Unveiling Pheochromocytoma: A Puzzling Prelude of Nausea, Vomiting, and Abdominal Pain.

BACKGROUND Pheochromocytomas, rare tumors arising from the adrenal medulla, can present with highly variable symptoms; therefore, pheochromocytomas frequently remain undiagnosed, leaving the potential for physiological complications. Acutely, these complications include pheochromocytoma crisis, in which high levels of catecholamines are released and cause a life-threatening hypertensive emergency. Over time, undiagnosed pheochromocytomas can lead to cardiovascular damage and end-organ disease related to chronic exposure to elevated blood pressure. CASE REPORT We share a case of pheochromocytoma in a 45-year-old woman who presented with gastrointestinal symptoms of intractable nausea, vomiting, and abdominal pain. Imaging revealed an adrenal mass that had radiographic features that were most consistent with myelolipoma. Before exposing the patient to anesthesia and endoscopy for further diagnostic workup of her gastrointestinal symptoms, which can trigger a catecholamine surge in individuals with a pheochromocytoma, further biochemical testing was performed. Testing of plasma and urine confirmed pheochromocytoma, and surgical resection was performed for definitive treatment. Ultimately, the patient had resolution of her symptoms following the removal of the tumor. CONCLUSIONS The resolution of symptoms following surgical resection suggests that symptoms may have been related to the mass effect of the tumor or as an atypical manifestation of increased catecholamine levels. Additionally, by screening for pheochromocytoma, the patient was able to avoid potential complications that can result from common gastroenterological diagnostic procedures. This case report highlights the potential benefit for screening for pheochromocytoma when faced with symptoms that may be non-specific or related to mass effect upon surrounding organs.

Jejunogastric intussusception after pancreaticoduodenectomy in a patient with HIV.

The incidence of jejunogastric intussusception (JGI) after gastric surgery is 0.1%. We report a case of JGI after pancreaticoduodenectomy in a patient with HIV. After presenting to the hospital with abdominal pain and emesis, a CT abdomen/pelvis showed evidence of gastrojejunal anastomosis intussusception into the stomach. Oesophagogastroduodenoscopy was performed, but endoscopic reduction was unsuccessful. Exploratory laparotomy was subsequently performed with a successful reduction of the intussusception and resection of a portion of the small bowel. With only five previously reported cases of JGI after pancreaticoduodenectomy, our case is novel in that it describes JGI in a patient with HIV on highly active antiretroviral therapy, which has been associated with an increased risk of intussusception. While rare, we highlight the importance of having high clinical suspicion for intussusception in patients with risk factors who present with abdominal pain after pancreaticoduodenectomy. Timely diagnosis is critical to optimise patient outcomes.

Idiopathic encapsulating peritoneal sclerosis presenting with abdominal mass.

A man in his late 30s presented with a history of recurrent colicky abdominal pain, bilious vomiting and intermittent mass formation in the lower abdomen. The mass was mobile, non-tender and fluctuant, and appeared in the right iliac fossa during episodes of pain and disappeared once the pain subsided. Contrast-enhanced CT (CECT) scan revealed a thick membrane-like structure covering the clumped small bowel loops, suggestive of an abdominal cocoon. A midline laparotomy was carried out with extensive adhesiolysis, and a membrane incision was performed. The final histopathological diagnosis was primary encapsulating peritoneal sclerosis. Encapsulating peritoneal sclerosis of idiopathic origin is rare and typically presents as an acute or subacute intestinal obstruction. A CECT scan is the diagnostic modality of choice, with a thick peritoneal membrane covering the small bowel loops being the hallmark sign. Surgical intervention is the preferred treatment for idiopathic cases, while medical management may address secondary causes.

Metformin-associated lactic acidosis: a serious complication of a common drug.

