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.

Identifying a perforated prepyloric ulcer during laparoscopy in a patient presumed to have cholecystitis.

Abdominal pain in patients with significant alcohol use and smoking history presents diagnostic challenges due to overlapping clinical features of complications like acute cholecystitis and peptic ulcers. The unreliable physical examinations of intoxicated patients often complicate accurate diagnosis. We present a case of a 56-year-old male with a history of alcoholism and smoking, who presented to the emergency department with nonspecific abdominal pain. Initial imaging suggested cholecystitis, but due to the patient's intoxication, his physical examination was unreliable. During a laparoscopic cholecystectomy, a perforated prepyloric ulcer was unexpectedly discovered, sealed by the gallbladder. This case highlights the limitations of relying solely on imaging for diagnosing abdominal conditions in intoxicated patients. The intraoperative discovery of the perforated ulcer necessitated a shift in the surgical approach, emphasizing the need for flexibility in surgical planning and a high index of suspicion for other abdominal pathologies in patients with significant lifestyle risks. The successful management of this patient through adaptive surgical techniques and comprehensive postoperative care, including Helicobacter pylori eradication therapy, underscores the importance of maintaining a broad differential diagnosis and readiness to adapt surgical plans. This approach is essential for managing complex cases effectively, ensuring that both the immediate surgical issues and underlying causes are addressed to optimize recovery and prevent recurrence.

Beyond Abdominal Pain: Decoding the Mysteries of Nutcracker Syndrome.

Nutcracker syndrome (NCS), a rare but impactful vascular condition, emerges from the compression of the left renal vein by adjacent major arteries, leading to a diverse array of symptoms such as hematuria, flank pain, and renal challenges. Highlighting the case of a 30-year-old male with an atypical presentation of NCS, this report explores the diagnostic complexities arising from its varied presentations and therapeutic options. It emphasizes the critical role of computed tomography (CT) in unveiling the underlying vascular constriction. Through this lens, the case underscores the necessity of considering NCS in the differential diagnosis of abdominal pain, advocating for a prompt and accurate diagnosis to guide effective management strategies, ranging from conservative approaches to surgical intervention. This stresses the importance of heightened awareness and ongoing research for optimizing patient outcomes in the face of this elusive condition.

Two cases of sigmoid colon cancer with intussusception prolapsing through the anus in adults: consideration of preoperative reduction and surgical approaches: case reports.

Background: Adult intussusception is a rare condition that is often associated with a high incidence of malignancy. The optimal management strategy remains controversial, particularly regarding the necessity for bowel reduction before resection. To date, there is a paucity of data on adult intussusception in the English literature. We present two cases of sigmoid colon cancer with intussusception prolapsing through the anus and highlight the different surgical approaches. Case Description: Case 1: an 84-year-old woman presented with sigmoid colon prolapse and biopsy-confirmed adenocarcinoma. Urgent surgery revealed intussusception. Despite unsuccessful manual reduction, the Hutchinson technique successfully resolved the intussusception. Resection with a temporary colostomy was performed. Histopathological examination revealed mucinous adenocarcinoma without metastasis; the patient recovered well. Case 2: a 76-year-old woman with sigmoid colon prolapse presented with abdominal pain and blood-streaked stools. Emergency surgery was performed because of failed reduction attempts and persistent symptoms. Intussusception resolution was achieved through transanal insertion of a circular sizer. Resection with temporary colostomy was performed, after which tubular adenocarcinoma was identified. The patient remains symptom-free 3 years post-surgery. Conclusions: Choice of the surgical approach depends on the ease of intussusception reduction. In cases wherein reduction is straightforward, routine preoperative examinations are preferred given the low risk of injury or cancer cell dissemination. Conversely, in situations such as ours, gentle reduction under general anesthesia might be crucial. In addition, laparoscopic surgery could be beneficial. Importantly, accumulation of reports on adult intussusception could contribute to the standardization of this approach.

Managing patients' reports of abdominal pain and irritable bowel syndrome-like symptoms during quiescent inflammatory bowel disease: a role for shared sensemaking.

