Rare presentations of small bowel endometriosis.

Despite endometriosis being a relatively common chronic gynecological condition in women of childbearing age, small bowel endometriosis is rare. Presentations can vary from completely asymptomatic to reported symptoms of abdominal pain, bloating, and diarrhea. The following two cases depict very atypical manifestations of ileal endometriosis that presented as obscure intermittent gastrointestinal bleeding and bowel obstruction requiring surgical intervention. The first case describes a previously healthy 40-year-old woman with severe symptomatic iron deficiency anemia and intermittent melena. A small bowel enteroscopy diagnosed multiple ulcerated strictures in the distal small bowel as the likely culprit. Despite nonsteroidal anti-inflammatory drug-induced enteropathy being initially considered as the likely etiology, histopathological examination of the resected distal ileal segment revealed evidence of endometriosis. The second case describes a 66-year-old with a presumptive diagnosis of Crohn's disease who reported a 10-year history of intermittent perimenstrual abdominal pain, diarrhea, and nausea with vomiting. Following two subsequent episodes of acute bowel obstruction and surgical resection of the patient's stricturing terminal ileal disease, histopathological examination demonstrated active chronic inflammation with endometriosis. Small bowel endometriosis should be considered as an unusual differential diagnosis in women who may present with obscure gastrointestinal bleeding from the small bowel or recurrent bowel obstruction.

Estudio comparativo del dolor abdominal en las culturas maya Tzeltal, maya Tzotzil y maya Q ́eqchi ́y el uso de Ageratina ligustrina para su tratamiento / Comparative study of abdominal pain in the Mayan cultures Tzeltal, Maya Tzotzil and Maya Q ́eqchi´ and use of Ageratina ligustrina for the treatment

El presente estudio es una comparación del dolor abdominal producido por trastornos gastrointestinales, aliviado por Ageratina ligustrina , entre los grupos maya Tzeltal, Tzotzil y Q ́eqchi ́, el cual integró un enfoque etnomédico, etnobotánico y transcultural, comparando estudios previos con el presente trabajo de campo. Para evaluar la eficacia de Ageratina para aliviar el dolor abdominal, se realizó un inventario de las moléculas reportadas en esta especie, así como de su actividad farmacológica, a través de una revisión bibliográfica. Los resultados mostraron que la epidemiología del dolor producido por TGI, su etnobotánica y el modelo explicativo del dolor abdominal fueron similares entre grupos étnicos. Asimismo, se identificaron 27 moléculas con efectos antiinflamatorios y antinociceptivos, lo que podría explicar por qué esta especie es culturalmente importante para los pobladores maya Tzeltal, Tzotzil y Q ́eqch i ́ para el alivio del dolor abdominal, mientras que, desde el punto de vista biomédico, es una especie con potencial para inhibir el dolor visceral.

The current study is a comparison of the abdominal pain conception produced by gastrointestinal disorders, relieved by Ageratina ligustrina , among inhabitants of the Mayan Tzeltal, Tzotzil, and Q'eqchi' groups ethnomedical, ethnobotanical, and cross -cultural approaches were used to compare previous studies with the present field work. To evaluate the efficacy of A. ligustrina to relieve pain, also through a bibliographic review an inventory of the molecules present in this species was performed, as well as their pharmacological activity. The results showed that the epidemiology of pain produced by GID, its ethnobotany, and the explanatory model of abdominal pain are similar among ethnic groups. Likewise, 27 molecules with anti-inflammatory and anti-nociceptive effects were identified, which could explain why this species is culturally important for the Mayan Tzeltal, Tzotzil, and Q'eqchi' groups for the relief of abdominal pain, while, from a biomedical point of view, it is a species with potential to inhibit visceral pain.

Acute Appendicitis in the Setting of Infectious Mononucleosis: A Case Report.