Metformin-associated lactic acidosis (MALA) is a rare and potentially life-threatening complication of metformin use. It typically occurs in patients who are diabetic and also have other risk factors for lactic acidosis, including kidney and liver conditions, malignancy, or use of certain medications. We report a case of MALA in a man in his 70s with diabetes who presented with gradually worsening gastrointestinal symptoms, including severe abdominal pain and nausea. He reported these symptoms in the setting of metformin use with an acute kidney injury (AKI), likely brought on by poor oral intake and excessive antibiotic use for a urinary tract infection. He was promptly started on intravenous fluids with a bicarbonate drip to concurrently treat his prerenal AKI and lactic acidosis, which resulted in rapid resolution of his symptoms. Renal function normalised within 12 days of admission. Since diabetic patients commonly use metformin and are also at higher risk of renal dysfunction, this case highlights the vulnerability of this group of patients and the need for increased knowledge and awareness of MALA.

Eosinophilic ascites and enteritis: a neglected case report from Vietnam.

Eosinophilic gastroenteritis poses a significant diagnostic challenge, particularly in developing countries, where the awareness of this condition may be limited. Here, the case of a patient in her early 30s, who presented with recurrent episodes of abdominal pain and diarrhea, is reported. Initial standard laboratory investigations revealed normal complete blood counts and elevated total serum immunoglobulin E levels. Upper and lower endoscopic evaluations with systemic biopsies did not reveal any significant abnormalities. However, computed tomography revealed a thickened small intestine wall, halo signs, and mild ascites. Analysis of the ascitic fluid confirmed eosinophilia. These findings prompted a diagnosis of eosinophilic gastroenteritis. The patient responded well to a targeted elimination diet, corticosteroids, and antileukotriene medication. The present case emphasizes the importance of considering eosinophilic gastroenteritis in the differential diagnosis of patients who present with abdominal pain and eosinophilic ascites.

Mesenteric ischemia: Recognizing an uncommon disorder and distinguishing among its causes.

Mesenteric ischemia occurs because of inadequate intestinal blood flow. Its severity depends on the vessels involved and whether collateral blood vessels are available to prevent malperfusion. Mesenteric ischemia is an uncommon cause of abdominal pain, but it is associated with high mortality and often poses a diagnostic challenge to clinicians because its symptoms are nonspecific. Early recognition and treatment are imperative to improve patient outcomes.

Spontaneous haemoperitoneum caused by a bleeding gastric gastrointestinal stromal tumour.

Spontaneous haemoperitoneum is described as a collection of blood in the peritoneal cavity due to non-traumatic aetiology. Common causes in the literature include splenic, hepatic and gynaecological pathology. Patients with spontaneous haemoperitoneum usually present with non-specific dull aching abdominal pain. Spontaneous haemoperitoneum can only be radiologically diagnosed and, if not treated in time, is life threatening. Rupture of a gastrointestinal stromal tumour (GIST) presenting as a spontaneous haemoperitoneum is a rare event. Gastric GIST presents as ambiguous abdominal pain, complications of which include melena, obstruction and rupture. This is a report of a male patient in his early 60s who presented with acute abdominal pain. A contrast-enhanced CT of the abdomen showed haemoperitoneum with an unknown source of origin. Diagnostic laparoscopy showed a bleeding exophytic mass arising from the stomach, which was resected. Thus, early diagnosis with proper imaging and prompt treatment has a favourable outcome.

Successful preoperative diagnosis and laparoscopic management of primary small bowel volvulus: A case report and literature review.