Background: Patients with inflammatory bowel disease (IBD) are often faced with distressing and confusing abdominal pain during remission. Some people respond adversely to healthcare professionals' (HCPs) suggestions that this pain and related symptoms are due to secondary irritable bowel syndrome (IBS). Exploring how HCPs view, manage, and explain pain during quiescent disease may provide insights into how communication can be improved to increase understanding and mitigate negative responses. Methods: In-depth semi-structured interviews were conducted with 12 IBD-nurses (n = 4) and gastroenterologists (n = 8) working in the United Kingdom or the Netherlands. Reflexive thematic analysis was used to analyse interviews. Results: Findings suggest that HCPs pay relatively little attention to pain when there is no underlying pathology and prefer to concentrate on objectifiable causes of symptoms and treating disease activity (Theme 1: Focus on disease activity, not pain and associated symptoms). Explanations of abdominal pain and IBS-like symptoms during remission were not standardised (Theme 2: Idiosyncratic and uncertain explanations for pain during remission). Processes of shared decision-making were outlined and shared sensemaking was reported as a strategy to enhance acceptance of IBS explanations (Theme 3: Shared decision making versus shared sensemaking). Conclusion: Future work should focus on establishing how pain during remission may be best defined, when to diagnose IBS in the context of IBD, and how to explain both to patients. The formulation of standardised explanations is recommended as they might help HCPs to adopt practices of shared sensemaking and shared decision-making. Explanations should be adaptable to specific symptom presentations and different health literacy levels.

Achieving Enteral Autonomy in Children with Intestinal Failure Following Inpatient Admission: A Case Series.

We describe cases of intestinal failure wherein inpatient admission was critical toward enteral autonomy. We performed a retrospective chart review of 6 children with long-term parenteral nutrition dependence who were weaned from parenteral nutrition following admission. Admissions included feeding and medication titration, interdisciplinary care, and home parenteral nutrition team consultation.

No small dilemma: small bowel volvulus mimicking acute coronary syndrome.

Acute abdominal pathologies can cause electrocardiogram (ECG) changes mimicking an acute coronary syndrome (ACS), resulting in diagnostic uncertainty and delay. We report a 65-year-old male with multiple risk factors for ACS who presented with four hours of progressive epigastric and chest pain that resolved in the emergency department. ECG findings were concerning for new deeply inverted T-waves with normal troponins, raising concerns for Wellens Syndrome. Emergent heart catheterization was negative but abdominal computed tomography angiography showed occlusion of the superior mesenteric vessels. Subsequent exploratory laparotomy revealed a small bowel volvulus with extensive necrosis, resulting in a 430 cm resection.

Acute mesenteric ischemia due to superior mesenteric artery thrombosis in a patient with protein S deficiency: A case report.

INTRODUCTION: Protein S deficiency resulting in mesenteric vein thrombosis has been reported in previous studies however those causing SMA thrombosis has been rarely reported. Multidisciplinary approach involving general surgeon, a vascular surgeon, an interventional radiologist, and an intensivist are crucial for management of SMA thrombosis. CASE PRESENTATION: A 39-year-old non-smoker hypertensive female who was diagnosed with partially occlusive thrombus in the superior mesenteric artery via Contrast-enhanced computed tomography (CECT) re-presented after 5 days and CECT revealed a partially occlusive thrombus in the superior mesenteric artery and Protein S deficiency (free protein S:15 %). She was managed by lysis of thrombus with streptokinase by interventional radiology team. The patient is on anticoagulants and without abdominal complaints on follow-up at 24 months. DISCUSSION: Computed tomography angiography should be done immediately in any patient suspected of AMI since delay in diagnosis accounts for high mortality rates of 30-70 %. The surgical treatment of the condition is well established and consists of revascularization and/or resection of nonviable bowel. Endovascular techniques have emerged as an alternative for occlusion of the SMA. Patients with protein C and/or S deficiency treated for AMI require lifelong anticoagulant/antiplatelet therapy to prevent relapse. CONCLUSION: Hereditary thrombophilia should be suspected in young people with unusual thrombotic presentations. Earlier diagnosis and aggressive antithrombotic therapy in individuals with hypercoagulable states can improve outcomes. Treatment involving a multidisciplinary approach improves outcomes.

Symptomatic uncomplicated diverticular disease: a critical appraisal.

INTRODUCTION: Symptomatic uncomplicated diverticular disease (SUDD) is a clinical condition included in the spectrum of symptomatic diverticular disease. The symptom profile associated with SUDD is highly heterogeneous, as there are currently discordant definitions, that encompass many clinical scenarios. AREAS COVERED: We conducted a narrative review to assess the symptom profile and diagnostic criteria of SUDD based on the available evidence. A thorough literature search was performed on PubMed following the SANRA scale. Abdominal pain, regardless of its duration and location, emerges as the cardinal symptom of SUDD, suggesting that it should be central to its diagnosis. Although abdominal bloating and changes in bowel habits are commonly reported, they do not appear to be specifically attributable to SUDD. Other issues considered are the possible overlap with irritable bowel syndrome and the identification of a subcategory of SUDD patients with chronic symptoms following an episode of acute diverticulitis. EXPERT OPINION: The future agenda should include the development of shared diagnostic criteria for SUDD, including well-defined inclusion and exclusion clinical features and symptom patterns.

