Acute abdominal pain from epiploic appendagitis.

Evaluating patients for abdominal pain is common in the ED and can involve many differential diagnoses and treatment options. This case report describes a 35-year-old active duty military man whose abdominal pain evaluation at a military treatment facility led to the diagnosis of epiploic appendagitis.

Conservative treatment of rectosigmoid endometriosis: A prospective study.

INTRODUCTION: Deep infiltrating endometriosis is a common cause of pelvic pain. However, some patients have limited problems that may be controlled by medical treatment, so avoiding the potentially severe complications of major surgery. This approach requires detailed knowledge on quality of life and clinical symptoms over time. The aim of the study was to monitor these parameters in patients with rectosigmoid endometriosis treated with oral contraceptives, oral gestagens, and/or the levonorgestrel-releasing intrauterine device. Moreover, nodule size measurements performed with transvaginal sonography were correlated to severity of symptoms. MATERIAL AND METHODS: Conservatively treated patients on oral contraceptives, oral gestagens, or the levonorgestrel-releasing intrauterine device underwent transvaginal sonography and answered a self-administered questionnaire regarding clinical symptoms and quality of life (Short Form 36 and Endometriosis Health Profile 30) at baseline, and 6 and 12 months later. RESULTS: Eighty women completed the follow up. Scores of quality of life were comparable to normative data for Danish women of similar age and did not change with time. No association between change in size of the rectosigmoid nodule and change in symptoms was seen. CONCLUSIONS: This study supports that simple treatment with oral contraceptives, oral gestagens, or the levonorgestrel-releasing intrauterine device represents a viable therapeutic approach to rectosigmoid Deep infiltrating endometriosis, provided that proper selection of patients in need of surgery exists.

Malakoplakia of the large intestine: an incidental extremely rare finding.

Malakoplakia is a rare inflammatory disease, most commonly found in the urinary tract. It appears be related to a functional deficiency of macrophages, resulting in an inability to destroy digested bacteria and it is associated with various conditions that cause immunodeficiency. A rare case of malakoplakia of the colon in a healthy 68-year old male is presented. The patient underwent emergency surgery with colon resection and an end stoma with closure of the distal bowel (Hartmann's procedure), due to incarcerated ventral hernia and sigmoid-colon rupture. He underwent reversal of the Hartmann's procedure four months after the initial operation. The histological examination from the anastomotic rings revealed Michaelis-Gutmann bodies that are pathognomonic of malakoplakia. He received per os ciprofloxacin, bethanecol and ascorbic acid for 12 months. Follow-up endoscopy did not exhibit any signs of the disease. A case of a healthy patient presenting with malakoplakia without any underlying disease that causes immunodeficiency is extremely rare. Treatment of malakoplakia involves the eradication of microorganisms. Cholinergic agonists, such as bethanechol and ascorbic acid, as well as antimicrobial treatment with trimpethoprim/sulphamethoxazol and rifampicin are most commonly being used. Long-term antimicrobial treatment has been reported (6 months to 3 years).

Casein glycomacropeptide for active distal ulcerative colitis: a randomized pilot study.

BACKGROUND: In ulcerative colitis (UC), dietary supplements may have anti-inflammatory properties and improve disease course. We investigated the effects of casein glycomacropeptide (CGMP), a fraction of bovine whey protein, in active UC. MATERIALS AND METHODS: In a randomized open-label intervention study, 24 patients with active UC involving 10-40 cm of the distal colon were randomized in a 2 : 1 ratio into two groups. The first group was administered their usual treatment plus a daily supplement of CGMP 30 g, and the second group was administered a dose escalation to 4800 mg oral mesalamine daily (standard treatment) for 4 weeks. Clinical, endoscopic, mucosal and circulating disease activity markers were monitored. Acceptance of and adherence to CGMP up to 8 weeks were documented. RESULTS: After 4 weeks of treatment, 10 of 16 (63%) patients who received CGMP had an unchanged or decreased Simple Clinical Colitis Activity Index (SCCAI), which was similar to the four of eight (50%) (P = 0·67) patients on the standard treatment. The number of patients in which SCCAI decreased by three or more did not differ between the two groups: nine of 16 (56%) in the CGMP group vs. four of eight (50%) in the standard treatment group (P = 0·77). Changes in disease extent and severity were similar between the two groups. CGMP was well tolerated and accepted by the patients. CONCLUSIONS: The addition of CGMP as a nutritional therapy to standard treatment was safe and accepted by patients with active distal UC. The disease-modifying effect of CGMP was similar to that of the mesalamine dose escalation.