Infectious mononucleosis (IM) is a viral illness caused by the Epstein-Barr virus that typically manifests with pharyngitis, lymphadenopathy, and fatigue. In rare cases, IM can cause acute appendicitis. We present the case of an 18-year-old female who arrived at the emergency department with worsening abdominal pain and an ongoing cough. Initial imaging showed a questionably dilated appendix, and a follow-up examination revealed cervical lymphadenopathy. She later returned to the ED with severe abdominal pain, clinical signs of acute appendicitis, and a positive monospot test, which led to an appendectomy. This case illustrates the need for complete history taking and thorough physical examination in patients with acute appendicitis, as their condition may be due to an atypical underlying cause.

When Diagnosis Curls a Little: Partial Bowel Obstruction Due to Ascaris. L in a Young Man.

Ascaris lumbricoides is a helminth commonly infecting humans, particularly in developing countries. It causes a range of clinical symptoms; However, many patients are asymptomatic. This article presents a case study of a young man who experienced diffuse abdominal pain and constipation, eventually being diagnosed with partial bowel obstruction due to Ascaris lumbricoides infection. The article emphasizes the importance of considering helminthic infections like ascariasis as a potential cause of intestinal obstruction, especially in endemic areas. Early diagnosis and intervention, including conservative management and anthelminthic drugs, can lead to a full recovery and avoid unnecessary surgery.

Spontaneous omental infarction as a rare differential for right iliac fossa pain: A case report and review of the literature.

Omental infarction is a rare cause of acute abdominal pain, often benign and self-limiting. The significance of infarction lies in the fact that it can mimic other abdominal pathologies including appendicitis, cholecystitis, pancreatitis, or reflux disease. Diagnostic laparoscopy provides the definitive diagnosis of omental infarction, but it is invasive and limited due to resources. Computed tomography of the abdomen and pelvis has been considered the gold standard to diagnosing omental infarction when a non-invasive diagnostic approach is required. Additionally, ultrasound can also be used alternatively for children. Currently, there is no consensus in the diagnosis and management of patients with imaging-proven omental infarction. Spontaneous infarcted omentum must be considered by surgeons and radiologists as a rare cause of acute abdominal pain as patients can experience good outcomes with either conservative or operative approach. However, conservative management must only be considered in stable patients where alternative pathology is unlikely.

Rectus Sheath Hematoma.

The authors report on the case of a 69-year-old female who presented to the emergency department due to exquisite abdominal pain she described as occurring after she coughed. Imaging revealed a rectus sheath hematoma (RSH). A RSH is an uncommon but significant cause of acute abdominal pain that occurs when blood accumulates in the sheath of the rectus abdominis muscle. It can be caused by a muscular tear or a ruptured epigastric artery and can happen spontaneously or after trauma. The etiology, presentation, diagnosis, and management are discussed.

Clinical impact of a multimodal pain management protocol for loop ileostomy reversal.

PURPOSE: As introduced, multimodal pain management bundle for ileostomy reversal may be considered to reduce postoperative pain and hospital stay. The aim of this study was to evaluate clinical efficacy of perioperative multimodal pain bundle for ileostomy. METHODS: Medical records of patients who underwent ileostomy reversal after rectal cancer surgery from April 2017 to March 2020 were analyzed. Sixty-seven patients received multimodal pain bundle protocol with ileostomy reversal (group A) and 41 patients underwent closure of ileostomy with conventional pain management (group B). RESULTS: Baseline characteristics, including age, sex, body mass index, American Society of Anesthesiologists classification, diabetes mellitus, and smoking history, were not significantly different between the groups. The pain score on postoperative day 1 was significant lower in group A (visual analog scale, 2.6 ± 1.3 vs. 3.2 ± 1.2; P = 0.013). Overall consumption of opioid in group A was significant less than group B (9.7 ± 9.5 vs. 21.2 ± 8.8, P < 0.001). Hospital stay was significantly shorter in group A (2.3 ± 1.5 days vs. 4.1 ± 1.5 days, P < 0.001). There were no significant differences between the groups in postoperative complication rate. CONCLUSION: Multimodal pain protocol for ileostomy reversal could reduce postoperative pain, usage of opioid and hospital stay compared to conventional pain management.

