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Background/objectives: Debilitating abdominal pain is a common symptom affecting patients with chronic pancreatitis (CP). CP pain is dynamic due to multiple underlying mechanisms. The objective of this study was to 1) evaluate changes in pain phenotype at one year follow-up and 2) validate putative pain biomarkers in a prospective cohort study., Methods: The Neuropathic and Nociceptive PROMIS-PQ questionnaires were used to classify pain for participants with in the PROCEED study. Putative serum biomarkers were measured via immunoassay., Results: At enrollment, 17.6 % (120/681) subjects with CP reported no pain in the previous year. Of those, 29 % experienced pain during the 1 yr follow-up whereas 18 % of those with pain prior to enrollment reported no pain during the 1 yr follow-up period. Of the 393 subjects with PROMIS-PQ data at enrollment, 212 also had follow-up data at 1 yr. Approximately half (53.3 %) of those individuals changed pain phenotype between baseline and follow-up. At 1 yr, serum TGFβ1 level was negatively correlated with nociceptive T-scores (p = 0.006). GP130 was significantly correlated with both nociceptive (p = 0.012) and neuropathic T-scores (p = 0.043) at 1 yr, which is consistent with the previously published findings., Conclusions: The positive association between TGFβ1 and pain is not maintained over time, suggesting it is a poor pain biomarker. However, serum GP130 is a consistent biomarker for mixed-type pain in CP. Preclinical studies show that targeting TGFβ1 or IL-6 (ligand for GP130) is sufficient to inhibit CP pain supporting further investigation of this as a potential therapeutic target., Competing Interests: Declaration of competing interest The co-authors have no conflicts of interest to disclose., (Copyright © 2024 IAP and EPC. All rights reserved.)

Centrally mediated abdominal pain syndrome (CAPS) has generated a heavy disease burden worldwide. This study aimed to explore the serum exosomal microRNAs (miRNAs) as potential diagnostic biomarkers for CAPS. From September 2022 to October 2023, 97 patients with CAPS and 96 healthy subjects were enrolled. Differentially expressed serum exosomal miRNAs between patients with CAPS and healthy controls were identified by high-throughput sequencing and quantitative real-time polymerase chain reaction. The receiver operating characteristic curves and multivariate logistic regression analysis were used to evaluate the diagnostic value of the serum exosomal miRNAs. MiR-6850-5p, miR-194-5p, miR-199a-3p, and miR-4525 were significantly downregulated in serum exomes of CAPS patients compared with healthy controls, which yielded the area under curve (AUC) values of .914 (95% confidence interval (CI), .873-.954), .767 (95% CI, .695-.839), .617 (95% CI, .527-.708), and .561 (95% CI, .465-.656), respectively, to distinguish CAPS patients from healthy subjects. And AUC of the integration of the above 4 miRNAs was .931 (95% CI, .896-.966). Multivariate logistic regression indicated that hsa-miR-6850-5p (odds ratio (OR) = .046, P < .001), anxiety (OR = 7.670, P = .025), and depression (OR = 22.967, P = .008) were the independent predictors of CAPS. Serum exosomal miR-6850-5p is a promising diagnostic biomarker for CAPS. PERSPECTIVE: This study may be the first to explore serum exosomal miRNAs as new diagnostic biomarkers for CAPS, and the findings may help clinicians to access comprehensive understanding and accurate diagnosis of CAPS., (Copyright © 2024 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

Acute appendicitis (AA) is the first cause of emergency surgery. Leucine-Rich Alpha-2-Glycoprotein 1 (LRG1) has been shown to be a potential biomarker in cases of AA in children, but there are conflicting results for its use in adults. The objective of this study is to compare the median plasma values of LRG1 in patients with acute abdomen with and without appendicitis. This case-control study was conducted prospectively at the emergency room (ER) of a tertiary teaching hospital, between March 1st, 2011 and December 31st, 2012. Patients with recent abdominal pain, aged 18-70 years who attended at the ER were included in the study. Blood samples were drawn at the first presentation. Those who were submitted to surgery and had a pathology report of AA were considered as cases. Those without a need for surgery and treated for other conditions, e.g., pelvic inflammatory disease, were considered as controls. Follow-up in controls was made up to 30 days. LRG1 plasma median values were measured using an ELISA kit and compared between groups. A total of 28 participants, 14 cases with acute appendicitis and 14 controls, were included. The median (range) values of leucine-rich alpha-2-glycoprotein-1 level in the group with appendicitis and control group were 8.8 ng/ml (5.5-31) and 11 (4.6-108) ng/ml, respectively (Mann-Whitney test P = 0.26). Median plasma leucine-rich alpha-2-glycoprotein-1 levels were not useful in diagnosing Acute Appendicitis in patients with acute abdominal pain.