Case Report: Acute Pancreatitis in an Uncontrolled Diabetic Patient Presenting With a Skin Rash Later Found to Be Eruptive Xanthoma, a Dermatological Manifestation and Diagnostic Clue to Recognizing Hypertriglyceridemia as the Cause of Disease.

Acute pancreatitis results from any insult that leads to inflammation of the organ. Hypertriglyceridemia is one of the risk factors associated with acute pancreatitis. The typical presentation is abdominal pain, nausea, and vomiting. We present a unique case in which the patient's condition was further complicated by diabetic ketoacidosis. Consequently, he presented somnolent to the emergency room, providing a limited history only pertaining to generalized weakness and a skin rash. The patient was found to have hypertriglyceridemia-induced pancreatitis, which was appropriately managed in the intensive care unit. The skin lesions were diagnosed as xanthomas, which are associated with hypertriglyceridemia and acute pancreatitis secondary to hypertriglyceridemia. The patient was discharged on fibrate therapy, dietary counseling, and strict monitoring by his primary care physician. This unique case highlights the importance of recognizing dermatological conditions and their associated diseases to allow for prompt diagnosis and treatment in the face of limited history.

A case series of fluoroscopy-guided neurolytic splanchnic nerve block for chronic pancreatitis pain.

Context: Splanchnic nerve block (SPN) with local anesthetic and steroid is used to relieve the pain of chronic pancreatitis. However, it does not provide long-lasting relief. We hypothesize that the use of 70% alcohol will give adequate analgesia for more than months. Aims: The primary objective was to find out the analgesic efficacy of the use of 70% alcohol with SPN. Secondary objectives included the incidence of side effects, analgesic consumption postintervention, quality of life (QOL) assessed via a self-reported quality of life scale, and repeat block during the 1-year follow-up period. Settings and Design: Retrospective analysis of all patients with chronic pancreatitis who received bilateral SPN over the last 4 years. Methods and Materials: SPN was performed using the posterior retrocrural approach with the patient in the prone position as described in the literature using a 23 G × 90 mm spinal needle bilaterally at the level of T12 using C-arm/fluoroscopy guidance. Data were collected from the procedure book of the pain clinic and medical records. Statistical Analysis Used: Quantitative data for change in pre- to post-block VAS score was collected using the non-parametric Wilcoxon signed ranks test. Results: The baseline VAS, post-procedure VAS, and VAS at 3 months follow-up was 7.69 ± 1.3,2.44 ± 0.96 and 1.56 ± 1.15. A pairwise comparison of VAS performed between baseline and immediate post-procedure, baseline, and VAS at 3 months was found to be highly significant. Conclusions: Fluoroscopy-guided neurolytic SPN with 70% alcohol gives significant pain relief for more than 3 months. It also leads to improvement in 3 months QOL.

Advancing Emergency Department Triage Prediction With Machine Learning to Optimize Triage for Abdominal Pain Surgery Patients.

