Primary segmental omental torsion, mimicking acute appendicitis.

Primary segmental omental torsion (PSOT) is a very rare cause of acute abdominal pain, and it may often imitate the clinical picture of acute appendicitis. In instances of acute abdominal pain without anorexia, nausea, and vomiting, omental torsion should be included in the differential diagnosis. Any misdiagnosis may lead to major complications such as intraabdominal abscesses and adhesions. A 63-year-old overweight man with a body mass index (BMI) of 41 Kg/m2 presented to the emergency department on a remote island with acute abdominal pain. His medical history included type 2 diabetes mellitus managed with insulin, essential hypertension, osteoarthritis, and no previous abdominal operations. He reported a sharp pain originating in the epigastrium and the right hypochondrium that started five days prior. Physical examination revealed rebound tenderness and guarding across the abdomen with a positive McBurney sign. However, the patient did not report vomiting and was not nauseous. Vital signs were as follows: blood pressure 116/56 mmHg, heart rate 98 beats/min, respiratory rate 19 breaths/min, and a temperature of 38.2 0C. Laboratory results showed a white blood cell count of 10.6, neutrophils of 8.11, C-reactive protein (CRP) 74 mg/l, haemoglobin11.6 g/dl, and hematocrit 36.9%. Due to the absence of a radiographer at the hospital during that period, no imaging investigations were conducted. Diagnostic laparoscopy demonstrated diffused hemoperitoneum and necrotic mass at the site of the hepatic flexure. Initially suspected to be an advanced colon cancer, the decision was made to proceed with open surgery. The necrotic segment of the omentum was found at the right superior point of attachment of the omentum to the hepatic flexure. Consequently, the necrotic segment of the omentum was resected. A thorough investigation of the abdominal cavity did not detect any other abnormalities or pathologies. The patient recovered uneventfully and was transferred to the surgical ward. Torsion of the omentum is a very rare cause of acute abdominal pain. This case highlights the necessity of considering PSOT in the differential diagnosis of acute abdominal pain, especially in cases where symptoms are suggestive of appendicitis but diagnostic findings are negative.

Manual & exercise therapy for treatment of chronic abdominal pain and diarrhea, a case report.

A 34-year-old male with a 9+ year history of right sided abdominal pain, associated diarrhea and a diagnosis of irritable bowel syndrome was referred for physical therapy and chiropractic care at a multidisciplinary primary care clinic. Multiple evaluations by various providers resulted in multiple tests and numerous medications without substantial relief in symptoms. Five physical therapy visits and three sessions of chiropractic care resulted in 90% improvement in subjective pain report and 60-70% reduction in diarrhea frequency. At a 6 month follow up phone visit, his symptoms had continued to decrease. While limited as a case study, this report may illustrate a potential somatovisceral relationship and subsequent reduction in gastrointestinal symptoms that can be addressed with conservative care.

Gastrointestinal Conditions: Pancreatitis.

Acute pancreatitis is among the most common gastrointestinal disorders requiring hospitalization. The main causes are gallstones and alcohol use. Patients typically present with upper abdominal pain radiating to the back, worse with eating, plus nausea and vomiting. Diagnosis requires meeting two of three criteria: upper abdominal pain, an elevated serum lipase or amylase level greater than 3 times the normal limit, and imaging findings consistent with pancreatitis. After pancreatitis is diagnosed, the Atlanta classification and identification of the systemic inflammatory response syndrome can identify patients at high risk of complications. Management includes fluid resuscitation and hydration maintenance, pain control that may require opioids, and early feeding. Feeding recommendations have changed and "nothing by mouth" is no longer recommended. Rather, oral feeding should be initiated, as tolerated, within the first 24 hours. If it is not tolerated, enteral feeding via nasogastric or nasojejunal tubes should be initiated. Antibiotics are indicated only with radiologically confirmed infection or systemic infection symptoms. Surgical or endoscopic interventions are needed for biliary pancreatitis or obstructive pancreatitis with cholangitis. One in five patients will have recurrent episodes of pancreatitis; alcohol and smoking are major risk factors. Some develop chronic pancreatitis, associated with chronic pain plus pancreatic dysfunction, including endocrine failure (insulin insufficiency) and/or exocrine failure that requires long-term vitamin supplementation.