A 55-year-old male presented to our emergency department with haematuria and abdominal pain. Investigations including a computed tomography (CT) scan revealed an intraluminal filling defect within the left collecting system, consistent in appearance with blood clot. With an initial working diagnosis of upper tract urothelial cell carcinoma, he was discharged with plans for an urgent cystoscopy and ureteroscopy. He subsequently represented with ongoing frank haematuria, anasarca, dropping haemoglobin and new right collecting system blood clot. Subsequent investigations showed that the patient had acquired haemophilia A resulting in the episodes of haematuria, highlighted after an elevated activated partial thromboplastic time prompted a thrombophilia screen. The patient was subsequently treated with factor eight inhibitor bypass activity, corticosteroids and cyclophosphamide., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

This case aims to remind all providers to scrutinise for atypical presentations of multisystem inflammatory syndrome in children (MIS-C) which may mimic a more routine diagnosis. In the absence of mucocutaneous symptoms, the diagnosis of MIS-C can be missed. Given the potential for rapid deterioration of patients with MIS-C, early treatment and inpatient interventions are necessary., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction:  The aim of this study was to assess the diagnostic value of the biomarker fibrinogen (FB), along with the markers white blood cell (WBC) count, absolute neutrophil count (ANC), and C-reactive protein (CRP), to discriminate appendicitis from nonspecific abdominal pain (NSAP) in preschool children., Materials and Methods:  We prospectively evaluated all children aged <5 years admitted for suspected appendicitis at an academic pediatric emergency department during 5 years. Diagnostic accuracy of FB (prothrombin time-derived method), WBC, ANC, and CRP were assessed by the area under the curve (AUC) of the receiver-operating characteristic curve., Results:  A total of 82 patients were enrolled in the study (27 NSAP, 17 uncomplicated, and 38 complicated appendicitides). WBC and ANC had moderate diagnostic accuracy for appendicitis versus NSAP (WBC: AUC 0.66, ANC: AUC 0.67). CRP and FB had good diagnostic accuracy for appendicitis versus NSAP (CRP: AUC 0.78, FB: AUC 0.77). WBC and ANC are not useful to discriminate complicated versus uncomplicated appendicitis (WBC: AUC 0.43, ANC: AUC 0.45). CPR and FB had good diagnostic accuracy for complicated versus uncomplicated appendicitis (CRP: AUC 0.80, FB: AUC 0.73)., Conclusion:  CRP and FB are more useful than WBC and ANC to discriminate appendicitis from NSAP in preschool children. CRP and FB are especially useful to discriminate complicated from uncomplicated appendicitis and NSAP. In a child with suspected appendicitis, a plasma FB level (prothrombin time-derived method) >540 mg/dL is associated with an increased likelihood of complicated appendicitis., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To investigate the additional value of blood parameters (hemoglobin, C-reactive protein, erythrocyte sedimentation rate) to anti-tissue transglutaminase (anti-tTG), fecal calprotectin, and Giardia lamblia when discriminating a functional from an organic cause in the clinical evaluation of children with chronic abdominal pain., Study Design: This retrospective cohort study included patients (4-18 years of age) with abdominal pain for >2 months. Data on hemoglobin, C-reactive protein, erythrocyte sedimentation rate, anti-tTG, fecal calprotectin, alarm symptoms, and diagnosis were collected., Results: We identified 853 patients, of whom 102 (12%) had an organic disorder. Sensitivity and the area under the curve of strategy 1 (fecal calprotectin, anti-tTG, G lamblia, blood parameters) were 90% (95% CI, 83-95) and 0.87 (95% CI, 0.81-0.93), respectively, compared with 88% (95% CI, 81-93) and 0.85 (95% CI, 0.79-0.91), respectively, for strategy 2 (fecal calprotectin, anti-tTG, G lamblia) (P = NS). In the presence of ≥1 alarm symptoms, the sensitivity of strategies 1 and 2 was 92% (95% CI, 83-96) and 92% (95% CI, 83-96), and the areas under the curve were 0.93 (95% CI, 0.89-0.98) and 0.90 (95% CI, 0.84-0.97) (P = NS)., Conclusions: To distinguish between a functional and an organic cause for chronic abdominal pain, hemoglobin, C-reactive protein, and erythrocyte sedimentation rate can be left out from the clinical evaluation as they might have no additional diagnostic yield. However, caution should be taken not to miss extraintestinal infections (2%)., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: In 2016, in a lead poisoning outbreak in Iran, physicians reported thousands of opium users who presented to emergency departments (EDs) with intractable severe abdominal pain which did not respond to any narcotic medication. During the same period of time, we investigated the efficacy of intravenous calcium gluconate in alleviating lead-induced abdominal pain., Methods: In a single-center, single blinded, randomized controlled trial, a convenient sample of adult opium-addicted patients who presented to an academic ED with abdominal pain and had an initial diagnosis of lead poisoning were included and randomly subjected to two treatment groups receiving conventional treatment (morphine 0.1 mg/kg + normal saline; group 1) and conventional treatment plus 1 g of intravenous calcium gluconate (group 2) to alleviate their abdominal pain. The visual analogue scale (VAS) was determined by each patient (0 to 100 mm) before treatment, and 15, 30, and 60 min after intervention., Results: A total of 50 patients (25 in each group) were enrolled. Blood lead levels, VAS scores before treatment, and mean administered dose of morphine were similar between the two groups. After treatment, mean VAS score dropped to 64.7± 10.4 vs. 67.1± 10.9 at 15 min (P = 0.437), 64.6± 10.9 vs. 58.0 ± 11.2 at 30 min (P = 0.041), and 63.8± 10.7 vs. 53.6± 10.9 at 60 min (P = 0.002) in groups 1 and 2, respectively., Conclusion: Intravenous calcium gluconate administration along with morphine can improve abdominal pain in lead poisoning due to the ingestion of lead-contaminated opium. Further interventional studies are recommended to see if response to calcium salts in suspected lead-induced abdominal pain can rule in lead toxicity., Trial Registration: IRCT20171009036661N2. Registered 27 May 2018 - Retrospectively registered.

