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BACKGROUND AND AIMS: Even if the motor activity of the gall bladder and sphincter of Oddi (SO) are integrated, it is not known if the presence of stones in the gall bladder affects SO function. The aim of the study was to compare SO motor activity in patients with and without gall stones. PATIENTS AND METHODS: In a series of 155 patients consecutively submitted to endoscopic retrograde cholangiopancreatography and SO manometry for suspected biliary or pancreatic disease, 23 gall stone patients had recurrent episodes of biliary or pancreatic pain (colicky group); 52 patients had non-biliary/pancreatic-type abdominal pain/discomfort, and of these, 15 had gall stones (non-colicky group), 25 were free of stones (controls), and 12 had undergone cholecystectomy. RESULTS: SO basal pressure in gall stone patients in the colicky or non-colicky group was significantly higher than in controls (p<0.001). SO basal pressure recorded in postcholecystectomy patients did not differ from controls. SO phasic activity did not differ between the patient groups. SO dysfunction was detected in more than 40% of gall stone patients irrespective of associated biliary/pancreatic pain but in none of the control subjects (p<0.001). CONCLUSIONS: Gall stones are frequently associated with increased SO tone which may obstruct bile flow thus acting to facilitate gall bladder stasis, and may play a role as a cofactor in biliary/pancreatic pain.

A case of lactobezoar is described in a toddler with an acute history of abdominal pain, vomiting, and lethargy. Despite normal dietary habits, he had developed a gastric milk coagulum which led to a palpable epigastric tumor. Intussusception was suspected but disproven by barium enema. In retrospect, plain abdominal radiographs demonstrated characteristic mottled filling defects in the stomach from a lactobezoar. Conservative therapy led to prompt disintegration of the lactobezoar.

AbstractExtragastrointestinal stromal tumors (EGISTs) are rare mesenchymal neoplasms, which develop in the retroperitoneum, mesentery, and omentum, lacking continuity to the stomach or intestines. Authors hereby present a female patient with a large heterogeneous abdominal mass as a case of an omental EGIST. A 46-year-old woman was referred to our hospital due to an insidious enlargement and colicky pain in the right iliac fossa. Abdominal palpation revealed a voluminous, freely mobile, and non-pulsatile mesoabdominal bulge expanding to the hypogastrium. On exploratory midline laparotomy, the tumor was densely fused to the greater omentum, not connected to the stomach, without gross involvement of adjacent structures. The large mass was completely excised after adequate mobilization. Immunohistochemical techniques showed strong and diffuse expression of WT1, actin and DOG-1, as well as multifocal c-KIT marking. Mutational study concluded a double mutation of KIT exon 9 and a mutation of PDGFRA exon 18. The patient was submitted to adjuvant treatment with imatinib mesylate 800 mg/day. Despite an extremely diverse presentation, omental EGISTs often remain clinically silent for a long time having enough space to grow before becoming symptomatic. These tumors have a consistent pattern of metastasis that typically spares lymph nodes unlike epithelial gut neoplasms. Surgery remains the preferred treatment for non-metastatic EGISTs of the greater omentum. It is possible that DOG-1 will supplant KIT as the leading marker in the future. The scarcity of knowledge on omental EGISTs implies a close monitoring of these patients to detect local relapse or distant metastasis.

Researchers at the GKT School of Medical Education have released new data on choledochal cysts, a rare congenital anomaly characterized by cystic dilations in the biliary trees. The research focuses on an atypical presentation of choledochal cysts in adulthood, as it primarily presents in children. The case study discusses a 50-year-old female who presented with severe colicky pain in the right upper quadrant of her abdomen. Diagnostic methods, treatment options, and potential outcomes for individuals with choledochal cysts during adulthood are also explored. The research contributes to existing knowledge on choledochal cysts by providing insight into clinical presentation, diagnostics, and treatment. [Extracted from the article]

Dysmenorrhea is one of the most frequent gynecological conditions, characterized by colicky pain that affects the lower abdomen. Many systems can be affected during the menstrual period. It is known that the different phases of the menstrual cycle influence the motility of the small and large intestine, even evolving with a delay in the intestinal transit time.

Jejunogastric intussusception (JGI) is a rare long‐term complication of Billroth II gastrectomy. It presents potentially lethal complication of gastrectomy or gastrojejunostomy which can occur any time after a gastric operation. Delayed diagnosis can lead to high morbidity and even mortality. Prompt surgical intervention is mandatory after early diagnosis. Endoscopy and abdominal computed tomography (CT) scanning are the main diagnostic tools. For gastric surgery patients who later experience sudden onsets of epigastric pain, vomiting, or subsequent hematemesis, JGI should be considered. A 77‐year‐old man who had a Billroth II gastrectomy 30 years prior to admission presented to our emergency department due to multiple episodes of epigastric colicky pain and hematemesis. He underwent esophagogastroduodenoscope and an abdominal CT scan. We provided a systemic image description of a rare case of internal herniation with retrograde JGI into the stomach. The patient received emergent laparotomy and resection of the efferent loop of the jejunum with the gangrenous segment. He was discharged 10 days after admission. JGI is a rare but potentially fatal disease. Early diagnosis and surgical treatment are important to avoid subsequent high mortality.