RATIONALE: Small bowel volvulus (SBV) is a rare cause of acute abdominal pain in adults, which requires surgical intervention to prevent small bowel necrosis. Primary SBV is rare, and its preoperative diagnosis is challenging. This report describes a case of primary SBV diagnosed preoperatively and treated laparoscopically. PATIENT CONCERNS: A 56-year-old man presented complaining of sudden-onset abdominal pain of 3-hour duration. Physical examination revealed tenderness in periumbilical and upper abdominal regions with no signs of peritonitis. DIAGNOSIS: Contrast-enhanced computed tomography revealed a 360°-clockwise rotation of the small intestine when viewed caudally at the mesenteric base. At this region, the superior mesenteric vein was interrupted. Although no dilation of the small intestine was observed, increased density in the mesentery of the affected area was observed. Minimal ascites was observed in the pelvic cavity. No evidence of congenital or secondary SBV was observed, supporting the diagnosis of primary SBV. INTERVENTIONS: Laparoscopic detorsion of the SBV was performed approximately 6 hours after the onset of symptoms. No signs of bowel necrosis were observed, and the procedure was concluded after releasing the torsion. OUTCOMES: Severe abdominal pain disappeared immediately after surgery. The postoperative course was uneventful, and the patient was discharged on the 8th postoperative day. LESSONS: This case highlights the importance of preoperatively diagnosing SBV, which enables early laparoscopic devolvulation without bowel resection.

Polypoid heterotopic gastric mucosa: in terminal ileum causing extensive lower gastrointestinal bleeding without Meckel's diverticulum: a case report.

BACKGROUND: Heterotopic gastric mucosa (HGM) can be located in various parts of the gastrointestinal tract. As a rare anomaly in the small intestine, it can become complicated by intussusception, obstruction, gastrointestinal bleeding, and even peritonitis, leading to death. CASE PRESENTATION: This case report focuses on a 12-year-old Middle Eastern boy who presented with hematochezia and abdominal pain for a couple of days. A tagged Red blood cell (RBC) scan and Technetium scan revealed gastrointestinal bleeding at the lower abdomen, highly suggestive of the diagnosis of Meckel's diverticulum. Subsequently, exploratory laparotomy revealed contiguous and scattered mucosal lesions with multiple polyps of various sizes in the terminal ileum. Meckel's diverticulum was absent, and the patient was treated with resection and primary anastomosis. The resected tissue revealed extensive ectopic gastric mucosa and polypoid tissues. The patient recovered uneventfully and was discharged four days after the surgery. The symptoms did not recur within six months after his surgery. CONCLUSION: Our case demonstrated that despite the rarity of multiple polypoid gastric heterotopias in the terminal ileum, it should be considered as one of the differential diagnoses of gastrointestinal tract bleeding.

Clinical and Molecular Analysis in Patients with Peutz-Jeghers Syndrome.

Peutz-Jeghers syndrome (PJS) is a rare hereditary disorder linked to increased cancer risk due to specific genetic variants in the STK11 gene. This study aimed to assess disease manifestations, genetic profiles, and genotype-phenotype correlations in PJS patients. Twenty patients from 14 families with PJS who were followed up at our clinic between 2011 and 2021 were included. Genetic susceptibility to hereditary cancers was assess-ed using targeted next-generation sequencing (NGS) and multiplex ligation-dependent probe amplification (MLPA) of the STK11 gene. Clinical data were also collected and analyzed in conjunction with the genetic findings. Initial symptoms appeared around 18.9 years, predominantly abdominal pain and intussusception. Mucocutaneous lesions were found in 85%, and hamartomatous polyps in 90%. Dysplastic polyps were found in 4 patients, with 3 cases of malignancy. Nextgeneration sequencing identified 11 pathogenic and 3 likely pathogenic mutations, including 3 novel STK11 variants (LRG_319: c.598- 8_601del, LRG_319: c.708_718del, and LRG_319: c.146_147del). Next-generation sequencing diagnostic rate was 78.5% (11/14), and the overall diagnostic rate with NGS and MLPA studies was 85.7% (12/14). Patients without STK11 mutations had later symptom onset and potentially lower cancer risk. Truncated mutations are associated with earlier symptoms and elevated cancer risk. This is the first PJS case series in Turkey using the NGS and MLPA methods. It reports 3 novel mutations and emphasizes the genotype-phenotype relationship of PJS. With further studies, the genotype-phenotype relationship of STK11 variants will be better understood.

Presentations of Waugh's syndrome:intra-luminal cecal cyst and trans-anal prolapsing intussusception: a case report.