Splenic artery pseudoaneurysm; a cause or consequence: a case report.

BACKGROUND: Splenic artery pseudoaneurysm is a rare complication of recurrent pancreatitis usually presenting as an incidental finding on abdominal computed tomography. CASE PRESENTATION: We present the case of a 66-year-old north African male with a known history of previous pancreatitis who presented with upper gastrointestinal bleeding along with recurrent epigastric pain for 3 days. Investigations did not reveal any particular pancreatitis etiology. Computed tomography of the abdomen with contrast showed splenic artery pseudoaneurysm along with findings suggestive of acute pancreatitis. Upper and lower endoscopies failed to identify gastrointestinal the bleed source. The patient underwent intervention radiology embolization of the aneurysm sac with multiple coils via right retrograde common femoral artery-celiac access. The patient was discharged with a plan for capsule endoscopy in outpatient setting. CONCLUSION: Splenic artery pseudoaneurysm is a life-threatening complication and carries a high mortality rate if left untreated. Prompt identification through various imaging modalities, followed by urgent intervention, is crucial to avoid adverse outcomes.

An Unexpected Lymphoma: A Rare Case of Primary Gastric Burkitt's Lymphoma.

Primary gastric Burkitt's lymphoma is an aggressive non-Hodgkin's lymphoma that has been rarely reported in the literature. The majority of primary gastric lymphomas are diffuse large B-cell lymphomas and mucosa-associated lymphoid tissue (MALT) lymphomas. Patients with primary gastric Burkitt's lymphoma can present with abdominal pain, hematemesis, melena, perforation, and obstruction. Diagnosis is made with a combination of clinical, radiological, and pathological findings. Treatment data are limited due to the limited cases reported. We present a case of a 47-year-old female who presented with diffuse abdominal pain, melena, and coffee-ground emesis that was diagnosed with primary gastric Burkitt's lymphoma following biopsies taken from a gastric ulcerated mass found on upper endoscopy.

Herlyn-Werner-Wunderlinch: An unusual presentation in a patient with Prader-Willi syndrome.

Herlyn-Werner-Wunderlich syndrome is an uncommon urogenital anomaly defined by uterus didelphys, obstructed hemi-vagina and unilateral renal anomalies. The most common clinical presentation is dysmenorrhoea following menarche, but it can also present as pain and an abdominal mass. Prader-Willi syndrome is a rare neuroendocrine genetic syndrome. Hypothalamic dysfunction is common and pituitary hormone deficiencies including hypogonadism are prevalent. We report the case of a 33-year-old female with Prader-Willi syndrome who was referred to the Gynaecology clinic due to vaginal bleeding and abdominal pain. Abdominal ultrasound revealed a haematometra and haematocolpos and computed tomography showed a uterus malformation and a right uterine cavity occupation (hematometra) as well as right kidney agenesis. Vaginoscopy and hysteroscopy were performed under general anaesthesia, finding a right bulging vaginal septum and a normal left cervix and hemiuterus. Septotomy was performed with complete haematometrocolpos drainage. The association of the two syndromes remains unclear.

Epigastric Pain and Dysphagia in a 36-Year-Old Man Due to Primary Esophageal Small Cell Carcinoma.

