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The common predisposing clinical findings in volvulus of the gallbladder are reviewed briefly. One case is presented which is typical of former cases with the exception of complaint of upper abdominal pain of several weeks' duration immediately preceding the acute episode.

Background With the increasing number of dengue virus infections imported into Germany, knowledge about the different phases of the disease and possible complications is essential for the treatment of patients. The virus is endemic in the tropics and subtropics and up to 2.5 billion people are at risk of infection. Case presentation Here we present a German traveller with dengue shock syndrome after returning from Thailand. After hospitalization the patient developed acute upper abdominal pain. The ultrasound findings were consistent with an acute acalculous cholecystitis, but were interpreted as dengue associated gallbladder wall thickening (GBWT). Therefore a surgical intervention was not indicated and would have been associated with an higher risk of complications in this situation. Under supportive care spontaneous regression of GBWT could be documented by sonography four days later as well as complete resolution of clinical symptoms. Conclusion GBWT in dengue virus infection mimicking acute cholecystitis is a differential diagnosis one should take into consideration in travellers returning from endemic areas and should be managed conservatively because of an high risk of bleeding and increased mortality under surgical therapy.

PDA endarteritis is a rare complication in the modern era of widespread antibiotic use. Vegetations are often present on the pulmonary arterial side and embolize to the pulmonary circulation. A 24-year-old male from Mexico presented with left sided upper abdominal pain and a few weeks of fevers. He

A 23-year-old woman was referred for a gastroscopy. She had a long history of upper abdominal pain, pyrosis and postprandial fullness without a complete response to proton-pump-inhibitors. She didn’t relate any other relevant symptom or antecedent. Routine blood analysis revealed no abnormalities. The exam was made with a confocal endomicroscope (Pentax EPK-1000, ISC-1000). White light examination found a small flat orange mucosal islet in the cervical esophagus adjacent to the upper esophagic sphincter. It had a diameter of approximately 30mm and beside it there was a 2mm satellite islet. The rest of the exam was normal. The islets were explored with CE after intravenous injection of 5 mL fluoresceine as a contrast agent. It provided images of small glands with round luminal openings and polygonal epithelial cells with cobblestone appearance distinctive of gastric mucosa. Intestinal metaplasia was ruled out since no goblet cells were visualized. The regular architecture of glandular epithelium and the microvasculature as well as the absence of a strong fluoresceine leakage indicated a benign process (figure 1). Heterotopic gastric mucosa diagnosed by confocal endomicroscopy

Acute abdominal pain occurs frequently in patients with sickle cell anaemia (SCA), and presents a difficult diagnostic and management problem as the clinical presentation may mimic an acute surgical condition. Good clinical judgement and careful observation are necessary to avoid increased morbidity and mortality. Chronic recurrent upper abdominal pain is also a common problem and in many the cause is unknown. These patients usually respond to simple symptomatic therapy.

A housewife, aged 65, was admitted for investigation of fever and left upper abdominal pain. She had been well until four months previously when she developed a sore throat followed by persistent fever which occurred each day, especially in the evening. The symptoms became worse and she then developed aching in the shoulders and wrists without swelling, and pain in the left upper quadrant of theabdomen, worse on deep inspiration radiating to the left shoulder. She felt ill and had lost 10 kg in weight.

Most of the patients with mal-rotated gut present in neonate and infancy either with acute strangulating obstruction or with recurrent episodes of sub-acute obstruction. Here an adolescent male patient of 17 years with mal-rotated gut presented with upper abdominal pain, vomiting after meal and loss of weight mimicking gastric out let obstruction. Because of rarity of the condition at this age, we are inspired to report this case. doi: 10.3329/taj.v18i1.3307 TAJ 2005; 18(1): 53-54

A 37-year-old man was evaluated for a 6-month history of upper abdominal pain with weight loss. Physical examination revealed a palpable mass at the left lobe of the liver. There was no associated fever or chills. Laboratory data showed a mild elevation of serum ALT (117 U/l), direct bilirubin (1.8 mg/dl), and white blood cells (11.7 x 10/l). He underwent abdominal contrast-enhanced phase multidetector computed tomography and the axial and coronal

A 56-year-old female patient on verapamil for hypertension experienced two episodes of jaundice, pruritus and upper abdominal pain with transaminase elevated up to six-fold and alkaline phosphatase up to four-fold when inadvertently re-challenged with the drug. Liver biopsy showed marked cholestasis. Verapamil can occasionally cause mixed cytotoxic-cholestatic liver injury.