Effects of ondansetron on symptoms during a gastric emptying study and enteral lipid challenge and on daily symptoms in diabetic gastroenteropathy.

BACKGROUND: This study compared the effects of ondansetron and placebo in patients with diabetes mellitus and symptoms of dyspepsia (diabetic gastroenteropathy [DGE]). METHODS: We performed a randomized, double-blinded, placebo-controlled study of ondansetron tablets (8 mg) three times daily for 4 weeks in DGE patients. Symptoms were assessed with the Gastroparesis Cardinal Symptom Index daily diaries. Gastric emptying (GE) of solids (scintigraphy) and duodenal lipid infusions (300 kcal over 2 h) were each assessed twice, with placebo and ondansetron. Drug effects on GE, symptoms during the GE study and during lipid infusion, and daily symptoms were analyzed. KEY RESULTS: Of 41 patients, 37 completed both GE studies and one completed 1; 31 completed both lipid infusions and four only placebo; and all 35 randomized patients completed 4 weeks of treatment. Compared to placebo, ondansetron reduced the severity of fullness (p = 0.02) and belching (p = 0.049) during lipid infusion but did not affect GE T1/2. Both ondansetron and placebo improved daily symptoms versus the baseline period (p < 0.05), but the differences were not significant. In the analysis of covariance of daily symptoms during the treatment period, the interaction term between treatment and the acute effect of ondansetron on symptoms during lipid challenge was significant (p = .024). CONCLUSIONS & INFERENCES: Ondansetron significantly reduced fullness during enteral lipid infusion in patients with DGE. Overall, ondansetron did not improve daily symptoms versus placebo. But patients in whom ondansetron improved symptoms during enteral lipid challenge were perhaps more likely to experience symptom relief during daily treatment.

An unusual case of giant jejunal diverticula presenting radiologically as toxic megacolon.

Jejunal diverticulosis is an uncommon entity of the gastrointestinal tract. It involves the presence of multiple diverticula (pouches) in the jejunal wall. Jejunal diverticulosis is not so common, and the epidemiology is ill defined, but usually, it is known to affect the elderly more. They are considered from a pathophysiological point of view as motility disorders, structural defects, or high intraluminal pressures, with the result of prolapse of the mucosa of the jejunum through weak points of the intestinal wall. It represents a rare entity with different clinical presentations, ranging from being asymptomatic to life-threatening complications such as obstruction, bleeding, or perforation. Treatment depends on the presentation and can be conservative or surgical management.

The gut microbiome in disorders of gut-brain interaction.

Functional gastrointestinal disorders (FGIDs), chronic disorders characterized by either abdominal pain, altered intestinal motility, or their combination, have a worldwide prevalence of more than 40% and impose a high socioeconomic burden with a significant decline in quality of life. Recently, FGIDs have been reclassified as disorders of gut-brain interaction (DGBI), reflecting the key role of the gut-brain bidirectional communication in these disorders and their impact on psychological comorbidities. Although, during the past decades, the field of DGBIs has advanced significantly, the molecular mechanisms underlying DGBIs pathogenesis and pathophysiology, and the role of the gut microbiome in these processes are not fully understood. This review aims to discuss the latest body of literature on the complex microbiota-gut-brain interactions and their implications in the pathogenesis of DGBIs. A better understanding of the existing communication pathways between the gut microbiome and the brain holds promise in developing effective therapeutic interventions for DGBIs.

Optimizing Outcomes for Acute Mesenteric Ischemia in the Context of Hypogammaglobulinemia: A Detailed Analysis of Surgical and Medical Strategies.