BACKGROUND Small cell carcinoma is an aggressive malignant neuroendocrine tumor that most commonly occurs in the lung. Primary small cell carcinoma of the esophagus (PSCCE) is rare and is an aggressive malignancy with poor prognosis and no clear management guidelines. This report describes the case of a 36-year-old man presenting with epigastric pain, dysphagia, and melena due to a primary esophageal small cell carcinoma. CASE REPORT A 36-year-old presented to the Emergency Department (ED) with epigastric pain associated with food intake. Initial workup was unremarkable, and a presumed clinical diagnosis of reflux esophagitis and peptic strictures was made, prompting empiric treatment with anti-secretory therapies. Despite these therapies, he presented to the emergency room with progressively worsening dysphagia. Endoscopic examination (EGD) revealed a large necrotic mass, and computed tomography (CT) imaging revealed liver metastasis. Biopsies from both the liver and esophageal masses confirmed small cell carcinoma. His clinical course was complicated by a broncho-esophageal fistula, leading to massive hemoptysis, necessitating intubation. Unfortunately, his condition deteriorated rapidly, and he chose to pursue hospice care. He died 3 months after his initial presentation. CONCLUSIONS This report has presented a rare case of primary esophageal small cell carcinoma and our approach to management. We highlight the importance of early diagnosis, supported by histopathology, and the need for management guidelines.

Pseudogestational Sac Delaying Diagnosis of Ectopic Pregnancy: A Case Report.

BACKGROUND: Diagnosis of ectopic pregnancy can be complicated by nonspecific laboratory and radiographic findings. The multiple alternative diagnoses must be weighed against each other based on the entire clinical presentation. CASE REPORT: We present a case of a 20-year-old woman who arrived to the Emergency Department (ED) with abdominal pain and ended up being transferred for an Obstetrics evaluation of a possible heterotopic pregnancy. Her radiology-performed ultrasound had revealed an "intrauterine gestational sac" along with an adnexal mass near the right ovary. The patient was not undergoing assisted-reproductive fertilization, nor did she have meaningful risk factors for heterotopic pregnancy. The patient was managed expectantly over the ensuing week to see whether the intrauterine fluid was a true gestational sac. After multiple repeat ED visits, the diagnosis of ectopic pregnancy was made. Ultimately, the patient elected for surgical management of her ectopic pregnancy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case offers a reminder of the subtleties of radiographic identification of intrauterine pregnancies and the ever-present need to "clinically correlate."

Gastroduodenal artery aneurysm - an extremely rare but insidious cause of abdominal pain: a case report.

An arterial aneurysm is a localized weakening of the artery wall that results in pathological dilatation. All intra-abdominal artery aneurysms are labeled as visceral artery aneurysms (VAA), apart from the aorto-iliac artery aneurysms. VAA´s are rare, gastroduodenal artery aneurysms (GDAA), constituting 1.5% of visceral artery aneurysms. A woman in her early 80s´ presented with chronic epigastric pain, weight loss, and nausea. Conservative management was unsuccessful. Imaging revealed a GDAA, prompting endovascular coil embolization. Subsequent evaluation confirmed Polyarteritis Nodosa (PAN), treated with rituximab. The report underscores the diagnostic challenges, emphasizing the need for a multidisciplinary approach using imaging and angiography. GDAA's potential life-threatening rupture necessitates prompt intervention, as illustrated in this case. The rare association with PAN, although infrequent, underscores the importance of considering underlying etiologies in multiple visceral aneurysms. Early diagnosis and intervention are pivotal for this uncommon yet potentially lethal condition.

Intestinal perforation due to colorectal cancer during pregnancy: case report and literature review.

Colorectal cancer (CRC) in pregnancy is sporadic. We reported a case of a woman at 23 + 4 weeks of gestation who presented with abdominal pain. The patient underwent an ultrasound and MRI, during which a colonic mass was noted. Considering a probable incomplete intestinal obstruction, a colonoscopy, biopsy, and colonic stenting were performed by a multidisciplinary team. However, sudden hyperthermia and CT demonstrated intestinal perforation, and an emergency caesarean section and colostomy were conducted. The histological analysis confirmed moderately high-grade adenocarcinoma.

Functional dyspepsia: How to manage the burn and the bloat.