A rare case report from JLN Medical College in Rajasthan, India, discusses the diagnosis and treatment of an obturator hernia in a 72-year-old female patient. Obturator hernias are extremely rare and present with signs and symptoms of intestinal obstruction. The patient also had multiple ileal diverticula in the terminal ileum. The only treatment for this type of hernia is surgery. For more information, readers can refer to the article published in the Journal of Society of Surgeons of Nepal. [Extracted from the article]

Aim of the study:Assessment of risk factors for cholelithiasis in pediatric population. Methods:A retrospective analysis of 143 patients with cholelithiasis treated during the period 2002–2012. Results:There was a significant female predilection for gallstones (73.4%). 70 (48.9%) children showed one or more risk factors for gallstones. 73 (51.1%) patients had no risk factors. Four groups of patients could be distinguished: 106 (74.3%) patients with colicky pain without jaundice, 10 patients with colicky pain with jaundice (7%), 16 (11.2%) children with pancreatitis, 8 (5.5%) with acute cholecystitis, and 3 patients with atypical symptoms (2%). According to therapy, patients could be divided in 3 groups: 130 children treated with laparoscopic cholecystectomy, 4 children treated with laparotomic cholecystectomy and 9 children treated with ursodeoxycholic acid. Conclusions:Laparoscopic cholecystectomy remains the golden standard in treatment for symptomatic cholelithiasis. Complications connected with laparoscopic cholecystectomy were noted in only 2% of patients in our series. Presence of relatives with cholelithiasis, obesity and hemolytic disorders were the predominant risk factors.

The objective is to compare immediate and delayed SWL as a treatment for ureter stones between 5 and 20 mm. Patients who applied to the emergency department with single, radio opaque ureteric stone of 5–20 mm size were included in the study. Patients were randomized into immediate and delayed SWL groups. SWL were carried out after pain relief in the delayed group. Maximum of three SWL sessions were applied to the patients with stones of 5 mm or bigger in diameter, leaving at least 3 days interval in-between. Stone-free rate after first session was similar in two groups. When CIRF was also considered as success, the success rate of SWL in the immediate SWL group was higher after first session (p= 0.02). Immediate SWL had a greater success rate in upper ureteric stones (p= 0.019). Overall average time required for elimination of stones was shorter in immediate SWL group than delayed SWL group (p= 0.033). The success rate after first SWL session (including CIRF) was 59 % for patients with chronic pain in the delayed group and 100 % for patients with acute pain in the immediate group. According to the hydronephrosis grade, success rates were 71 and 44.4 % for patients with grade 1 or no hydronephrosis in the immediate SWL group, and for patients with grade 2 or larger hydronephrosis in the delayed SWL group, respectively, after first SWL session. Immediate SWL insures stone-free status in a shorter time in cases with renal colicky pain and ureteral stones, particularly upper ureteral stones.The objective is to compare immediate and delayed SWL as a treatment for ureter stones between 5 and 20 mm. Patients who applied to the emergency department with single, radio opaque ureteric stone of 5–20 mm size were included in the study. Patients were randomized into immediate and delayed SWL groups. SWL were carried out after pain relief in the delayed group. Maximum of three SWL sessions were applied to the patients with stones of 5 mm or bigger in diameter, leaving at least 3 days interval in-between. Stone-free rate after first session was similar in two groups. When CIRF was also considered as success, the success rate of SWL in the immediate SWL group was higher after first session (p= 0.02). Immediate SWL had a greater success rate in upper ureteric stones (p= 0.019). Overall average time required for elimination of stones was shorter in immediate SWL group than delayed SWL group (p= 0.033). The success rate after first SWL session (including CIRF) was 59 % for patients with chronic pain in the delayed group and 100 % for patients with acute pain in the immediate group. According to the hydronephrosis grade, success rates were 71 and 44.4 % for patients with grade 1 or no hydronephrosis in the immediate SWL group, and for patients with grade 2 or larger hydronephrosis in the delayed SWL group, respectively, after first SWL session. Immediate SWL insures stone-free status in a shorter time in cases with renal colicky pain and ureteral stones, particularly upper ureteral stones.

Amyloidosis of the gastrointestinal tract is an uncommon disorder characterized by the extracellular deposition of an abnormal fibrillar protein. It is rarely proven by biopsy. Amyloid deposition interferes with organ structure and its function. We report a case of a 64-year-old male who presented with severe colicky pain, unable to pass feces, and progressive abdominal distension for 2 days. Physical examination revealed marked abdominal distension, visible peristalsis, high-pitched hyperactive bowel sounds, and generalized tenderness. Plain abdominal radiograph showed markedly diffuse disproportional dilatation of the small bowel with different heights of air-fluid levels in the same loop. Abdominal computed tomography showed an evidence of small bowel obstruction, which revealed no gross mass or cause of obstruction, but long segment narrowing of the terminal ileum was seen. Ileocolonoscopy showed diffuse edematous mucosa of the ileum without mechanical obstruction but loss of normal bowel peristalsis. A random biopsy of the ileum was performed for pathological diagnosis, which reported extensive deposits of amorphous material within the muscle layers and in the submucosal vessels that stained strongly with Congo red and displayed the typical apple-green birefringence of amyloid protein when viewed under plane polarized light. Serum electrophoretic tests disclosed a monoclonal band of IgG-kappa monoclonal protein. His clinical symptoms improved after receiving chemotherapy with melphalan and prednisolone. Our case illustrated the rare cause of acute intestinal obstruction which mimicked a surgical condition. Primary intestinal amyloidosis should be in a differential diagnosis in patients without a demonstrated cause of obstruction.