Long-term follow-up of lung transplant recipients supports non-operative treatment of uncomplicated diverticulitis.

BACKGROUND: We aim to assess the incidence, current treatment, and outcome of diverticulitis in highly immunosuppressed lung transplant recipients. METHODS: Retrospective analysis of a prospective database of 403 lung transplant recipients transplanted between 1992 and 2013 with a mean follow-up of 100 months (SD 58.0). RESULTS: 4.46% of lung transplant recipients (n=18) developed diverticulitis. Eight lung transplant recipients developed uncomplicated diverticulitis, which were all treated successfully with antibiotics. Three patients (37.5%) underwent elective sigmoid resection with severe Grade 3b complications after two of five (40%) surgical procedures. Diverticulitis recurrence occurred in five patients (60%). In total, 10 lung transplant recipients presented with 11 episodes of perforated diverticulitis with a 30-day mortality rate of 9.1%. Hartmann procedure was performed in eight lung transplant recipients. Sigmoid resection with primary anastomosis and protective ileostomy was performed in three patients with Hinchey I. Two of these patients developed anastomotic leakage with a secondary Hartmann procedure. CONCLUSION: Due to high leakage rate after resection with primary anastomosis and protective ileostomy in our cohort of lung transplant recipients with perforated diverticulitis, the Hartmann procedure seems to be the safer option. In contrast, in uncomplicated diverticulitis, non-operative treatment can be considered as a safe and highly successful treatment option, even for recurrences.

Diffuse Autoimmune Enteropathy and Colopathy in an Adult Patient Successfully Treated With Adalimumab and a Review of the Literature.

Autoimmune enteropathy (AIE) is a rare disease that causes intractable diarrhea not responsive to a gluten free diet and must be distinguished from refractory sprue. It is associated with circulating autoantibodies against goblet cells and enterocytes. AIE mainly involves the small intestines, with very few cases reported in adults. Because of the paucity of cases, the epidemiology of the disease remains unclear, and treatment is based on the cases found in the literature. Of the 35 adult cases reported, only 4 involved the colon. Because of the low number of cases, there have been no clear recommendations on treatment modalities with most reports heavily emphasizing steroids as the mainstay of treatment. We present the case of adult female patient who developed postpartum AIE and colopathy with profuse diarrhea successfully treated with adalimumab and a review of the literature. To the best of our knowledge, this case is only the fourth case of a tumor necrosis factor alpha antagonist being used in the treatment of AIE and the first case of adalimumab being used.

Selective non-antibiotic treatment in sigmoid diverticulitis: is it time to change the traditional approach?

BACKGROUND: A growing body of knowledge is calling into question the use of antibiotics in acute diverticulitis (AD). Moreover, recent studies provide evidence regarding the security of treating patients with AD as outpatients. The aim of this study was to evaluate a restrictive antibiotic outpatient protocol for the treatment of mild-to-moderate episodes of AD. METHODS: All patients with symptoms of AD presenting to our emergency department were assigned a modified Neff stage. Patients with mild AD received outpatient treatment without antibiotics. Patients with mild AD and comorbidities were admitted to receive the same treatment. Patients with moderate AD were admitted for 48 h and were then managed as outpatients until they had completed 10 days of antibiotic treatment. RESULTS: Between April 2013 and November 2014, we attended 110 patients with a diagnosis of AD, 77 of whom we included in the study: 45 patients with mild AD and 32 with moderate AD. Of the patients with mild AD, 88.8 % successfully completed the non-antibiotic, non-admission treatment regime and 95.5 % benefited from a non-antibiotic regime, whether as outpatients or inpatients. A total of 88 % of patients with mild AD and 87.5 % of patients with moderate AD who met the inclusion criteria completed treatment as outpatients without incident. No major complications (abscess, emergency surgery) or deaths were recorded. CONCLUSIONS: Outpatient treatment without antibiotics for patients with mild AD is safe and effective. Patients with moderate AD can be safely treated with antibiotics in a mixed regime as inpatients and outpatients.

[Effectiveness of anti-tumor necrosis factor-α therapy in Crohn's disease with abscesses around the sigmoid colon: a case report].

We report the case of a man in his 50s who was diagnosed with Crohn's colitis in his 30s and who presented with post-prandial lower abdominal pain in January, 20XX. Colonoscopy and abdominal contrast-enhanced computed tomography revealed abscesses around the sigmoid colon. Although his response to antibiotics was poor, treatment with a combination of antibiotics and adalimumab resolved the abscesses. Nine months later, however, the abscesses around the sigmoid colon recurred. Treatment comprising bowel rest and antibiotics led to immediate improvement of the symptoms. We report a case of effective anti-tumor necrosis factor-α therapy in Crohn's colitis with abscesses around the sigmoid colon.