Functional dyspepsia is defined as persistent symptoms of postprandial bloating, early satiety, or pain in the center of the upper abdomen, without findings on upper endoscopy such as peptic ulcer disease to explain these symptoms. It is common, affecting up to 30% of the global population, but it often goes undiagnosed for years. There are 2 subtypes: epigastric pain syndrome (burning and pain) and postprandial distress syndrome (bloating and satiety). The authors discuss how to diagnose and treat both subtypes.

Chief complaints and computed tomography results in the emergency department: a three-year retrospective cohort study.

BACKGROUND: Computed tomography (CT) is frequently performed in the patients who admitted to the emergency department (ED), discharged but returned to ED within 72 h. It is unknown whether the main complaints of patients assist physicians to use CT effectively. This study aimed to find the association between chief complaints and the CT results. METHODS: This three-year retrospective cohort study was conducted in the ED of a tertiary medical center. Adult patients who returned to the ED after the index visit were included from 2019 to 2021. Demographics, pre-existing diseases, chief complaints, and CT region were recorded by independent ED physicians. A logistic regression model with an odds ratio (OR) and 95% confidence interval (CI) was used to determine the relationship between chief complaints and positive CT results. RESULTS: In total, 7,699 patients revisited ED after the index visit; 1,202 (15.6%) received CT. The top chief complaints in patients who received CT were abdominal pain, dizziness, and muscle weakness. Patients with abdominal pain or gastrointestinal symptoms had a significantly higher rate of positive abdominopelvic CT than those without it (OR 2.83, 95% CI 1.98-4.05, p < 0.001), while the central nervous system and cardiopulmonary chief complaints were not associated (or negatively associated) with new positive CT findings. CONCLUSION: Chief complaints of patients on revisit to the ED are associated with different yields of new findings when CT scans of the chest, abdomen and head are performed. Physicians should consider these differential likelihoods of new positive findings based on these data.

Demographic and Clinical Characteristics of Functional Dyspepsia and Its Subtypes in Adult Patients: An Experience from a Tertiary Care Centre in Bangladesh.

Functional dyspepsia (FD) is a common gastrointestinal problem in the world. The Rome III consensus subdivided functional dyspepsia into two groups: meal-related postprandial distress syndrome (PDS) and meal-unrelated epigastric pain syndrome (EPS). Limited data are available regarding FD in Bangladesh. The aim of this study was to investigate the demographic and clinical characteristics of FD and its sub-types. This cross-sectional study was conducted in which we recruited patients who attended the outpatient department of Gastroenterology of Bangabandhu Sheikh Mujib Medical University, Bangladesh from March 2017 to February 2018. Patients fulfilling Rome III FD criteria and a negative upper GIT endoscopy were included for this study. The patients were then subdivided into 'pure' PDS (i.e. meeting criteria for PDS without EPS symptoms), 'pure' EPS (i.e., meeting criteria for EPS without PDS symptoms), and overlapping PDS-EPS (i.e., symptoms of both PDS and EPS) groups. Total of 368 FD patients (56.0% females, mean age 32.8±8.6 years, BMI: 22.0±2.7), were included in this study. Out of them, 112(30.4%) patients (57.2% females, mean age 33.9±9.3 years, BMI: 22.0±2.7) fulfilled criteria of pure EPS and 64(17.4%) patients (68.8% females, mean age 33.2±7.8 years, BMI: 22.1±2.4) fulfilled criteria of pure PDS. However, the majority of patients [192(52.2%), 52.1% females, mean age 32.0±8.4 years, BMI: 21.9±2.8] had symptoms of overlapping EPS-PDS. More than 40% of patients in our study presented with 3 or more of the four key symptoms of FD. A longer duration of presenting symptoms was seen among patients with overlapping EPS-PDS in comparison to pure EPS and pure PDS (p<0.001). A significant overlap of symptoms of both EPS and PDS was noticed among patients with FD. The value of dividing functional dyspepsia into the subgroups of PDS and EPS is thus questionable. Further research and modification of the diagnostic criteria for FD subtypes are necessary.

Peripheral nerve stimulation (PNS): A valid and definitive therapeutical option for a case of anterior cutaneous nerve entrapment syndrome (ACNES).