直接経口抗凝固薬内服中に広範囲結腸粘膜下出血を生じ結腸亜全摘を要した症例を経験した。症例は81歳の女性で非弁膜症性心房細動に対しダビガトランを内服していた。臍周囲間歇痛と嘔吐で発症し，約5時間後にショックとなり搬送された。搬入時，PT–INRが4.52，APTTは測定不能と高度の凝固異常があったが，腎機能は正常であった。汎発性腹膜炎と診断し緊急開腹術を施行したが，凝固障害のため，結腸亜全摘術後の出血部にガーゼパッキングを行いopen abdomen managementとした。ダビガトランの作用が消失するまでの72時間にわたり凝固障害が持続し，出血制御に難渋した。ダビガトラン特異的中和剤であるイダルシズマブの認可前であったため，凝固異常に対し大量輸血で対処せざるを得なかった。72時間以降，凝固能は急速に改善し，第44病日に軽快転院となった。病理組織検査では，結腸のほぼ全域に粘膜下出血と，粘膜固有層から筋板下までの出血凝固壊死がみられた。経口抗凝固薬の消化器系合併症には消化管出血以外に壁内血腫の報告が散見される。その多くは限局性で保存治療によって軽快するが，本症例のように広範囲粘膜下出血より粘膜固有層・筋板下までの出血凝固壊死を生じて腸管切除を要した症例は極めてまれである。治療は凝固因子補充が主体だが，新たにイダルシズマブが認可されたため，今後はイダルシズマブが治療の第一選択となり得る。 We report a case of an 81–year–old female who urgently had subtotal colectomy for dabigatran–associated extensive submucosal hemorrhage. She was brought in our hospital with paraumbilical colicky pain, vomiting and hypotension. She was known to have non–valvular atrial fibrillation, which had been managed with dabigatran. Laboratory findings on arrival also revealed abnormal coagulation values and normal renal function. Given the clinical findings, diffuse peritonitis was suspected, and an urgent laparotomy was performed. Severe coagulopathy made it so difficult to achieve hemostasis, and open abdomen management was selected. Persistent bleeding had lasted for 72 hours despite of massive transfusion until the anticoagulant effect of dabigatran was thought to be worn off. This case was experienced before idarucizumab, a specific neutralizing agent of dabigatran, was available to use. A histopathological findings confirmed a submucosal hemorrhage covering most of the entire colon, and that caused diffuse peritonitis. One of the gastroenterological complications of direct oral anticoagulant is intramural hematoma, developing as acute abdomen, and most of the cases are treated conservatively. Extended submucosal hematoma such as our case, requiring surgical management, has rarely been reported. The main treatment is coagulation factor supplementation, but now idarucizumab can be the first choice of treatment.

Abstract:  In advanced cancer patients with inoperable bowel obstruction, the administration of antisecretive and antiemetic drugs has proved to be effective in controlling gastrointestinal symptoms caused by bowel obstruction. However, controlled studies concerning the most effective antisecretive drug are lacking. The aim of this randomized controlled study was to determine whether octreotide or hyoscine butylbromide was the more effective antisecretive drug for use in states of inoperable bowel obstruction. Eighteen patients with inoperable bowel obstruction randomly received octreotide 0.3 mg daily (n=9) or hyoscine butylbromide (HB) 60 mg daily (n=9) s.c. The following parameters were measured: episodes of vomiting, nausea, drowsiness, continuous and colicky pain, using a Likert scale corresponding to a numerical value: (none 0, slight 1, moderate 2, severe 3) recorded before starting the treatment (T0) and 24 h (T1), 48 h (T2) and 72 h after (T3), and the mean daily amounts of fluids administered i.v. or s.c. during the period of study. Three patients dropped out of the study because data were incomplete. Octreotide treatment induced a significantly rapid reduction in the number of daily episodes of vomiting and intensity of nausea compared with HB treatment at the different time intervals examined. No relevant changes were found in dry mouth, drowsiness and colicky pain. Lower levels of hydration were associated with nausea regardless of the treatment. At the doses used in this study, octreotide was more effective than HB in controlling gastrointestinal symptoms of bowel obstruction. Further studies are necessary to understand the role of hydration more clearly in such a clinical situation.

Great debate exists in the initial acute management of large bowel obstruction from obstructing left colon carcinoma. While endoscopic stenting is well established as the first approach in the setting of palliative care of patients with advanced metastatic disease as well as a bridge to elective surgery in elderly patients who have an increased risk of postoperative mortality (age >70 years and/or ASA status ≥3), controversies exist regarding oncological safety and long-term outcomes of endoscopic colonic stenting in younger patients and ESGE Guidelines do not recommend SEMS placement in patients <70 and fit for curative surgery. Particularly, the Consensus Panelists currently state that SEMS placement as a bridge to surgery is not recommended as the standard treatment because (1) it does not reduce the postoperative mortality in the general population, (2) SEMS may be associated with an increased risk of tumor recurrence, and (3) acute resection is feasible in young and fit patients, with an acceptable postoperative mortality rate. A 32-year-old lady was admitted with complete LBO from obstructing sigmoid carcinoma. Initial i.v. CE-CT scan detected a large bowel partial obstruction with fecal impaction in the entire colon until sigmoid with some mildly dilated SB loops. The presence of a thickened area in the colonic wall could not be assessed because the patient was young and thin and in such patients the CT appearance of bowel wall cannot be clearly appreciated. She was initially managed with laxatives and gastrografin. The patient’s obstruction did not improve and abdominal distension worsened with nausea and colicky pain. Urgent endoscopy detected a friable mass, consistent with completely obstructing carcinoma of the mid sigmoid. Biopsies were taken and distal ink marking was made. Whole-body urgent CT scan with i.v. contrast was performed in order to obtain full preoperative staging and to rule out distant metastases. CT scan and the previously given oral gastrografin confirmed complete large bowel obstruction with a tight stricture in the sigmoid. Cecum was markedly distended.

The article presents a study in Iranian hospitals, which showed that the prenatal probiotic Lactobacillus reuteri is effective in reducing the risk and severity of colic in newborn infants. Also cited are the colicky pain postures like flushed face, wrinkled brow, and clenched hands, as well as the zero effect of mode of delivery on the risk and severity of colic.