Minimally invasive and surgical management strategies tailored to the severity of acute diverticulitis.

BACKGROUND: The severity of acute diverticulitis ranges from mild, simple inflammation to pericolic abscesses, or perforation with faeculent peritonitis. Treatment of diverticulitis has evolved towards more conservative and minimally invasive strategies. The aim of this review is to highlight recent concepts and advances in management. METHODS: A literature review was performed on the electronic databases MEDLINE from PubMed, Embase and the Cochrane Library for publications in English. The keywords 'diverticulitis', 'diverticular' were searched for the past decade (to September 2013). RESULTS: Diverticulitis occurs frequently in the Western world, but only one in five patients develops complications (such as abscess and perforation) during the first acute presentation. The reported perforation rate is 3.5 per 100,000 population. Based on recent data, including the AVOD and DIVER trials, antibiotic therapy for mild episodes may be unnecessary and outpatient management reasonable in most patients. Antibiotics and admission to hospital is required for complicated diverticulitis confirmed on imaging and for patients with sepsis. Diverticular abscesses (about 5 per cent of patients) may require percutaneous drainage if antibiotics alone fail. Laparoscopic management of non-faecal perforated diverticulitis is feasible in selected patients, and peritoneal lavage in combination with antibiotic therapy may avoid colonic resection and a stoma. However, the collective, published worldwide experience is limited to fewer than 800 patients, and results from ongoing randomized trials (LapLAND, SCANDIV, DILALA and LADIES trials) are needed to inform better decision-making. CONCLUSION: The treatment of diverticulitis continues to evolve with a trend towards a more conservative and minimally invasive management approach. Judicious use of antibiotics in uncomplicated cases, greater application of laparoscopic techniques, and primary resection and anastomosis are of benefit in selected patients.

[Medical treatment of sigmoid diverticulitis]. / Traitement médical des diverticulites sigmoïdiennes.

Acute diverticulitis is defined by diverticular and peridiverticular inflammation and infection and is efficiently treated medically in most of the cases. For most patients, outpatient treatment is possible and hospitalization is only indicated if the patient is unable to eat, suffers from an acute attack, has diverticulitis related complications or if symptoms fail to improve despite adequate outpatient therapy The treatment of acute uncomplicated diverticulitis usually consists of broad-spectrum antibiotics covering both aerobic and anaerobic bacteria. Antibiotic therapy is usually administrated for 7 to 10 days but its duration can be longer if any complications occur. If there is no clinical improvement within 2 or 3 days, repeat CT imaging is needed, as this may reveal an abscess, phlegmon or fistula, which may require percutaneous drainage or surgery. The published literature does not support the recommendation of any prophylactic diet or medical treatment for reducing the risk of first or recurrent diverticulitis in patients with diverticulosis.

Acute diverticulitis--an unusual cause of liver abcesses in a young man: a case report.

Liver abscess is a rare complication of sigmoid diverticulitis and must be considered within the differential diagnosis. We report a case of a male patient, age 42, admitted to our hospital with chief complaints of a dull pain in upper right abdominal quadrant, fever, weakness, diarrhoea and weight loss of approximately 3 weeks duration. Physical examination on initial work-up revealed tenderness on palpation in upper right abdomen, and left iliac fosa and a 39 degrees C fever. Biochemistry showed marked inflammatory syndrome, leukocitosis, increased level of platelets, altered liver function. Ultrasound examination revealed inhomogeneous liver nodules and the thickening of the sigmoid wall. Further CT scan examination and MRI confirmed the lesions as beeing abscesses and also revealed trombosis of right portal vein. The sigmoid wall lesions proved to be an acute diverticulitis with perisigmoiditis, stenosis and abscess. Patient underwent a surgical treatment of sigmoid resection, but the punction of the abscesses revealed no pus at aspiration, making the surgical excision of the lesions unnecessary. After the surgery, during the antibiotic treatment, the patient developed pseudomembranous colitis treated with specific antibiotics. The evolution under this treatment was positive and the aspect of the liver lesions was improuved.

Association of steroid use with complicated sigmoid diverticulitis: potential role of activated CD68+/CD163+ macrophages.