BACKGROUND: The development of emergency department (ED) triage systems remains challenging in accurately differentiating patients with acute abdominal pain (AAP) who are critical and urgent for surgery due to subjectivity and limitations. We use machine learning models to predict emergency surgical abdominal pain patients in triage, and then compare their performance with conventional Logistic regression models. METHODS: Using 38 214 patients presenting with acute abdominal pain at Zhongnan Hospital of Wuhan University between March 1, 2014, and March 1, 2022, we identified all adult patients (aged ≥18 years). We utilized routinely available triage data in electronic medical records as predictors, including structured data (eg, triage vital signs, gender, and age) and unstructured data (chief complaints and physical examinations in free-text format). The primary outcome measure was whether emergency surgery was performed. The dataset was randomly sampled, with 80% assigned to the training set and 20% to the test set. We developed 5 machine learning models: Light Gradient Boosting Machine (Light GBM), eXtreme Gradient Boosting (XGBoost), Deep Neural Network (DNN), and Random Forest (RF). Logistic regression (LR) served as the reference model. Model performance was calculated for each model, including the area under the receiver-work characteristic curve (AUC) and net benefit (decision curve), as well as the confusion matrix. RESULTS: Of all the 38 214 acute abdominal pain patients, 4208 underwent emergency abdominal surgery while 34 006 received non-surgical treatment. In the surgery outcome prediction, all 4 machine learning models outperformed the reference model (eg, AUC, 0.899 [95%CI 0.891-0.903] in the Light GBM vs. 0.885 [95%CI 0.876-0.891] in the reference model), Similarly, most machine learning models exhibited significant improvements in net reclassification compared to the reference model (eg, NRIs of 0.0812[95%CI, 0.055-0.1105] in the XGBoost), with the exception of the RF model. Decision curve analysis shows that across the entire range of thresholds, the net benefits of the XGBoost and the Light GBM models were higher than the reference model. In particular, the Light GBM model performed well in predicting the need for emergency abdominal surgery with higher sensitivity, specificity, and accuracy. CONCLUSIONS: Machine learning models have demonstrated superior performance in predicting emergency abdominal pain surgery compared to traditional models. Modern machine learning improves clinical triage decisions and ensures that critically needy patients receive priority for emergency resources and timely, effective treatment.

Experience of admission and readmission to the emergency department for patients with acute abdominal pain: A qualitative study.

BACKGROUND: Abdominal pain is one of the most common complaints when patients are admitted to emergency departments (ED). Unfortunately, many of these patients are readmitted to the ED shortly after initial discharge. The perspectives of these patients have not yet been explored. PURPOSE: The study aimed to explore how patients readmitted with acute abdominal pain in the ED experienced their initial admission, the time after discharge, and the cause of readmission. METHODS: The study had a qualitative explorative design with a phenomenological-hermeneutic approach. Semi-structured individual telephone interviews were conducted with 14 patients readmitted with acute abdominal pain. RESULTS: The analysis showed four themes: 1) being vulnerable during hospitalisation, 2) the meaning of information during hospitalisation, 3) discharged without being diagnosed, and 4) readmitted in the pursuit of relief. The patients wanted more knowledge and better communication despite their vulnerable condition. Patients were discharged whilst still in pain, and uncertainty of the situation at home contributed to mistrust of the health professionals. CONCLUSION: Patients' experience of the first ED admission due to acute abdominal pain was loneliness, minimal contact with healthcare professionals, and lack of information and involvement in pain management. Discharge was associated with feelings of insignificance and contributed to a fear of death. Pain was the main reason for readmission. Patients described how multiple readmissions contributed to being taken seriously by healthcare professionals.

Global trends in opioid use for pain management in acute pancreatitis: A multicentre prospective observational study.

BACKGROUND: Since there is no current international consensus on the optimal approach for pain management in acute pancreatitis (AP), analgesic practices may vary across different healthcare settings. OBJECTIVE: This study explored global disparities in analgesic use, in particular opioids, during admission and at discharge in hospitalised AP patients. METHODS: This was a post hoc analysis of the prospective PAINAP database, which included all admissions for AP between April and June 2022 with a 1-month follow-up. Demographic details, analgesic use, and clinical outcomes were recorded during admission and at discharge. Odds ratios (ORs) for opioid use during admission and at discharge were identified using multivariable regression analyses. RESULTS: Amongst the 1864 patients (52% males, median age 56 (interquartile range, 41-71)) across three different continents, simple analgesics were predominantly used as the primary analgesic (70%). Opioid use during admission was lowest in European centres (67%). Admission in Asian (OR, 2.53 (95% confidence interval (CI), 1.59-4.04), p < 0.001), and Australian (OR, 5.81 (95% CI, 3.19-10.56), p < 0.001) centres was associated with opioid administration during admission compared with European centres. Increased pain severity, longer pre-admission pain duration, organ failure, and longer length of admission increased opioid use during admission. At discharge, Asian (OR, 2.01 (95% CI, 1.40-2.88), p < 0.001) and Australian (OR, 1.91 (95% CI, 1.28-2.85), p = 0.002) centres were associated with opioid prescription compared with European centres. Increased pain severity, longer pre-admission pain duration, acute necrotic collections, and walled-off necrosis also increased the likelihood of opioid prescription at discharge. CONCLUSION: There are substantial intercontinental differences in opioid use for AP pain. Accordingly, there is a need for international guidelines on pain management in AP.

Health care utilization of patients with acute abdominal pain before and after emergency department visits.