Acute mesenteric ischemia is a critical condition marked by a sudden loss of blood supply to the intestines, often leading to rapid tissue necrosis and severe clinical outcomes if untreated. In the context of hypogammaglobulinemia, an immunodeficiency characterized by decreased levels of immunoglobulins, this vascular emergency becomes even more daunting. Hypogammaglobulinemia can impair the immune system's response to both infection and ischemic injury, intensifying the severity of intestinal damage. This report describes the case of a 52-year-old female with hypogammaglobulinemia who presented with severe abdominal pain. Surgical exploration revealed 100 cm of necrotic small bowel extending from 150 cm distal to the ligament of Treitz to within 10 cm of the ileocecal valve. The necrotic section was surgically removed, and primary anastomosis was performed. This instance highlights the significant impact of immunodeficiency on the progression and management of acute mesenteric ischemia, demonstrating the critical need for early intervention and tailored management strategies, especially in immunocompromised patients, to prevent severe outcomes. The case illuminates the importance of recognizing immunodeficiency as a complicating factor in acute gastrointestinal emergencies, stressing the necessity for prompt and effective medical and surgical interventions to improve prognosis and patient outcomes in complex clinical scenarios.

Gallbladder Diverticulum as a Rare Disease and a Therapeutic Challenge: A Case Report.

This case report details a rare instance of gallbladder diverticulum, highlighting the diagnostic and therapeutic challenges associated with this condition. Gallbladder diverticulum is an uncommon anomaly that often mimics the symptoms of more prevalent gallbladder diseases, making an accurate diagnosis challenging. The patient, a 55-year-old female, presented with atypical abdominal pain and was initially suspected to have chronic cholecystitis. Ultrasound examinations and subsequent enhanced computed tomography imaging revealed a gallbladder diverticulum without the presence of gallstones or polyps. Given the rarity of this condition and the potential for complications, a laparoscopic cholecystectomy was performed. The surgery was successful, and the patient's symptoms were completely resolved postoperatively, confirming the diagnosis. This report underscores the importance of considering gallbladder diverticulum in the differential diagnosis for atypical gallbladder symptoms and advocates for prompt surgical intervention to prevent complications. Our findings contribute to the limited literature on this rare condition and emphasize the need for awareness among clinicians to achieve optimal patient outcomes.

Navigating through 65 years of insights: lessons learned on functional abdominal pain in children.

In 1958, Apley and Naish authored a groundbreaking paper in Archives of Disease in Childhood, elucidating the epidemiology and risk factors of recurrent abdominal pain in children-a subject that had confounded clinicians of their time. Surprisingly, even after 65 years, there are several unanswered questions regarding the etiology, pathophysiology, and management of pediatric abdominal pain. Contrary to the prevailing notion that children naturally outgrow functional abdominal pain, compelling evidence suggests it's possible these children develop a number of clinically significant psychological issues that could profoundly impact their quality of life and, consequently, future health and educational outcomes. In this light, we aimed to comprehensively review the current literature to update the knowledge of practicing clinicians on functional abdominal pain, summarizing the evidence from the last 65 years.Conclusion: The enduring unanswered questions surrounding childhood abdominal pain continue to challenge clinicians, resulting in unnecessary investigations, thereby contributing to substantial healthcare expenditures. It is also evident that children with long-standing symptoms would progress to adulthood with the potential to develop irritable bowel syndrome and many psychological disturbances. Several key interventions using pharmacological agents, such as amitriptyline, showed that some of these drugs are no more effective than the placebo in clinical trials. Several research during the recent past suggest that psychological interventions such as gut-directed hypnotherapy alleviate symptoms and ensure better prognosis in the long run. Therefore, clinicians and researchers must join hands to explore the pathophysiological mechanisms underpinning functional abdominal pain and novel therapeutic strategies to ensure the well-being of these children. What is Known: • Functional abdominal pain disorders are common among children, with a worldwide prevalence of 13.5% of children suffering from at least one of these disorders • These disorders contribute to a significant reduction in the quality of life of affected children and their families and lead to an array of psychological problems What is New: • The biological basis of functional abdominal pain is becoming more explicit, including complex interactions between altered microbiome, deranged motility, and psychological dysfunction with gut-brain interactions • Novel approaches giving minimal emphasis on pharmacological interventions and exploring psychological interventions are showing promising results.