BACKGROUND: Immunosupression and, especially, intake of steroids have previously been identified as risk factors for complicated types of sigmoid diverticulitis. However, little is known about the underlying molecular and cellular mechanisms. We aimed to elucidate the potential role of activated macrophages in this respect. METHODS: A consecutive series of n = 101 patients having undergone surgical resection for sigmoid diverticulitis at our institution was analyzed regarding the inflammatory infiltrate and prevalence of comorbid diseases as well as risk factors, including steroid use. Fifty-seven patients had complicated types of diverticulitis with severe inflammation (group A). Forty-four patients had moderate inflammation, most of whom had been operated for chronically recurrent diverticulitis (group B). Randomly selected 50 patients (n = 20/group A/n = 30 group B) underwent immunolabelling against CD68 and CD163. RESULTS: Using immunofluorescence double labeling experiments we found a strong positive correlation of CD68 expression with CD163 expression (т = 0.934). High CD68 expression (x ≥ 23%) and high CD163 expression (x ≥ 22%) within stromal cells of the lamina propria was significantly associated with steroid use (CD68, p = 0.012 and CD163, p = 0.004, respectively) and complicated sigmoid diverticulitis with severe inflammation (CD68, p = 0.0001 and CD163, p = 0.001, respectively). CONCLUSIONS: Inflammation, especially mediated by activated (CD68+/CD163+) macrophages in histopathological specimen might resemble the cellular link between steroid use and complicated types of sigmoid diverticulitis. Macrophages might be a suitable target for future supportive/preventive therapies. However, as long as we are lacking such strategies, we must bear in mind that steroid intake is a risk factor for complicated diverticulitis, especially when indicating surgical resection.

Dienogest, a new conservative strategy for extragenital endometriosis: a pilot study.

Extragenital endometriosis severely impairs the quality of life for affected women but its standard management has not yet been well established because of its relatively low incidence. As extragenital organs, intestine, followed by urinary tract, is the most common place affected by endometriosis, for which surgical treatment is sometimes difficult and accompanied by severe complications. Recently, dienogest, a novel progestin, has emerged as a new alternative for endometriosis, especially for endometriosis-associated pain. In this report, we presented four cases with rectosigmoidal and one with bladder endometriosis, treated with oral 2 mg/day dienogest for over 6 months. For all cases, the measurable extragenital lesions exhibited the reduction in their size after 10 to 11 months of use, accompanied with immediate relief of subjective symptoms related with extragenital lesions. This report suggests that dienogest can be a novel conservative alternative for extragenital endometriosis.

Role of serotonin in systemic impairment of motor function of the digestive tract.

We studied the role of serotonin in systemic impairment of motor function of the digestive tract. Administration of a nitric oxide donor methylene blue into the pre-fundal portion of the stomach and application of a loose ligature to the terminal part of the sigmoid colon were performed after pretreatment with serotonin. Serotonin had a stabilizing effect on esophageal antiperistalsis under conditions of dynamic obstruction of the sigmoid colon.

Crohn's-like acute severe colitis associated with Hermansky-Pudlak syndrome: A case report.

BACKGROUND: Hermansky-Pudlak syndrome (HPS) is a rare autosomal recessive disorder characterized by oculocutaneous albinism, platelet storage pool deficiency and systemic complications associated with ceroid deposition in the reticuloendothelial system. HPS types 1 and 4 are associated with Crohn's disease (CD)-like gastrointestinal disorders, such as granulomatous enterocolitis or perianal disease. Cases of colitis can be particularly severe and, before the use of anti-tumor necrosis factor alpha (TNFα) therapy had become common, were reported as showing poor responsiveness to medical treatment. CASE SUMMARY: We present the case of a 51-year-old albino woman who presented with acute severe colitis that led to the diagnosis of HPS. Histologic findings of biopsy samples showed chronic inflammation with deep ulcerations, and granulomas without caseous necrosis. Molecular genetic analysis confirmed HPS type 1, with a homozygous 27 base-pair deletion in exon 20 of the HPS1 gene. Once the patient's bleeding diathesis was corrected by platelet transfusion, the granulomatous colitis responded dramatically to a medical treatment regimen that included corticosteroids, azathioprine and infliximab; this regimen is similar to that used in CD treatment. Although it remains unclear if the granulomatous enterocolitis in HPS is due to ceroid deposition or reflects the co-existence of CD and HPS, the fact that this case of HPS-related granulomatous colitis responded to the same therapeutic approach used in CD suggests that this type of colitis may result from HPS patients' genetic susceptibility to CD. CONCLUSION: We report a case of severe colitis that led to the diagnosis of HPS, which was responsive to azathioprine and infliximab.

Hormone treatment as first line therapy is safe and relieves pelvic pain in women with bowel endometriosis.