A recent report from Zhejiang Chinese Medicine University discusses the use of herbs-partitioned moxibustion (HPM) on the navel in a rat model of primary dysmenorrhea. The study highlights the potential benefits of HPM in treating gynecological disorders, particularly functional diseases like primary dysmenorrhea. The research provides detailed procedures and precautions for applying HPM at the Shenque acupoint in female rats, offering insights for further development and application of this therapy. This study has been peer-reviewed and offers valuable information for those interested in complementary and alternative medicine approaches to managing dysmenorrhea. [Extracted from the article]

Cystic lymphangioma is an uncommon, slowly growing tumor derived from of the lymphatic vessels, which is rarely found as intra-abdominal masses usually located in the small-bowel mesentery, followed by the omentum, mesocolon and retroperitoneum. A 66 month –old girl presented with diffuse abdominal distention and severe colicky pain after a 2-month history of abdominal discomfort. Physical examination revealed severe abdominal distention and a palpable abdominopelvic mass localized on the right side of the abdomen. An abdominal CT scan revealed a cystic mass, about 13 × 7 cm × 6.9 cm in size, at the right upper and lower quadrant, which compressed the adjacent bowel loops. The child underwent an emergency laparotomy under general anesthesia. There were two cystic mass (6 × 8 cm and 6 × 7 cm) lesions with cystic and solid areas in the jejunal mesentery adjacent to the bowel wall, about 150 cm from the ileocecal valve. The mesenteric mass was excised with about 10 cm jejunal segment, and bowel continuity was achieved by end-to-end hand-sewn anastomosis. Pathological examination confirmed a diagnosis of mesenteric cystic lymphangioma containing chylous milky fluid. The patient remained well at 3 months from the surgery. Abdominal cystic lymphangiomas is an intra-abdominal cystic mass usually affecting infants and young children, which may be detected incidentally or present with acute life-threatening abdominal obstruction. A total surgical excision seems to be the best therapeutic option in order to minimize the risk of recurrence of symptomatic abdominal cystic lymphangiomas.

Among diseases causing acute lower abdominal pain in women, isolated fallopian tube torsion is very rare, with an annual prevalence of 1 in 1.5 million. Because it has fewer findings on imaging compared to adnexal torsion, the correct diagnosis can rarely be made before an operation. We present a case of isolated fallopian tube torsion that was suspected preoperatively by its clinical course and findings on computed tomography. A 24-year-old woman repeatedly experienced acute colicky pain in the right lower back. Transvaginal ultrasonography and magnetic resonance imaging showed a right pelvic cystic lesion with intact ovaries; these findings led us to schedule a laparoscopic examination. However, the patient presented to the emergency room with acute severe right back pain. The preoperative diagnosis considering the computed tomography findings and clinical course was consistent with fallopian tube torsion. An earlier diagnosis may have helped to preserve the fallopian tube and future fertility.

A recent report from King Hamad University Hospital discusses the emerging global health issue of obesity. The report focuses on a specific complication of bariatric surgery called internal hernia (IH) post-single anastomosis gastric bypass (SAGB). IH is a less recognized clinical entity, and its symptoms can vary from mild to severe. The report emphasizes the importance of diagnostic laparoscopy for the diagnosis and management of patients with a high suspicion of IH. Computed tomography (CT) with intravenous and oral contrast is the most common imaging modality used for preoperative evaluation. This research provides valuable insights into the complications associated with bariatric surgery and highlights the need for further investigation in this area. [Extracted from the article]

Chronic pain is usually treated with pharmacological measures using opioids alone or in combination with adjuvant analgesics that play an important role in the treatment of pain not fully responsive to opioids administered alone, especially in neuropathic, bone and visceral colicky pain. The important part of the chronic pain treatment is the appropriate use of non-pharmacological measures along with psychosocial and spiritual support. Opioids may be administered by different routes; the most common and most convenient for majority of treated patients are oral and transdermal. However, in certain circumstances such as inability to swallow, lack of analgesic efficacy and intractable opioid-induced adverse effects parenteral routes (subcutaneous, intravenous) might be more useful. When these routes fail, in some patients intrathecal administration of opioids is required. Recently, more patients have been treated with short-acting opioids for breakthrough pain with sublingual, buccal and intranasal routes of opioid administration that may provide efficacy superior to oral and comparable to intravenous routes. Alternative routes comprise rectal, inhaled and topical administration of opioids. This article discusses various routes of opioid administration.

AbstractA 69-year-old cholecystectomized female with known total situs viscerum inversus presented recurrent colicky pain in the left upper abdominal quadrant and jaundice. Laboratory parameters showed increased neutrophils and coniugated bilirubin of 5.53 mg/dl. US and MRCP confirmed total situs viscerum inversus and a dilatation of the intra- and extrahepatic ducts with a peripapillary 13 mm stone. ERCP, sphincterotomy and successful common bile duct stone extraction were performed in the conventional way. ERCP was carried out successfully despite situs inversus maintaining the patient in the prone position with the endoscopist on the right side of the table. Some authors have reported similar cases in whom ERCP was performed in other positions, while this report shows that an experienced endoscopist can achieve the same results in the conventional way as it is possible when anatomical changes, Billroth II or Roux-en-Y, or different positions of the patient, supine or on the left side, are present.Copyright © 2008 S. Karger AG, Basel