BACKGROUND: Acute abdominal pain (AAP) is a major driver for capacity-use in emergency departments (EDs) worldwide. Yet, the health care utilization of patients with AAP before and after the ED remains unclear. The primary objective of this study was to describe adult patients presenting to the ED with AAP and their outpatient care (OC) use before and after the ED. Secondary objectives included description of hospitalization rates, in-hospital mortality, ED re-visits, and exploration of potential risk factors for hospitalization and ED re-visits. METHODS: For the analysis, we combined routine hospital data from patients who visited 15 EDs in Germany in 2016 with their statutory health insurance OC claims data from 2014 to 2017. Adult patients were included based on a chief complaint or an ED diagnosis indicating unspecific AAP or the Manchester Triage System indicator "Abdominal pain in adults". Baseline characteristics, ED diagnosis, frequency and reason of hospitalization, frequency and type of prior-OC (prOC) use up to 3 days before and of post-OC use up to 30 days after the ED visit. MAIN RESULTS: We identified 28,085 adults aged ≥ 20 years with AAP. 39.8% were hospitalized, 33.9% sought prOC before the ED visit (48.6% of them were hospitalized) and 62.7% sought post-OC up to 30 days after the ED visit. Hospitalization was significantly more likely for elderly patients (aged 65 and above vs. younger; adjusted OR 3.05 [95% CI 2.87; 3.25]), prOC users (1.71 [1.61; 1.90]) and men (1.44 [1.37; 1.52]). In-hospital mortality rate was 3.1% overall. Re-visiting the ED within 30 days was more likely for elderly patients (1.32 [1.13; 1.55) and less likely for those with prOC use (0.37 [0.31; 0.44]). CONCLUSIONS: prOC use was associated with more frequent hospitalizations but fewer ED re-visits. ED visits by prOC patients without subsequent hospitalization may indicate difficulties of OC resources to meet the complex diagnostic requirements and expectations of this patient population. Fewer ED re-visits in prOC users indicate effective care in this subgroup.

Endoscopic Resection of a Cavernous Hemangioma in the Sigmoid Colon: A Case Report.

Hemangiomas in the gastrointestinal tract are extremely rare, benign vascular tumors, known for their associated complication of bleeding. They are usually difficult to diagnose, despite the characteristic definition of radiolucent phleboliths on radiology and purplish, tannish brown nodule or polyp on endoscopy. Surgical resection is the treatment of choice. We describe a rare case of sigmoid colon cavernous hemangioma in a 49-year-old male who underwent colonoscopy for lower abdominal pain and revealed a large pedunculated polyp in the sigmoid colon measuring 1.7 cm in diameter. The hemangioma was completely resected endoscopically via hot snare with a favorable outcome.

Isolated diaphragmatic hydatid cyst: a rare entity in the paediatric population.

Isolated primary diaphragmatic hydatid disease (HD) occurs in approximately 1% of adult cases. However, this unique presentation of a pediatric diaphragmatic cystic mass has not been previously described in the literature. This study reports a rare case of a 12-year-old girl who was diagnosed with a diaphragmatic hydatid cyst. Surgical exploration via subcostal incision revealed an isolated cyst, free from the thoracic and abdominal viscera. Cystotomy, removal of daughter cysts, and excision of the pericyst cavity were performed, followed by diaphragmatic repair. Histopathological examination confirmed the diagnosis. The postoperative course was uneventful, and the patient completed an 8-week mebendazole regimen with no recurrence at 3 months' follow-up. This paper recommends including HD in the differential diagnosis for pediatric patients presenting with diaphragmatic lesions, particularly in regions endemic for echinococcosis.

Primary caecal epiploic appendagitis mimicking acute appendicitis: A diagnostic dilemma of right lower abdominal pain.

Epiploic appendagitis is a benign and self-limiting condition that has garnered more recognition, particularly in preoperative settings, thanks to advancements in imaging techniques, notably computed tomography (CT). Its distinct radiologic features facilitate accurate diagnosis prior to surgery. Despite its unique characteristics, the clinical presentation of epiploic appendagitis often resembles that of various other intra-abdominal medical and surgical conditions, leading to potential confusion. Here, we present the case of a 37-year-old otherwise healthy woman who was diagnosed with primary epiploic appendagitis based on CT scan findings conducted initially for suspected appendicitis. The patient received successful conservative treatment. This paper seeks to highlight the importance of recognizing this clinical condition and its characteristic imaging features, aiming to prevent unnecessary hospitalizations, antibiotic treatments, and the associated morbidity and mortality linked with surgical interventions.