Background/aims: The objective of this study is to determine the role of circulating resolvin D1 (RvD1) in patients with constipation subtype of irritable bowel syndrome (IBS-C) and evaluate the relationship between abdominal pain severity and RvD1 levels., Materials and Methods: This research included 55 patients with IBS-C and 36 healthy controls. Controls were selected from patients who applied to our department with similar complaints as IBS but were not diagnosed with any type of pathology after further investigations. All participants underwent complete blood count, C-reactive protein (CRP), and RvD1 levels measurements. We also recorded abdominal pain severity and the number of bowel movements. Patients with IBS-C were compared with respect to the demographic features and laboratory measurements., Results: The median CRP concentration in patients with IBS-C was significantly higher than that of controls (p=0.003). However, the median RvD1 concentration was significantly lower in the IBS group than that of the control group (p<0.001). The receiver operating characteristic curve analyses revealed that RvD1 concentration lower than 0.47 ng/mL and CRP concentration higher than 3.40 mg/L may identify patients with IBS-C with a high specificity. In the IBS group, there was a strong negative correlation between abdominal pain severity and RvD1 concentration (r=-0.766, p=0.001)., Conclusion: This research demonstrates that patients with IBS-C have higher CRP and lower RvD1 concentrations than healthy controls. Both RvD1 and CRP concentrations predict the presence of IBS-C. Additionally, RvD1 concentrations decreased with the increase in abdominal pain severity. Further research works are needed for investigating the role of the RvD1 analogs in the treatment of IBS.

Hb Dompierre [β29(B11)Gly→Arg, HBB : c.88G>C] is a rare β-globin gene variant that was previously described in the heterozygous state in a 24-year-old female patient. It is defined in the HbVar database as being clinically and biologically asymptomatic. A few years after the first description, we had an opportunity of reassessing the index case because she presented with splenomegaly and clinical and biological manifestations of hemolysis. After ruling out the most common causes of hemolysis, further analyses on the variant hemoglobin (Hb) using brilliant cresyl blue staining, indicated that it showed mild instability, which may explain the clinical and biological manifestations. A structural bioinformatic analysis on the Hb variant suggested that the amino acid replacement may be deleterious to the integrity of the Hb. This report confirms the importance of completely characterizing all new Hb variants in order to guide the patients' clinical management and follow-up, as well as to provide the probands and their family members with appropriate genetic counseling.