Abstract: Situs inversus totalis is a rare congenital anomaly that often occurs concomitantly with other disorders. We report a case of situs inversus totalis with malignant lymphoma of the stomach, which was successfully treated by surgery followed by chemotherapy and irradiation. The patient was a 51-year-old woman who present with colicky pain in the left upper quadrant of her abdomen. Chest X-ray showed a right-sided heart, and ultrasonography and computed tomography (CT) of the abdomen showed a situs inversus totalis with multiple gallstones in the gallbladder. Tree-dimensional reconstructed CT of the abdomen showed no other malformations coexisting with situs inversus totalis, but a barium upper gastrointestinal series found an inverted stomach and an elevated tumor with ulceration in the center, localized in the antrum of the stomach. First, we performed a cholecystectomy, followed by a total gastrectomy with dissection of the lymph nodes and splenectomy, and Roux-en-Y reconstruction. Histopathological examination confirmed a diagnosis of malignant lymphoma of the stomach (diffuse large B-cell type) with metastasis to the regional lymph nodes. Chemotherapy using the CHOP regimen was given three times, starting 1 month postoperatively. A follow-up CT scan showed enlargement of one lymph node around the abdominal aorta and irradiation was delivered to the area of the inverted Y in the abdomen. At the time of writing, 10 months after surgery, the patient is well with no signs of recurrence and leading a normal life. Careful preoperative assessment is very important for determining the most appropriate surgical procedure in patients with situs inversus totalis associated with a malignancy.

A case of Bouveret's syndrome with obstruction of the duodenojejunal flexure diagnosed preoperatively by sonography is presented. A 48-year-old man with a history of cholelithiasis presented with colicky pain of 2 days' duration. Real-time sonography revealed a fluid-distended stomach and duodenum and a 3.4-cm bright curvilinear echo with dense shadowing in the duodenojejunal flexure, suggesting a gallstone. In addition, there was pneumobilia and evidence of chronic cholecystitis. The findings were confirmed with CT, which showed a partially calcified gallstone at the duodenojejunal flexure, pneumobilia, and a fistulous communication between the gallbladder and duodenum. At surgery, a large gallstone was found impacted at the duodenojejunal flexure. The stone and gallbladder were successfully removed and the fistula repaired. The sonographic diagnosis of Bouveret's syndrome enabled early surgical intervention. © 2003 Wiley Periodicals, Inc. J Clin Ultrasound 31:163–166, 2003

Malignant bowel obstruction is a common complication in patients with advanced abdominal or pelvic cancer. Whereas surgery should be considered in all cases of malignant bowel obstruction, many advanced and terminal cancer patients are considered unfit for surgery. In such patients with a short life expectancy, gastrointestinal symptoms such as nausea, vomiting, continuous and/or colicky pain, can be controlled by using a pharmacologic approach made up of analgesics, antiemetics and antisecretory drugs, without the use of a venting nasogastric tube. Among the antisecretory drugs, octreotide has been shown to reduce nausea and vomiting in bowel-obstructed patients owing to a reduction of gastrointestinal secretions, thus allowing in most patients removal of the nasogastric tube and the associated distress. Preclinical and clinical studies that demonstrated the role of somatostatin and octreotide in bowel obstruction are reviewed.

As part of a continuing audit of patients undergoing laparoscopic cholecystectomy (which now numbers over 1500) 468 of the 508 patients (92·1 per cent) operated on between October 1989 and March 1991 were studied between 350 and 988 days after the operation (mean 19 months). A questionnaire was filled in by each patient before operation and at the late follow-up visit. Eight specific symptoms were sought - non-colicky pain, colic, abdominal distension, nausea, vomiting, loss of appetite, flatulence, and dietary restriction. The result of each operation was assessed by two surgeons and by the patient. In 453 patients (96·8 per cent) the symptoms had improved as a result of the operation, but 260 patients (55·6 per cent) had some abdominal symptoms. The result was assessed as excellent in 310 patients (66·2 per cent); 143 (30·5 per cent) still had abdominal complaints but they were willing to cope with those symptoms. In 15 patients (3·2 per cent) the result was unsatisfactory. Statistical analysis of 26 preoperative variables showed few significant differences between patients with excellent results and patients with persisting or new symptoms. The percentage of patients with biliary colic was reduced from 82·9 per cent before to 6·4 per cent after laparoscopic cholecystectomy (P<0·05), and of those with flatulence from 62·6 per cent to 45·3 per cent (P <0·05). Flatulence persisted in 147 (50·2 per cent) of the 293 patients who had complained of flatulence before the operation, and of the 175 patients who had not complained of flatulence before surgery, 65 (37·1 per cent) reported the symptom for the first time after the operation. It appears that ‘flatulent dyspepsia’ after cholecystectomy has many causes, one of which may be removal of the gallbladder. It is concluded that the long-term results of laparoscopic cholecystectomy in patients with symptomatic gallstone disease were excellent but the prognosis in individual patients was unpredictable.

Recurrent upper gastrointestinal haemorrhage arising from the pancreatic duct presents diagnostic difficulties. Bleeding can be secondary to pancreatic disease (pancreatitis, pseudocysts) or vascular disorders (aneurysms of the splanchic arteries). Of the 5 cases reported here, 3 involved a ruptured aneurysm of the splenic artery and 2 chronic pancreatitis. Attacks of colicky pain in the left epigastric region associated with haematemesis and/or melaena were characteristic symptoms. Pancreatectomy controlled the bleeding in 4 and ligation of the splenic artery and the pancreatic duct in one. Fifty-five patients with similar pathology have been previously reported, suggesting that this syndrome should be borne in mind when gastrointestinal haemorrhage of obscure origin is encountered.If routine endoscopy does not reveal the site of the haemorrhage and there are no signs of cholestasis, endoscopic retrograde pancreatography (ERP) and selective coeliac arteriography should be performed to evaluate the possibility of haemorrhage from the pancreatic duct. Surgical management depends on the site of the causative lesion.