Anterior cutaneous nerve entrapment syndrome (ACNES) is a cause of moderate to severe chronic pain, hyperesthesia/hypoesthesia, and altered perception of heat/cold in a specific region of the anterior abdominal wall, referable to the territory of innervation of one or more anterior branches of the intercostal nerves. None of the therapeutic options currently available has proved to be effective in the long term or decisive. In recent years, we have begun to treat purely sensory neuropathies, such as this, with the implantation of wireless peripheral nerve stimulators (PNS), achieving the safety of modular and personalized analgesia. We report the case of a 41-year-old man suffering from ACNES of the 8th intercostal nerve for two years. We first performed two consecutive ultrasound-guided diagnostic blocks of the anterior cutaneous branch of the 8th intercostal right nerve and then elected the patient for ultrasound-guided nerve decompression followed by neuromodulation and pulsed-radiofrequency (PRF). Taking into account full employment, young age, and the likelihood of having to repeat the treatment several times, we considered him for Peripheral Nerve Stimulation (PNS) implantation under ultrasound guidance, and we implanted the wireless lead at the anterior branch of the right 8th intercostal nerve, and programmed tonic stimulation 100 Hz PW 200 ms. The patient reported immediate pain relief and never took medication for this problem again, at two years follow-up. PNS has had an increasing role in the management of chronic neuropathic pain, especially in merely sensitive neuropathies like ACNES. We support future research on this theme.

[Gastrointestinal symptoms and problems in children cared by pediatric palliative care teams. Observational study]. / Síntomas y problemas gastrointestinales en niños asistidos por equipos de cuidados paliativos pediátricos. Estudio observacional.

Gastrointestinal symptoms and problems (GI- SP) frequently cause discomfort and suffering in pediatric patients with life-threatening and/or life-limiting illnesses (LTI/LLI). Pediatric palliative care (PPC) professionals should be aware of them and perform a comprehensive approach. OBJECTIVE: To determine the prevalence of GI- SP in patients treated in PPC units and to describe the pharmacological and non-pharmacological measures prescribed. PATIENTS AND METHOD: Observational, prospective, multicenter, prospective study in patients with LTI/LLI, seen by PPC teams in Uruguay. The variables analyzed included age, sex, origin, type of LTI/LLI, presence of mucositis, vomiting, swallowing disorders, abdominal pain, constipation, diarrhea, digestive bleeding, problems with digestive prosthesis, and prescribed pharmacological and non-pharmacological treatment. RESULTS: 10 out of 16 PPC teams participated. 96 out of 436 patients seen presented GI- SP (22%). Median age was 4.2 years (1 month-18 years). LTI/LLI: 65% neurological and 7% oncological. The 96 patients had 114 consultations; 50% had 2 or more GI- SP per consultation. GI- SP observed: swallowing disorders (57%), constipation (53%), nausea and/or vomiting (24%), gastrostomy problems (17%), abdominal pain (10%), digestive bleeding (3%), and diarrhea (2%). There were variable prescriptions of pharmacological and non-pharmacological measures; only 50% of those with swallowing disorder received speech and hearing therapy. CONCLUSIONS: GI- SP motivated consultations in all PPC settings, frequently due to 2 or more GI- SP. Swallowing disorders and gastrostomy complications are frequent but not very visible problems in PPC. According to the comprehensive approach, pharmacological and non-pharmacological measures were implemented.

Parietal abdominal pain with lower leg discrepancy: a case report.