BACKGROUND: Intussusception with intestinal malrotation is termed as Waugh's syndrome. The incidence of Waugh's syndrome is less than 1%. There are very few reported cases. Once presented, it is a pediatric surgical emergency. CASE PRESENTATION: We present here two cases of Waugh's syndrome: an 11-month-old male patient of Punjabi descent and a 4-month-old female patient of Afghan descent who presented to us with abdominal pain and bleeding per rectum. Abdominal sonography revealed an intussusception with a target sign. They were explored and perioperatively had intestinal malrotation alongside intussusception, thus a diagnosis of Waugh's syndrome was made. A right hemicolectomy and Ladd's procedure was performed. CONCLUSION: Waugh syndrome is a rare congenital anomaly but can present with vague abdominal symptoms. Once presented, it is a pediatric surgical emergency. The patient should be optimized followed by surgical exploration.

Early detection of multiple endocrine neoplasia type 1: A case report.

BACKGROUND: Multiple endocrine neoplasias (MENs) are a group of hereditary diseases involving multiple endocrine glands, and their prevalence is low. MEN type 1 (MEN1) has diverse clinical manifestations, mainly involving the parathyroid glands, gastrointestinal tract, pancreas and pituitary gland, making it easy to miss the clinical diagnosis. CASE SUMMARY: We present the case of a patient in whom MEN1 was detected early. A middle-aged male with recurrent abdominal pain and diarrhea was admitted to the hospital. Blood tests at admission revealed hypercalcemia and hypophosphatemia, and emission computed tomography of the parathyroid glands revealed a hyperfunctioning parathyroid lesion. Gastroscopy findings suggested a duodenal bulge and ulceration. Ultrasound endoscopy revealed a hypoechoic lesion in the duodenal bulb. Further blood tests revealed elevated levels of serum gastrin. Surgery was performed, and pathological analysis of the surgical specimens revealed a parathyroid adenoma after parathyroidectomy and a neuroendocrine tumor after duodenal bulbectomy. The time from onset to the definitive diagnosis of MEN1 was only approximately 1 year. CONCLUSION: For patients who present with gastrointestinal symptoms accompanied by hypercalcemia and hypophosphatemia, clinicians need to be alert to the possibility of MEN1.

[Solitary splenic neoplasm as an unusual presentation in an adolescent with sporadic Burkitt lymphoma]. / Neoplasia esplénica solitaria como presentación inusual en una adolescente con linfoma de Burkitt esporádico.

Burkitt lymphoma is a non-Hodgkin B-cell lymphoma with a high prevalence in the pediatric population. Abdominal manifestations are well known in sporadic Burkitt lymphoma and vary from nonspecific symptoms to intestinal obstruction due to intussusception; however, mass-like splenic involvement has been scarcely described. OBJECTIVE: To present a case of a patient with a splenic mass whose histopathological analysis revealed Burkitt lymphoma. CLINICAL CASE: A 13-year-old female patient presented with abdominal pain, progressive weight loss, and fever. Imaging studies showed a splenic mass, intestinal thickening, and ileal intussusception. Histopathological analysis of spleen biopsy revealed Burkitt lymphoma. After the first cycle of chemotherapy (BFM95-NHL protocol), abdominal symptoms resolved; no other signs suggestive of intussusception were observed, as well as a significant reduction of the splenic mass was observed. CONCLUSIONS: Burkitt lymphoma in pediatric patients can present as a well-defined splenic tumor, causing no splenomegaly. In addition, its management does not require surgery since it can be resolved with chemotherapy.

Constipation and DIOS: Diagnosis, differential diagnosis, and management.