Summary: Volvulus of the sigmoid colon is a very uncommon cause of acute obstruction in children. Although common in adults in India, it was found to account for only 0.8 per cent of all acute obstructions in infants and children in this institution. It causes a proximal torsional obstruction of the colon with an acute onset of symptoms. the onset of volvulus is characterized by colicky pain over the left lower quadrant, vomiting, tenderness, and rigidity in the left lower quadrant. A scout film of the abdomen may be inconclusive, but a barium-enema examination is diagnostic. The number of cases reported is too small to allow conclusions about the best treatment for children who have sigmoidal volvulus.

Using breath hydrogen analysis after an oral lactose load (2 g/kg; maximum 50 g), we investigated the prevalence of lactose malabsorption in 61 healthy Italian children aged 6–13 years. We also examined the relationship between symptoms and small bowel transit time and the degree of sugar malabsorption. Three of 61 subjects produced no H2after both lactose and lactulose load and thus were eliminated at the outset. Lactose malabsorption was defined as excretion of >20 ppm H2. Lactose intolerance was classified as mild (colicky pain, flatulence, abdominal distension, borborygmi) or severe (diarrhea). The frequency of lactose malabsorption in the children aged 6–8 years (group I) was 25; in the children aged 8–11 years (group II), it was 35, and in the children aged 11–13 years (group III) 56. The differences in frequency between the first and the third groups were significant (p = 0.05). Three of 20 (15) in group I, two of 20 (10) in group II, and three of 18 (17) in group III were classified not only as lactose malabsorbing, but also as lactose intolerant, with symptoms during and after the test. We found no difference in the small bowel transit times or in the quantities of malabsorbed lactose in symptomatic and asymptomatic malabsorbing subjects. Other factors that may play a role in symptom production are discussed.

The presenting clinical features of a series of cases of biliary tract ascariasis are described, in particular the characteristic colicky pain which occurs. The term ‘ascaritic biliary pain’ is introduced for the symptom diagnostic of liveAscaris adult worms inside the biliary passages. Methods of diagnosis before, and in the course of, operation are discussed and seem adequate. The management of worms discovered in the bile ducts, and those in the proximal small bowel, is described.

A case of giant gallbladder is presented. A 36-yr-old female complaining of colicky pain and a mass in the right upper quadrant underwent cholecystectomy, when the giant gallbladder, 18cm in length and 4cm in maximum diameter, and an extremely long cystic duct was confirmed. Since neither marked biliary inflammation nor biliary obstruction was observed, this giant gallbladder is considered to be congenital.

Dysmenorrhea is one of the most common gynecologic complaints of young women, affecting approximately half of menstruating females. Although most patients have primary dysmenorrhea, which although creating much discomfort does not lead to significant physical problems, it is very important to rule out secondary dysmenorrhea to prevent problems with health and fertility. Primary dysmenorrhea is seen only in ovulatory cycles, usually developing within 6 to 12 months of menarche and is characterized by lower midabdominal colicky pain that may radiate to the back and upper thighs. The pain of primary dysmenorrhea starts with the onset of menstrual flow or a few hours following onset and may last for a few hours up to 2 days. The pain of secondary dysmenorrhea usually begins several days before the start of menstrual flow and may be present during much of the menstrual cycle. Pain that occurs with the first menses or after the age of 25 or is associated with anovulatory cycles is more likely to be secondary dysmenorrhea.

Abstract: Impaired gallbladder motility plays an important role in the pathogenesis of benign gallbladder disorders. Defective gallbladder muscle contraction is associated with supersaturated bile with cholesterol and with pregnancy due to high circulating levels of progesterone. These abnormalities result in bile stasis that facilitates gallstone growth. A defective gallbladder muscle contraction may also contribute to the pathogenesis of acute and chronic cholecystitis. In addition, an impaired gallbladder contraction may be the source of recurrent biliary colicky pain in patients with acalculus gallbladder disease. The gallbladders of these patients have an abnormal ejection fraction of less than 35% in response to an intravenous infusion of cholecystokinin (CCK). Although histology of the gallbladder wall is grossly normal, the muscle cells are functionally abnormal, with an impaired response to agonists that act on membrane and cytosolic receptors.

POSTCHOLECYSTECTOMY colic, or biliary dyskinesia, is a poorly defined syndrome which tends to occur in nervous and hypersensitive persons and which can be diagnosed only by the exclusion of organic disease. The cause of the dyskinesia has not been established, but it is supposed by some that spasm of the sphincter of Oddi plays a part in the production of the symptoms.1Biliary dyskinesia may cause symptoms indistinguishable from biliary colic due to a calculus. The patient complains of intermittent attacks of colicky pain in the right upper quadrant and epigastrium which may radiate to the scapula and to the right shoulder. Nausea and vomiting frequently are associated with the attacks. Chills, fever and jaundice do not ordinarily occur.The possibility of somatic pain as well as stone in the stump of the cystic duct, stone in the common duct, and disease of adjoining viscera (such as duodenal ulcer,

A BENIGN single polypus is rarely found in the stomach of a child. In the case to be reported the polypus was in a position where it could prolapse through the pylorus into the duodenum and cause obstructive symptoms. In addition, on microscopic examination it was found that this polypus contained aberrant pancreatic tissue. REPORT OF CASE In November 1945 a 6 year old white boy was brought to the Mayo Clinic. He had had intermittent umbilical pain for three years and intermittent spells of nausea and vomiting during most of his life.During the first three months of life this child had symptoms of vomiting after each feeding until atropine was administered, relieving the spasm. At the age of 6 months roentgenologic examination showed a retarded gastric emptying time. From this time, 1940 to 1943, the child experienced only intermittent spells of mild colicky pain around the umbilicus, usually