A rare occurrence of isolated superior mesenteric artery dissection, a case image report.

Isolated spontaneous superior mesenteric artery (SMA) dissection is relatively rare. Often found incidentally on cross-sectional imaging, often managed non-operatively. We present a patient who presented with chest pain and was found to have a SMA dissection.

Rapunzel Syndrome: Diagnostic Challenges and Multidisciplinary Treatment Strategies.

Rapunzel syndrome, a rare yet complex condition, poses diagnostic and therapeutic challenges. Trichobezoars, stemming from trichotillomania and pica, manifest as hair conglomerates within the gastrointestinal tract, often necessitating surgical intervention. This review synthesizes literature on symptomatology, diagnostic methods, and treatment modalities, emphasizing the multidisciplinary approach essential for effective management. Psychological interventions, including cognitive-behavioral therapy, complement surgical measures in addressing underlying psychiatric factors. Diagnostic imaging, endoscopic examinations, and histopathological analysis aid in an accurate diagnosis. Enhanced awareness among healthcare providers regarding the association between psychological disorders and gastrointestinal complications is crucial for timely intervention and improved outcomes in individuals with Rapunzel syndrome.

Malignant myopericytoma originating from the colon: A case report.

BACKGROUND: Myopericytoma is a benign tumor that typically occurs within subcutaneous tissue and most often involves the distal extremities, followed by the proximal extremities, neck, thoracic vertebrae and oral cavity. Complete resection is often curative. Malignant myopericytoma is extremely rare and has a poor prognosis. Here, we report for the first time a case of malignant myopericytoma originating from the colon. CASE SUMMARY: A 69-year-old male was admitted to our hospital with right upper quadrant pain for five days. Imaging suggested a liver mass with hemorrhage. A malignant hepatic tumor was the initial diagnosis. Surgical resection was performed after a complete preoperative work up. Initial postoperative pathology suggested that the mass was a malignant myoblastoma unrelated to the liver. Four months after the first surgery, an enhanced computed tomography (CT) scan revealed a recurrence of the tumor. The diagnosis of malignant myopericytoma derived from the colon was confirmed on histopathological examination of the specimen from the second surgery. The patient did not return to the hospital regularly for surveillance. The first postoperative abdominal CT examination six months after the second surgery demonstrated multiple liver metastases. Survival time between the diagnosis of the tumor to death was approximately one year. CONCLUSION: Malignant myopericytoma is a rare cancer. Preoperative diagnosis may be difficult. Due to a lack of treatment options, prognosis is poor.

Hepatic round ligament necrosis: A report of two cases managed differently.

INTRODUCTION AND IMPORTANCE: Hepatic round ligament necrosis is a rare condition that has atypical clinical presentation. Its diagnosis; however, being a combination of clinical and biological signs, is very dependent on the computed topography scan. CASE PRESENTATION: This report demonstrates 2 cases that had different presentations. Case 1 was an elderly female with multiple comorbidities presenting with signs of sepsis, perturbation of liver enzymes and presence of thrombosis of portal vein as well as dilatation of bile ducts. On the other hand, case 2 was a younger male patient presenting with inflammatory syndrome, no other biological abnormalities and only an evident fatty stranding in his radiological workup. CLINICAL DISCUSSION: Our 2 cases had different presentations in severity and were thus treated differently. The first patient had clinical, biological and radiological signs of severity; thus, he was treated surgically. On the other hand, the other patient with benign presentation was treated medically with antibiotics. CONCLUSION: In the absence of recommendations concerning the management of hepatic round ligament necrosis, we suggest that treatment choice be based on the severity signs being: clinical, biological or radiological.

