pelvic surgery has also been recognized causes. Most cases are thought to arise from multiple ovulation, and thus with the advent of ovulation induction it is not surprising the incidence has increased. Its frequency in spontaneous conception cycles is 1 in 30,0004 and in assisted fertilization cycles is 1:26005. Its diagnosis is often difficult and serial serum samples of βhCG can be misleading1. Abdominal pain, adnexal mass, peritoneal irritation and enlarged uterus are common signs. Transvaginal sonography however has increased the diagnosis up to 91%6. This case illustrates the need of follow-up in a patient who has ‘‘normal'‘ histology on evacuation despite ultrasound features prior to the operation suggestive of a molar pregnancy. A repeat serum BHCG +/follow-up scan at an earlier stage may have revealed the presence of the ectopic pregnancy sooner, avoiding the serious potential consequences, which she experienced. The heterotopic pregnancy was most likely to be there at the Heterotopic Pregnancy In A Low Risk Woman: A Diagnostic Dilemma 2 of 3 time of the initial presentation, especially in view of the original scan findings, as the pregnancy in the tube as well as in the uterus, may have given the appearance of a molar pregnancy. An alternative explanation however, may have been the possibility of retrograde spill of products of conception during the initial suction curettage, resulting in persistent trophoblastic disease especially as the ectopic was found in the interstitial/cornual portion of the tube.

Optimal electrode placement for noninvasive electrical stimulation of human abdominal muscles

Abdominal muscles are the most important expiratory muscles for coughing. Spinal cord-injured patients have respiratory complications because of abdominal muscle weakness and paralysis and impaired ability to cough. We aimed to determine the optimal positioning of stimulating electrodes on the trunk for the noninvasive electrical activation of the abdominal muscles. In six healthy subjects, we compared twitch pressures produced by a single electrical pulse through surface electrodes placed either posterolaterally or anteriorly on the trunk with twitch pressures produced by magnetic stimulation of nerve roots at the T(10) level. A gastroesophageal catheter measured gastric pressure (Pga) and esophageal pressure (Pes). Twitches were recorded at increasing stimulus intensities at functional residual capacity (FRC) in the seated posture. The maximal intensity used was also delivered at total lung capacity (TLC). At FRC, twitch pressures were greatest with electrical stimulation posterolaterally and magnetic stimulation at T(10) and smallest at the anterior site (Pga, 30 +/- 3 and 33 +/- 6 cm H(2)O vs. 12 +/- 3 cm H(2)O; Pes 8 +/- 2 and 11 +/- 3 cm H(2)O vs. 5 +/- 1 cm H(2)O; means +/- SE). At TLC, twitch pressures were larger. The values for posterolateral electrical stimulation were comparable to those evoked by thoracic magnetic stimulation. The posterolateral stimulation site is the optimal site for generating gastric and esophageal twitch pressures with electrical stimulation.

The relationship between pelvic cross syndrome and chronic low back pain

Objective: Specific patterns of muscle impairments, known as Pelvic Cross Syndrome (PCS), in the lumbo-pelvic region have been attributed to causing chronic Low Back Pain (LBP). In PCS, based on their primary functions, muscles are categorized as or phasic, and it has been assumed that phasic (abdominal and gluteal muscle weakness) or postural (decreased flexibility in the hip flexor and back extensor) muscle impairments could lead to an exaggerated Lumbar Lordosis (LL), which in turn might cause chronic low back pain. PCS theory also indicates that exaggerated lordosis in impaired subjects is controlled by hamstring muscle shortening. The purpose of this study was to examine the relationship among Pelvic Cross Syndrome, degree of lumbar lordosis and chronic low back pain. Design: A total of 600 subjects between the ages of 20 and 65 were selected. Subjects were categorized into four groups of males and females with and without low back pain. The degree of LL, the strength of abdominal and gluteal muscles and the extensibility of iliopsoas, erector spine, and hamstring muscles were measured in each group. The cut-off values obtained from Receiver Operating Characteristic (ROC) curve analysis were used to categorize subjects as having weak or short muscles in accordance with the PCS assumptions. The degree of lumbar lordosis in subjects with and without patterns of muscle impairments, and the association between lumbar lordosis and low back pain and the effects of hamstring muscle length on lordosis were assessed. Results: The results of this study showed no significant difference in the degree of LL in subjects with and without patterns of muscle impairment, or in subjects with and without LBP, or in those with and without short hamstring muscles. However, a significant difference in the strength of abdominal and gluteal; and in the length of hip flexor and hamstring muscles was found between subjects with and without LBP. Conclusions: The findings of this study did not support the assumptions of the PCS theory that certain patterns of muscle impairment would lead to exaggerated LL and LBP. Our data indicated that certain muscle impairments could contribute to chronic LBP, but probably not via changing the degree of lumbar lordosis as has been proposed in PCS theory.