A case is presented of a residual common duct stone removed by chloroform instillation and biliary flush, with a discussion of the problem and the report of an unexpected reaction. REPORT OF A CASE A 25-year-old white housewife had had two episodes of right upper quadrant abdominal pain with radiation to the right posterior lumbar area during the past two years. The condition was diagnosed as gallbladder infection and was relieved each time with meperidine (Demerol) and penicillin injections.Five weeks before admission she had colicky pain in the right subscapular area. Three weeks later, she was slightly jaundiced, and x-rays showed a nonfunctioning gallbladder. Pain radiated to the right upper quadrant of the abdomen and persisted in the back. Occurrence of this pain was unrelated to intake of fatty foods.Eight days before admission she had icteric sclerae and dark urine. Six days later the stools became clay-colored. Although

Lymphangioma has been called the rarest of tumors found in the retroperitoneal region. Only isolated case reports of cavernous or cystic retroperitoneal lymphangiomas have been seen.1-4,7-13,15,17-21 I am reporting two cases of retroperitoneal cystic lymphangioma because of the rarity of the lesion. A review of the literature of all previously recorded cases of retroperitoneal lymphangioma has been added to acquaint the general surgeon, urologist, and gynecologist with the clinical findings of this condition. REPORT OF CASES CASE 1. —A 17-year-old sheet-metal worker entered Mount Carmel Hospital on July 10, 1955, complaining of nausea, vomiting, and generalized abdominal pain of 14 hours' duration. The colicky pain increased with activity and defecation. The past history was negative.Physical examination disclosed a well-developed. well-nourished youth who appeared acutely ill. The temperature was 100.2 F, pulse 92, B. P. 114/80, and respirations 24. Physical examination was essentially normal except for muscle spasm throughout

PARATHYROID adenoma rarely occurs in children. Ony two cases were reported from this institution during the period 1930 to 1960.1,2 However, within the past year, three cases have been seen. This report describes these, with special emphasis on one case in which there were unusual joint findings (case 1). REPORT OF CASES Case 1.—A 13½-year-old boy, admitted to the Mayo Clinic in May 1965, had been in good health until 3½ years previously when he experienced the sudden onset of colicky pain in the left lower quadrant of the abdomen. No medical advice had been sought at that time. He was said to have had a urinary tract infection (on the basis of frequency) one year prior to admission; these symptoms had subsided after one week of treatment. Three months before admission the attacks of abdominal pain had become more frequent, with hematuria developing one month later. Subsequently, a

BLEEDING into the biliary tree, or hemobilia, is an unusual source of gastrointestinal hemorrhage. A large majority of these cases are posttraumatic, as in handlebar injuries, with about half occurring in children and teenagers.1 Up to two months after such injury, a triad of jaundice, melena, and colicky pain should lead to the diagnosis and cure. A tremendous amount of blood can enter the gastrointestinal tract from the liver via the common bile duct. Hemobilia may also follow several diseases of the biliary tract or liver such as cholelithiasis, aneurysms of the right hepatic artery, hepatic necrosis due to infection or toxins, erosion or rupture of malignant tumors or hemangiomata, and hepatic apoplexy following occlusion of the hepatic artery.2 The feature common to all is injury to a portion of the liver or biliary tree intimately associated with its blood supply.One rare cause is hepatic necrosis associated

It is the purpose of this paper to present in greater detail a report of the effectiveness of demerol, a new synthetic analgesic, for the control of postoperative pain and restlessness. A complete discussion1 of the properties of the drug, including its effectiveness, safety and potency in the treatment of a large variety of conditions, has already been presented by one of us (R. C. B.).Demerol2 (1-methyl-4-phenyl-piperidine-4-carboxylic acid ethyl ester hydrochloride) was introduced by Eisleb and Schaumann3 in 1939 and was almost immediately acclaimed by numerous investigators4 as a potent and safe analgesic approaching morphine in effectiveness. Its advantages, especially its antispasmodic properties, soon became apparent. Thus the atropine-like effect combined with sedative action makes it an ideal drug for the treatment of severe colicky pain. With exception of rare hypersensitive persons, demerol may be used without contraindication in patients with severe anemia, disease of

Patients with pancreatitis, in particular with chronic relapsing pancreatitis have recently been experienced by the authors, in which chlorophyll-a intravenously administered showed a marked therapeutic effect. Both fever and abdominal colicky pain were relieved shortly, and remarkably high levels of amylase activity in their urine returned to normal, after administration.

The article describes the case of three patients who developed intestinal haematoma during treatment with warfarin. One patient is a 67-year-old woman who presented with acute abdominal pain and a history of epigastric discomfort. Another patient, a 70-year-old man, was hospitalised with a acute colicky pain, haematemesis and melena.

Introduction and Importance: Ventriculoperitoneal shunt (VPS) is the most common procedure performed on children with hydrocephalus. Migration of VPS outside the peritoneal cavity is rare, especially fallopian tube migration with vaginal extrusion without organ perforation. Presentation of Case: A 3-year-old girl came to the hospital with the main complaint of having a white tube exposed from her vagina 4 days before admission. A history of frequent clear watery discharge from the vagina since one week before the admission alongside intermittent pain in the suprapubic area was obtained from the parents. A laparotomy was conducted on the patient. We found the distal shunt catheter had adhered to the omentum and it appeared that the catheter tube entered the right fallopian tube before it went into the uterus and out to the vagina. We replaced the distal catheter with a new one. The patient came home on the fourth day of the post-surgery in a good condition. Clinical Discussion: The etiology of distal shunt catheter migration into the vagina remains unclear. Our patient is the third documented case of fallopian tube migration with vaginal extrusion without organ perforation, suspected due to postsurgical adhesions to the fallopian tube. An evaluation of vaginal discharge associated with abdominal pain is an important clue for distal migration of the VPS to the vagina. Conclusion: The migration of catheter to the vagina should be considered of profuse watery discharge from vagina alongside intermittent abdominal colicky pain. The surgical goal is to re-establish a new VP shunt system.