• The efficacy of bismuth subsalicylate in relieving the symptoms of indigestion was evaluated in a randomized, placebo-controlled, double-blind, cross-over study in 48 adults. Each patient was treated for six episodes of indigestion, three episodes with bismuth subsalicylate and three with placebo. Volunteers took 30 ml when the symptoms first occurred and repeated the dose every half hour, as needed, for eight doses. The volunteers rated the severity of each symptom 15 and 30 minutes after each dose. Overall relief was achieved faster and in a higher proportion of cases in bismuth subsalicylate-treated episodes than in placebo-treated episodes. Bismuth subsalicylate provided greater and faster relief than placebo for nausea, sense of fullness, heartburn, feeling of abdominal distention, and flatulence, but not for upper abdominal pain. (Arch Intern Med1984;144:269-272)

Torsion of the spleen about its pedicle is a rare condition in North America and Europe, comprising only 0.2% of splenectomies performed at the Mayo Clinic between 1904 and 1945 (Pugh, 1946). In underdeveloped nations the rate of occurrence is probably slightly higher due to the increased presence of splenomegaly secondary to malnutrition and malaria (Cross, 1974; Carswell, 1974). Although this event is seldom suspected preoperatively, a thorough radiographic evaluation may be useful. This report will describe an approach to the correct diagnosis employing barium studies, diagnostic ultrasound, nuclear medicine and angiography. By utilizing all of these procedures, a specific diagnosis may be possible. A 26-year-old white female was hospitalized for evaluation of severe left upper abdominal pain of one week's duration. The patient had a three-year history of mild intermittent abdominal pain, exacerbated by blunt trauma.

Ninety-two patients underwent a transduodenal sphincteroplasty and transampullary septectomy (extended papilloplasty) for chronic, incapacitating upper abdominal pain over an 11-year period. Seventy-nine had a prior cholecystectomy; 42 of 56 patients with reported pathology had documented gallstone disease. Serious morbidity included two moderately severe cases of postoperative pancreatitis and a pulmonary embolus. There were no deaths. Operative findings revealed stenosing papillitis (n = 45), transampullary septitis (n = 40), and papillary dysfunction (n = 7). Histologic examination of septal biopsy specimens revealed inflammation in 34 cases and fibrosis in 19 cases. There were no microscopic abnormalities in 39 biopsy specimens. The results at 1 to 10 years in 83 patients is as follows: good in 36 patients (no pain--43%), fair in 27 patients (occasional pain--33%), and poor in 20 patients (unrelieved by the procedure--24%). Patients with prior sphincteroplasty (12 of 15 with a fair to good result) benefitted the most from the procedure. Those who underwent concomitant cholecystectomy responded poorly. Risk factors for failure include alcoholism, drug addiction, mental illness, and duodenal ulcer disease. The finding of papillary cholesterolosis at operation also was accompanied by a less than optimal result. Transduodenal sphincteroplasty with transampullary septectomy provides long-term benefit to carefully selected patients with chronic abdominal pain after cholecystectomy.

Excerpt To the Editor:We report the case of a hemophiliac who presented with spontaneous hemobilia. A 45-year-old man was hospitalized for episodic upper abdominal pain. Severe hemophilia A had pre...

THE DIAGNOSIS of various phases of pancreatitis and their proper management have been long-recognized problems.1Little has been added to the description of the clinical features of the acute disease since that of Fitz in 1889.2These features are sufficiently characteristic in the acute and severe episodes of pancreatitis to generally permit reliable diagnosis. The less severe forms of the disease were, and are, frequently not recognized. Only since confirmatory laboratory tests have been readily available3has the frequency of pancreatitis become generally recognized. The severe forms of the disease as originally described by Fitz, and generally considered typical, are the fulminating episodes of pancreatitis. Less severe inflammatory reaction within the pancreas produces upper abdominal pain, various gastrointestinal symptoms, and no reliably detectable changes in the blood constituents or gastrointestinal secretions. The anatomical location of the gland, laboratory tests of function that indicate only extensive changes, and

A 40-year-old woman was admitted to Billings Hospital from the emergency room on July 3, 1954. Her chief complaint on admission was dyspnea of three weeks' duration. About one month prior to admission, she first noted upper abdominal pain that was rather sharp and that was accentuated by coughing or hiccuping. This pain became progressively worse. About two weeks prior to admission, she noted slight exertional dyspnea and, because of this, was hospitalized elsewhere. At that hospital electrocardiograms, gastric analyses, and roentgenograms of the chest, gallbladder, and gastrointestinal tract, all of which were normal according to the patient, were obtained. Her liver at that time was large and somewhat tender. Her dyspnea grew worse daily. She was told that this was probably caused by anxiety and that she should not consider it of any importance and was discharged. When she came to the emergency room, her dyspnea had progressed to

WHILE the frequency of strangulation in diaphragmatic hernias is not great, the complication is a fatal one demanding early surgical therapy. All physicians should be aware of this condition and consider it a possibility in any patient with lower thoracic or upper abdominal pain, the etiologic basis of which has not been clearly established. I wish to present my experience with four cases and in outline form summarize a group of cases 1 collected from the literature since the report of Carter and Giuseffi 2 in 1948. These authors presented in detail the clinical symptomatology and the physical and x-ray findings in strangulated diaphragmatic hernia, and these findings will be omitted from this presentation. REPORT OF CASES Case 1 (Mrs. L. B., Seaside Hospital). —This case has been previously reported in detail. 3 The patient was a 32-year-old white woman. On Feb. 25, 1949, seven hours after a normal delivery, she began