OBJECTIVE: To evaluate clinical features and complications in patients with bowel endometriosis submitted to hormonal therapy. METHODS: Retrospective study based on data extracted from medical records of 238 women with recto-sigmoid endometriosis treated between May 2010 and May 2016. RESULTS: Over the course of follow-up, 143 (60.1%) women remained in medical treatment while 95 (39.9%) presented with worsening of pain symptoms or intestinal lesion growth (failure of medical treatment group), with surgical resection performed in 54 cases. Women in the Medical Treatment Group were older (40.5±5.1 years versus 37.3±5.8 years; p<0.0001) and had smaller recto sigmoid lesions (2.1±1.9 versus 3.1±2.2; p=0.008) compared to those who had failed to respond to medical treatment. Similar significant reduction in pain scores for dysmenorrhea, chronic pelvic pain, cyclic dyschezia and dysuria was observed in both groups; however greater reduction in pain scores for dyspareunia was noted in the Surgical Group. Subjective improvement in pain symptoms was also similar between groups (100% versus 98.2%; p=0.18). Major complications rates were higher in the Surgical Group (9.2% versus 0.6%; p=0.001). CONCLUSION: Patients with recto-sigmoid endometriosis who failed to respond to medical treatment were younger and had larger intestinal lesions. Hormonal therapy was equally efficient in improving pain symptoms other than dyspareunia compared to surgery, and was associated with lower complication rates in women with recto-sigmoid endometriosis. Medical treatment should be offered as a first-line therapy for patients with bowel endometriosis. Surgical treatment should be reserved for patients with pain symptoms unresponsive to hormonal therapy, lesion growth or suspected intestinal subocclusion.

Localized vasculitis of the gastrointestinal tract.

BACKGROUND AND OBJECTIVES: Isolated vasculitis of the gastrointestinal (GI) tract is a rare entity. Endoscopic biopsies have low sensitivity to diagnose intestinal vasculitis, even though the endoscopic findings may be suggestive of this condition. Our aims were to describe a case of biopsy-proven colonic leukocytoclastic vasculitis and review the literature. METHODS: A patient with biopsy-proven colonic leukocytoclastic vasculitis is described. A Medline database search of cases with localized GI vasculitis between January 1985 and September 2005 was conducted. RESULTS: A 32-year-old man was admitted to the hospital because of abdominal pain and diarrhea. A colonic biopsy showed leukocytoclastic vasculitis. There are very few articles on leukocytoclastic GI vasculitis as a separate disease, and most of them emphasize the difficulty in classification. Unlike our case, in former cases of localized vasculitis a diagnosis was made after surgery. Although our patient had steroid-refractory biopsy-proven isolated intestinal vasculitis, treatment with intravenous cyclophosphamide resulted in rapid resolution of symptoms and surgery was not required. CONCLUSIONS: In patients with abdominal pain a diagnosis of intestinal vasculitis should be considered. Immunosuppressive therapy allowed our patient to avoid surgery and may be similarly beneficial in other similar cases.

Intra-abdominal Sepsis in Elderly Persons.

Elderly patients represent a greater percentage of the population now than ever before, with 12.4% of North Americans being >65 years of age. Intra-abdominal illnesses in this population often have different etiologies than those seen in younger populations. Because of a variety of physiologic changes that occur as people age, elderly persons have different sites of infection, may present with vague symptoms and longer histories, are more gravely ill, and, overall, have worse prognoses. The major causes of intra-abdominal sepsis in elderly persons are reviewed, explanations for the differences in presentation and prognosis are offered, and the treatments of each cause are reviewed.

Successful management of visceral Klippel-Trenaunay-Weber syndrome with the antifibrinolytic agent tranexamic acid (cyclocapron): a case report.

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare, congenital disorder characterized by vascular nevus formation, deep venous thrombosis, varicosities, and hypertrophy of affected tissues. A patient with known thrombosis of his splanchnic circulation and visceral KTWS presented with life-threatening hemorrhage from rectosigmoid varices. Portosystemic shunting was not feasible. Endoscopic sclerosis, variceal ligation, and proctocolectomy were not possible due to the size and number of the varices. Previous treatment with epsilon-aminocaproic acid had been unsuccessful and complicated by thrombophlebitis. Conservative treatment with blood transfusions, cryoprecipitate, fresh frozen plasma, vitamin K, propanolol, and somatostatin analog failed to stop the bleeding. The patient was given the antifibrinolytic agent, tranexamic acid, with cessation of his hemorrhage. Serial thromboelastograms confirmed improved reaction time, coagulation time, clot formation rate, and maximum amplitude. We conclude that tranexamic acid may be a useful adjunct in the medical treatment of high-risk patients with KTWS and other vascular nevi complicated by coagulopathy.