Gastrointestinal Symptoms and Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols Sources in Schoolchildren-A Pilot Study.

Bothersome gastrointestinal (GI) signs/symptoms, including abdominal pain, distension, nausea, and flatulence, are common in children. A diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) is frequently recommended for children with GI symptoms. Currently, there are no studies on the effect of FODMAPs in healthy schoolchildren. In this cross-sectional study, schoolchildren reported an association between FODMAPs and GI symptoms through a standardized questionnaire and images of 20 common staples known to be rich in FODMAPs. A total of 208 schoolchildren aged 8-18 years old participated. A proportion of 38.0% of children reported GI symptoms, with abdominal pain (33%) being the most common complaint followed by abdominal distension (24%) and nausea (23%). The majority of children who reported intolerances to FODMAP-containing foods were intolerant to less than two food groups (76%). While vegetables and legumes (26%), particularly black beans (11%) and onions (7%), emerged as the most common group of triggers, milk (12%) stood out as the single food most frequently associated with GI symptoms. In conclusion, there was a high prevalence of FODMAPs intolerance among schoolchildren. Larger studies are recommended to confirm these findings and to inform possible dietary interventions to reduce the effect of FODMAPs on schoolchildren.

Biliary Ascariasis in a Pediatric Patient in Lithuania: Case Report and Literature Review.

Hepatobiliary ascariasis is caused by the entry of the nematode A. lumbricoides from the duodenum into the biliary duct. We report a case of an Ascaris-induced extrahepatic biliary tract obstruction in a pediatric patient admitted to the hospital due to a wide spectrum of symptoms of biliary disease, which included abdominal pain in the upper abdominal quadrants, vomiting, and jaundice. Imaging tests-including ultrasound, magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP)-were performed to confirm the diagnosis of biliary ascariasis. The tests did, in fact, demonstrate signs of this disease. Nevertheless, during the ERCP, only the remains of Ascaris parasites in the form of tissue fragments were extracted. We also aim to discuss the prevalence of ascariasis in children, the causes of migration of Ascaris parasites into the bile ducts, together with its clinical manifestations, as well as the diagnostic and treatment methods of this disease.

Introducing AEM-RADS: A novel reporting and data system for abdominal emergencies.

PURPOSE: The Reporting and Data System (RADS) has proven successful in various medical settings, but a standardized reporting system for abdominal emergencies is lacking. In this study, the Abdominal Emergency Reporting and Data System (AEM-RADS) for urgent findings on abdominal CT scans is introduced to address the need for consistency in emergency radiology. METHODS: In this prospective observational study, conducted over a six-month period, the urgency of abdominal CT scans was assessed using the proposed AEM-RADS scoring system. The committee developed a scale ranging from AEM-RADS 1 (normal) to AEM-RADS 5 (urgent disease). Interobserver agreement between two observers with different experience was evaluated, and robust AEM-RADS reference values were established by radiologists who were not observers. Statistical analysis used mean, standard deviations and Kendall's tau analysis for interobserver agreement. RESULTS: Among 2656 patients who underwent CT for abdominal emergencies, the AEM-RADS distribution was 17.50% AEM-RADS 1, 28.57% AEM-RADS 2, 7.22% AEM-RADS 3, 35.61% AEM-RADS 4, and 11.06% AEM-RADS 5. Interobserver agreement was high, especially for urgent and emergent cases (p < 0.0001). Notable discrepancies were observed in AEM-RADS categories 2C-D and 3B-C, emphasizing the influence of radiologists' experience on interpretation. However, the interobserver agreement for both AEM-RADS 2C-D and 3B-C were statistically significant (p < 0.001). CONCLUSIONS: AEM-RADS showed promising reliability, particularly in identifying urgent and emergent cases. Despite some inter-observer discrepancies, the system showed potential for standardized emergency workups. AEM-RADS could significantly enhance diagnostic accuracy in abdominal emergencies and provide a structured framework for shared decision-making between clinicians and radiologists.0.