A patient admitted with abdominal pain requires careful questioning, a thorough examination, and indicated laboratory tests. All surgeons are familiar with the patient who is admitted with postprandial upper abdominal colicky pain, some degree of fatty food intolerance, nausea, and flatulence, but whose oral cholecystogram is "within normal limits." It is becoming increasingly apparent that the symptoms described above may be associated with motor dysfunction of the gallbladder, originally termed "biliary dyskinesia" by Westphal in 1923.In the early years of this century, prior to the advent of oral cholecystography, the gallbladder was removed in many patients who had the "classical" symptoms of upper abdominal colicky pain associated with fatty food intolerance, flatulence, and occasional nausea. Additional factors, such as constipation, headache, or being female, fat, and fertile, simply made cholecystectomy more urgent. Many of these patients had an abnormal gallbladder; the majority were helped by cholecystectomy; some continued to

During a 10-year period 2610 patients were operated on for biliary lithiasis; in 225 (8·6 per cent) cases the operation concluded with a choledochoduodenostomy. The commonest preoperative diagnosis (62·2 per cent) in these 225 patients was choledocholithiasis; 30 patients had previously had a cholecystectomy. After choledochoduodenostomy, 4·0 per cent of patients had an intra-abdominal complication; six patients developed an intra-abdominal abscess and three developed an external biliary fistula. Four patients (1·8 per cent) died, three from pulmonary complications and one from a biliary fistula. After a mean follow-up period of 4·6 years, 71·5 per cent of patients were asymptomatic. The remainder suffered from dyspepsia (15·1 per cent), colicky pain (8·7 per cent) or episodes of cholangitis (4·7 per cent). Endoscopy in the symptomatic patients allowed the following conclusions: (a) no patient with dyspepsia had a problem at the anastomosis; (b) 27 per cent of those with colic had anastomotic stenosis or the sump syndrome; and (c) all patients with cholangitis had anastomotic stenosis and residual calculi.

Over a 10-year period, 2610 patients underwent operation for biliary lithiasis. Exploratory choledochotomy was indicated in 591 patients (22·6 per cent). This was followed by simple choledochorrhaphy over a T tube in 240 patients (40·6 per cent), transduodenal sphincterotomy and choledochorrhaphy over a T tube in 126 (21·3 per cent), supraduodenal choledochoduodenostomy in 216 (36·5 per cent), and choledochoduodenostomy and transduodenal sphincterotomy in nine (1·5 per cent). Choledochoduodenostomy was performed if the bile duct was more than 12 mm in diameter. The indication for transduodenal sphincterotomy was the presence of a stone impacted in the papilla and/or papillary stenosis. Six patients developed abdominal abscess and three an external biliary fistula following choledochoduodenostomy. There were four abscesses and two episodes of acute pancreatitis in patients undergoing sphincterotomy. There was no difference in mortality rate between the two groups. After a mean follow-up of 5·6 years, 71·5 per cent of patients who underwent choledochoduodenostomy and 75·2 per cent of those who received transduodenal sphincterotomy were asymptomatic. The remainder suffered from dyspepsia, colicky pain or episodes of cholangitis. Nine patients underwent reoperation for residual calculi (six choledochoduodenostomies, three sphincterotomies).

Summary.: Haemobilia is defined as bleeding into the hepatoboliary system caused by a pathologic connection between blood vessels and biliary ducts. A rare cause of haemobilia is gallstone disease, with only 52 reported cases in the literature. The haemobilia is characterised by the classical triad: jaundice, colicky pain in the right upper quadrant and signs of gastrointestinal bleeding. Diagnosis can be made with endoscopic procedures and with angiography of the coeliac trunk, which has the highest sensitivity in localisation of bleeding source. The therapy of choice is cholecystectomy. We report the case of a patient with a massive gastrointestinal haemorrhage caused by a solitary gallstone and present the diagnostic and therapeutic management of this disease, which is accompanied by a high mortality.

Abstract: Peptic ulcer disease, lower abdominal colicky pain, increasing diarrhea, and ulcers of the colon and rectum developed in a patient more than one year after he had an extensive resection of the small bowel. Parenteral adinistration of cimetidine, with blood levels of 2.00 mg/ml, caused resolution of the colonic ulcerations and other symptoms, after orally administered cimetidine had failed to produce a measurable blood concentration level.

Mrs. F. B., aged 45, married and the mother of two children, admitted to St. Elizabeth Hospital, July 23, 1933, had three days previously had a sudden onset of colicky pain in the epigastrium, which localized in the right lower quadrant within twenty-four hours. Simultaneously with the onset of pain she vomited repeatedly and felt as if she had a fever. After three days of ineffectual self medication, a physician was called, who advised immediate removal to the hospital.Her previous history was essentially negative with the exception of an attack of scarlet fever in infancy and a fracture of the right seventh rib due to an automobile accident in January 1933. The family history revealed that one sister had died of pulmonary tuberculosis.On admission her temperature was 100 F., pulse 104 and respiration rate 28. There was marked rigidity of the right abdominal muscles with pronounced tenderness at

Twenty-two cases of internal biliary fistula observed between the years 1944 and 1961 are reviewed. Two were artificial fistulas. Of the 20 spontaneous fistulas, only 3 were diagnosed before operation. The signs and symptoms suggest cholecystitis. Recurring colicky pain suddenly relieved or recurrent symptoms of cholecystitis followed by diarrhea, lower abdominal pain, vomiting, and fever should suggest spontaneous internal biliary fistula. The most important roentgenographic finding is air in the biliary tree. This, with intestinal obstruction and a stone shadow in the abdomen, makes the diagnosis certain. Much depends on careful interpretation of roentgenograms and on the alertness of the diagnostician for this particular condition.