Cystic Fibrosis (CF) is a complex disorder that requires multidisciplinary expertise for effective management. The GALAXY study estimated the prevalence of constipation to be about 25% among People with Cystic Fibrosis (PwCF), identifying it as one of the common gastrointestinal (GI) symptoms within this patient population. Quality of Life (QoL) assessments uncovered high patient dissatisfaction, highlighting the imperative need for enhanced treatment strategies. Similarly, Distal Intestinal Obstruction Syndrome (DIOS) is a unique condition exclusive to PwCF that, if left undiagnosed, can lead to considerable morbidity and mortality. Given the broad spectrum of differential diagnoses for abdominal pain, including constipation and DIOS, it is paramount for healthcare providers to possess a clear understanding of these conditions. This paper aims to delineate various differentials for abdominal pain while elucidating the pathogenesis, diagnostic criteria, and treatment options for managing constipation and DIOS in PwCF.

Adrenaline intravenous therapy persistence grade I severe allergic reaction: A case report and literature review.

RATIONALE: At present, there is still insufficient understanding of the progression from persistent allergic reactions to severe reactions. Adrenaline remains the preferred medication for severe allergic reactions, and intramuscular injection of adrenaline can also be considered for patients with grade I reactions that are difficult to alleviate gastrointestinal symptoms. It is worth further discussing whether it is possible to break the conventional intramuscular injection recommended by the guidelines when the effect of intramuscular injection is not ideal for persistent grade I severe allergic reactions. PATIENT CONCERNS: A young male, 20 years of age, was admitted to emergency department because of repeated rash for 3 days and abdominal pain for 6 hours after taking traditional Chinese medicine. After hormone therapy, the rash continued to recur and secondary gastrointestinal symptoms occurred on the 3th day. Adrenaline intramuscular injection was given to temporarily relieve the rash and abdominal pain, but symptoms still persisted. DIAGNOSIS: The patient was diagnosed with persistent severe allergic reaction (grade I). INTERVENTIONS: Continuous intravenous infusion of low-dose adrenaline under electrocardiographic monitoring, real-time monitoring of heart rate and blood pressure, and routine treatment with methylprednisolone, diphenhydramine, calcium gluconate, and cetirizine. During this period, adrenaline intramuscular injection is temporarily added when abdominal pain symptoms are obvious. The entire treatment process used a total of 6.8 mg of adrenaline. OUTCOMES: During the entire period of adrenaline intervention, the patient did not experience any new discomfort, and there were no abnormal fluctuations in heart rate, rhythm, or blood pressure. The symptoms of rash and abdominal pain gradually improved. LESSONS: For patients with persistent grade I severe allergic reactions, intravenous administration of low-dose adrenaline under close vital sign monitoring is safe, feasible, and highly effective in preventing biphasic, persistent, or worsening allergic reactions.

This is a successful removal of more than 450 pieces of metal objects from a patient's stomach: a case report.

BACKGROUND: Ingestion of foreign bodies may be seen unconsciously or intentionally in patients with mental health problems. Most cases pass through the esophagus slowly; however, in some cases, the tumor may be located in narrower areas of the digestive tract that require endoscopic or surgical intervention. This study describes a rare case of successful removal of more than 450 pieces of metal objects from the stomach of a 36-year-old man via ingestion of foreign bodies at Imam Khomeini Hospital in Ahvaz. CASE PRESENTATION: A 36-year-old male patient (Aryan race) presented with complaints of chronic abdominal pain, frequent vomiting, and intolerance to liquids and food. The patient's companions mentioned a history of gradual ingestion of small metal objects 3 months prior. The patient was conscious and had stable vital signs. In the patient's X-ray and endoscopy, multiple metal objects inside the patient's stomach were observed, causing gastric outlet obstruction. The patient underwent gastrostomy surgery, and 452 screws, nuts, keys, stones, and other metal parts weighing 2900 g were removed from the stomach. Five days after the operation, the patient was transferred to the psychiatric service in good general condition and was diagnosed with psychosis, and her condition returned to normal at follow-up. CONCLUSION: Successful removal of this foreign body is rare. In chronic abdominal pain, especially in the context of psychiatric disorders, attention should be given to the ingestion of foreign bodies. In swallowing large amounts of sharp and metallic foreign objects, surgical intervention is necessary, especially in cases of obstruction, and saves the patient's life.