BACKGROUND: This report involves the first publication describing a case of parietal abdominal pain due to lower limb length discrepancy. CASE PRESENTATION: A Caucasian male patient in his 50s was referred to our rehabilitation department with chronic abdominal pain that began in childhood. This chronic pain was associated with episodes of acute pain that were partially relieved by grade 3 analgesics. The patient was unable to sit for long periods, had recently lost his job, and was unable to participate in recreational activities with his children. Investigations revealed contracture and hypertrophy of the external oblique muscle and an limb length discrepancy of 3.8 cm (1.5 inches) in the left lower limb. The patient was effectively treated with a heel raise, physiotherapy, intramuscular injection of botulinum toxin, and lidocaine. The patient achieved the therapeutic goals of returning to work, and reducing analgesic use. CONCLUSIONS: Structural misbalances, as may be caused by lower leg discrepancy, may trigger muscular compensations and pain. Complete anamnesis and clinical examination must not be trivialized and may reveal previously ignored information leading to a proper diagnosis.

A unicentric center, multicenter, and mixed-type Castleman disease: Three case reports and a review of the literature.

RATIONALE: Due to the lack of specificity symptoms and site of onset of castleman disease (CD), it is difficult to diagnose and poses unique challenges for both patients and clinicians, leading to confusion in diagnosis and delays in treatment. To enhance understanding, we present 3 cases of CD treated at our hospital, including a single-center, multicenter, and mixed-type CD. PATIENT CONCERNS: Case 1: A 53-year-old female patient was admitted with a chief complaint of "abdominal pain and fever for 10 days." Marked enlargement of inguinal lymph nodes on both sides was observed. Case 2: A 58-year-old female patient was admitted with the main complaint of "discovering a left lower abdominal mass during a routine checkup for the past 10 days." Upon deep palpation, a palpable mass of approximately 5.0 * 3.0 cm was identified in the left lower abdomen. Case 3: A 40-year-old male patient was admitted with the main complaint of "progressive right upper abdominal and lumbar back pain for over 6 months." Computed tomography examination revealed multiple nodular soft tissue masses between the abdominal aorta and inferior vena cava, with the largest measuring 5.0 * 4.0 cm. DIAGNOSES: Based on the immunohistochemical results, the diagnoses for the 3 patients are as follows: Case 1: Multicentric Castleman's Disease (Mixed Type). Case 2: Pelvic Retroperitoneal Castleman Disease (Hyaline Vascular Type). Case 3: Castleman Disease Multicentric Type. INTERVENTION: Case 1: cyclophosphamide 0.6-1 g + vincristine 2 mg + methylprednisolone 50 mg/5 days. Cyclophosphamide 1 g + prednisone 30-50 mg/5 days. This alternating chemotherapy cycle is repeated every 6 months. Case 2: Laparoscopic pelvic mass excision surgery. Case 3: Surgical excision of the mass. OUTCOMES: Case 1: After a 43-month follow-up, the patient's general symptoms have improved compared to before, but regular chemotherapy is still necessary at present. Case 2: The patient did not take any medication postoperatively, and there has been no evidence of metastasis or recurrence during the 18-month follow-up. Case 3: The patient did not take any medication, and there has been no evidence of metastasis or recurrence during the 21-month follow-up. LESSONS SUBSECTIONS: The lack of specific signs on imaging studies and nonspecific blood tests increases the difficulty of diagnosis. However, tissue biopsy remains a feasible option. Therefore, we recommend conducting thorough examinations for suspected CD patients to reduce misdiagnosis and determine the CD type for effective targeted treatment.

Colonoscopy-assisted laparoscopic wedge resection for a large symptomatic colonic lipoma.

A colonic lipoma is an uncommon lesion that is linked with clinical symptoms in only a small portion of patients. Patients with large lipomas are often referred for major surgery, which is associated with significant morbidity and mortality. In this case, we described a female patient with recurrent episodes of gastrointestinal blood loss, abdominal pain and colocolic intussusceptions due to a large, lumen-filling, obstructive lipoma in the splenic flexure. On abdominal CT, a lesion of 3.6 cm was visualised with a fat-like density without solid components. Considering its benign nature, we intended to preserve the colon by deroofing the upper part of the lesion and then performing a colonoscopy-assisted laparoscopic wedge resection. During reassessment, auto-amputation of part of the lesion was observed, most likely as a result of long-lasting mechanical effects, which made it possible to perform solely a wedge resection with an excellent outcome.