Midline extraperitoneal approach to upper urinary tract surgery: Anatomical basis of surgical technique

To overcome the disadvantages inherent in the standard surgical approach to the kidney, we introduced a novel surgical technique via a midline extraperitoneal approach. The surgical technique is not substantially different from that of the standard midline transperitoneal approach, except no entry is made into the peritoneal cavity. Although the peritoneum itself is extremely thin and fragile, the peritoneum together with underlying subperitoneal fascia can be dissected readily as a substantial layer, if the proper plane is dissected. Further medial mobilization of the peritoneal sac en bloc by pursuing the fusion fascia plane allows full exposure of the kidney, ureter and great vessels. This approach was adopted for consecutive 51 patients during a 10-month period in 2003. All operations, including 33 radical nephrectomies and 11 nephroureterectomies were completed successfully without significant technical difficulties and differences in operation time and estimated blood loss compared to the transperitoneal approach. No intra- or perioperative complication occurred. All patients did seem to have a much more comfortable postoperative period with minor pain and few abdominal complaint, and the clinical impression was that they resumed the physical activity and oral intake earlier than those after the transperitoneal approach (P = 0.056). There are no operation-related problems such as intra-abdominal adhesion or abdominal muscle weakness resulting in some deformity at 2-year or more follow up. This approach combines the advantages of the transperitoneal midline and extraperitoneal flank approach. Its use will undoubtedly reduce the complications inherent in the transperitoneal approach or the flank approach.

Neospora caninumassociated with septic peritonitis in an adult dog

A 7-year-old, male neutered Rhodesian Ridgeback dog was referred to the University of California-Davis Veterinary Medical Teaching Hospital with a 4-month history of peritonitis and episodic abdominal discomfort, lethargy, and weakness. Marked abdominal distension with a prominent fluid wave was noted on physical examination. Cytologic analysis of the abdominal fluid indicated a septic exudate with mixed bacteria and many protozoal zoites. Differentials for the identity of the protozoal zoites included Toxoplasma gondii, Sarcocystis neurona, and Neospora caninum. Indirect latex agglutination antigen testing, standard indirect fluorescent antibody testing, and PCR analysis were performed to identify the zoites. The dog's serum antibody titer for N caninum tachyzoites was 1:20,480, known polysera to N caninum reacted against zoites in the abdominal fluid, and PCR analysis of the abdominal fluid was positive for the presence of a known gene of N caninum. Based on the morphologic, immunologic, and molecular findings, the zoites were identified as N caninum. It remains unclear how the tachyzoites gained access to the peritoneal cavity. To the authors' knowledge, there are no reports of free N caninum in abdominal fluid of any species.

Clinicopathological phenotype of ALS with a novel G72C SOD1 gene mutation mimicking a myopathy

A 71-year-old woman with a family history of amyotrophic lateral sclerosis (ALS) was investigated for symmetrical, proximal limb and abdominal muscle weakness. Initial examination showed mild proximal muscle weakness in the arms and legs, slightly elevated serum creatine kinase (CK) level, and normal electromyographic (EMG) findings. A myopathy was the presumed diagnosis. Over the next year, weakness became severe and tendon reflexes became unelicitable; no upper motor signs were present. EMG then showed acute and chronic denervation and a muscle biopsy showed target fibers and grouped atrophy. DNA analysis revealed a G72C CuZn-superoxide dismutase (SOD1) mutation. Fasciculations were absent throughout the disease. The patient died 53 months after symptom onset and autopsy revealed loss of lower motor neurons (LMN) and SOD1-positive inclusions. This case expands the phenotypic spectrum of ALS associated with SOD1 mutations to include presenting features that mimic a myopathy.