The acid perfusion test indicated an esophageal origin of symptoms limited to the abdomen in patients with mild degrees of inflammation who had no radiologic abnormality of the esophagus and in whom esophageal origin of symptoms would not have been otherwise recognized. The test may also delineate in which organ symptoms originate when more than one organ is involved. A positive response in a patient with symptoms but without endoscopic abnormality has been called pseudoesophagitis, suggesting that microscopic abnormalities may be present underlying the symptoms. Gastroduodenal ulcer does not, per se, give a positive test for esophagitis. In a group with negative responses, possible false-negative responses were present. It is in the interpretation of negative responses in a small percentage of cases that the fallibility of the clinical test lies. On the other hand, a positive response (whether it duplicates or is unrelated to the clinical complaints) gives helpful information.

When patients present symptoms of chronic pain referable to the right upper quadrant with acute exacerbations, one immediately thinks of a diseased biliary or genito-urinary tract and possibly a gastric or duodenal ulcer associated with chronic pancreatitis. If these are excluded, one's attention is directed to the cardiovascular or central nervous system or to diseases of the vertebral column; if after careful clinical and laboratory studies no cause can be found to account for the pain, the patient may be considered a psychoneurotic. Curtis 1 recently called attention to adhesions in the right upper quadrant as a sequela of a gonorrheal infection in females. He describes them as violin string or banded adhesions occurring between the anterior surface of the liver and the anterior abdominal wall. In the case I encountered in which the operation was performed before Curtis published his recent observations, the adhesions were between the liver and

STRANGULATION of a diaphragmatic hernia is sufficiently rare an occurrence to warrant reporting in the literature. It is important that this diagnosis be kept in mind in any case of obscure lower thoracic or upper abdominal pain because the history and clinical picture of strangulated diaphragmatic hernia make an almost classic entity. Early diagnosis is essential for adequate therapy, whereas procrastination spells disaster for the patient. Carter and Giuseffi1surveyed the literature in 1948 and collected 43 cases of strangulated diaphragmatic hernia. To these Pearson3later added 29 more from the literature and 4 of his own, to bring the total to 76 cases to date. As far as involvement of the stomach is concerned, we have been able to find six reports of gangrene of the stomach due to strangulated diaphragmatic hernia. Hamilton and Phillips2in 1949 treated two cases of their own and collected three

The abdominal complications of the epidemic of influenza in October, 1918, present problems of interest in diagnosis and treatment. The clinical pictures varied so greatly that a grouping of the cases will be of value. ABDOMINAL RIGIDITY AND TENDERNESS The question frequently arose as to whether the boardlike rigidity and tenderness of one or both upper quardrants of the abdomen was due to acute abdominal affection or to muscle spasm from lesions of the chest. Some of these cases were seen in the first twenty-four hours of the disease, before the physical signs of a pneumonia or of a pleurisy were sufficiently evident to make a positive diagnosis, all available methods, including the roentgen ray, being employed. The upper abdominal pain, with or without accompanying rigidity, which is seen in acute thoracic disease, has always been held to be reflex. Two cases of pneumonia following influenza showed at necropsy localized

THE DIFFERENTIAL diagnosis of the patient with vague upper abdominal pain apparently arising in the right upper quadrant includes the standard considerations such as cholecystitis, ulcer disease, and functional bowel distress. This last diagnosis was made in several of the patients whose cases are reported here and who later proved to have intermittent hydronephrosis caused by accessory renal vessels. Unless specific questions are put regarding the periodicity of the pain and its relationship to maintained positions of the body and/or the ingestion of large quantities of fluid, the correct diagnosis may not be suspected. When the diagnosis is considered and an excretory urogram is performed in the absence of the pain, the hydronephrosis may not be demonstrated.1,2The necessity of performing the urogram during an attack of pain is emphasized herein. The data on nine young adults with this syndrome observed during the past ten years at the University

Rupture of the spleen without apparent cause is a relatively unusual condition, only a few cases having been reported prior to this time. The following case is presented as a spontaneous rupture of the spleen; however, we feel that in this instance the predisposing conditions can be adequately explained. REPORT OF A CASE A 42-year-old white woman was admitted on the medical service of Vanderbilt University Hospital on March 15, 1954, seven hours after the sudden onset of severe left upper abdominal pain with associated tenderness. The pain was intermittent, was of gradually increasing intensity, and was described as cramping in character. There had been a similar episode of pain 10 days prior to admission, but this had subsided spontaneously after four or five hours. The patient's past history was not remarkable except for the fact that over a period of two and one-half years she had had repeated episodes

Excerpt Severe pain in the lower chest and upper abdomen is a symptom common to many affections involving several different systems of the body. Cardiovascular disease, respiratory disease, lesions...