Celiac Disease: Evaluation of the Diagnosis and Dietary Compliance in Canadian Children

We sought to characterize the clinical features at presentation as well as the associated disorders, family history, and evaluation of compliance with a gluten-free diet in children with celiac disease from across Canada. All members (n = 5240) of the Canadian Celiac Association were surveyed with a questionnaire. Of the 2849 respondents with biopsy-confirmed celiac disease, 168 who were < 16 years old provided the data reported here. The mean age when surveyed was 9.1 +/- 4.1 years, and 58% were female. Median age at diagnosis was 3.0 years with a range of 1 to 15 years. Presenting symptoms included abdominal pain (90%), weight loss (71%), diarrhea (65%), weakness (64%), nausea/vomiting (53%), anemia (40%), mood swings (37%), and constipation (30%). Almost one third of families consulted > or = 2 pediatricians before confirmation of the diagnosis. Before the recognition of celiac disease, other diagnoses received by these children included anemia (15%), irritable bowel syndrome (11%), gastroesophageal reflux (8%), stress (8%), and peptic ulcer disease (4%). A serological test was performed to screen for celiac disease in 70% of those in this population. Eight percent had either type 1 diabetes mellitus or a first-degree relative with celiac disease. Almost all respondents (95%) reported strict adherence to a gluten-free diet, and 89% noted improved health. Reactions after accidental gluten ingestion developed in 54% of the children between 0.5 and 60 hours after ingestion with a median of 2.0 hours. Reactions included abdominal discomfort (87%), diarrhea (64%), bloating (57%), fatigue (37%), headache (24%), and constipation (8%), and most displayed > 1 symptom. Although most adjusted well to their disease and diet, 10% to 20% reported major disruptions in lifestyle. Twenty-three percent felt angry all or most of the time about following a gluten-free diet. Only 15% avoided traveling all or most of the time, and during travel, 83% brought gluten-free food with them all of the time. More than half of the families avoided restaurants all or most of the time. Twenty-eight percent of the respondents found it extremely difficult to locate stores with gluten-free foods, and 27% reported extreme difficulty in finding gluten-free foods or determining if foods were free of gluten. Sixty-three percent of the respondents felt that the information supplied by the Canadian Celiac Association was excellent. Gastroenterologists provided excellent information to 44%, dietitians to 36%, and the family physician to 11.5%. When asked to select 2 items that would improve their quality of life, better labeling of gluten-containing ingredients was selected by 63%, more gluten-free foods in the supermarket by 49%, gluten-free choices on restaurant menus by 49%, earlier diagnosis of celiac disease by 34%, and better dietary counseling by 7%. In Canada, children with celiac disease present at all ages with a variety of symptoms and associated conditions. Delays in diagnosis are common. Most children are compliant with a gluten-free diet. A minority of these children experience difficulties in modifying their lifestyles, and gluten-free foods remain difficult to obtain.

Umbilical Movement After Spinal Cord Injury

Background/Objective: Charles Beevor first discussed the movement of the umbilicus seen upon abdominal muscle contraction in neuro muscular diseases and spinal cordinjury (SCI)over a century ago.Since then, other examples of this phenomenon have been reported in the literature.Methods: This case review study documents movements of the umbilicus caused by abdominal muscle weakness after SCI.Results: SCI results in characteristic weakness of the abdominal muscles resulting in predictable movement of the umbilicus upon abdominal muscle contraction.Conclusions: Observation of umbilical movement with abdominal muscle contraction after SCI gives further confirmatory information about neurological level and typeof spinal cord lesion. Further study should include information about the effect of abdominal weakness on motor and respiratory function.