Background: Chest pain associated with transient electrocardiogram changes mimicking an acute myocardial infarction have been described in acute pancreatitis. These ischemic electrocardiogram changes can present a diagnostic dilemma, especially when patients present with concurrent angina pectoris and epigastric pain warranting noninvasive or invasive imaging studies., Case Presentation: A 45-year-old African-American man with a history of alcohol use disorder presented to the emergency department of our institution with 36 hours of concurrent epigastric pain and left-sided chest pain radiating to his left arm and associated with nausea and dyspnea. On physical examination, he was afebrile; his blood pressure was elevated; and he had epigastric tenderness. His laboratory test results were significant for hypokalemia, normal troponin, and elevated serum lipase and amylase levels. Serial electrocardiograms for persistent chest pain showed ST-segment elevations with dynamic T-wave changes in the right precordial electrocardiogram leads, consistent with Wellens syndrome. He was immediately taken to the cardiac catheterization laboratory, where selective coronary angiography showed normal coronary arteries with an anomalous origin of the right coronary artery from the opposite sinus. Given his elevated lipase and amylase levels, the patient was treated for acute alcohol-induced pancreatitis with intravenous fluids and pain control. His chest pain and ischemic electrocardiogram changes resolved within 24 hours of admission, and coronary computed tomography angiography showed an interarterial course of the right coronary artery without high-risk features., Conclusions: Clinicians may consider deferring immediate cardiac catheterization and attribute electrocardiogram changes to acute pancreatitis in patients presenting with angina pectoris and acute pancreatitis if confirmed by normal cardiac enzymes and elevated levels of lipase and amylase. However, when clinical signs and electrocardiogram findings are highly suggestive of myocardial ischemia/injury, immediate noninvasive coronary computed tomography angiography may be the best approach to make an early diagnosis.

Purpose: The purpose of this study was to compare the diagnostic accuracy and inter-reader agreement of unenhanced computed tomography (CT) to those of contrast-enhanced CT for triage of patients older than 75years admitted to emergency department (ED) with acute abdominal pain (AAP)., Patients and Methods: Two hundred and eight consecutive patients presenting with AAP to the ED who underwent CT with unenhanced and contrast-enhanced images were retrospectively included. There were 90 men and 118 women with a mean age of 85.4±4.9 (SD) (range: 75-101.4years). Three readers reviewed unenhanced CT images first, and then unenhanced and contrast-enhanced CT images as a single set. Diagnostic accuracy was compared to the standard of reference defined as the final diagnosis obtained after complete clinico-biological and radiological evaluation. Correctness of the working diagnosis proposed by the ED physician was evaluated. Intra- and inter-reader agreements were calculated using the kappa test and interclass correlation. Subgroup analyses were performed for patients requiring only conservative management and for those requiring intervention., Results: Diagnostic accuracy ranged from 64% (95% CI: 62-66%) to 68% (95% CI: 66-70%) for unenhanced CT, and from 68% (95% CI: 66-70%) to 71% (95% CI: 69-73%) for both unenhanced and contrast-enhanced CT. Contrast-enhanced CT did not significantly improve the diagnostic accuracy (P=0.973-0.979). CT corrected the working diagnosis proposed by the ED physician in 59.1% (range: 58.1-60.0%) and 61.2% (range: 57.6-65.5%) of patients before and after contrast injection (P>0.05). Intra-observer agreement was moderate to substantial (k=0.513-0.711). Inter-reader agreement was substantial for unenhanced (kappa=0.745-0.789) and combined unenhanced and contrast-enhanced CT (kappa=0.745-0.799). Results were similar in subgroup analyses., Conclusion: Unenhanced CT alone is accurate and associated with high degrees of inter-reader agreement for clinical triage of patients older than 75years with AAP in the emergency setting., (Copyright © 2019 Société française de radiologie. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Previous studies have shown single CRP measurements at time of presentation to have limited predictive benefit for appendicitis. Our objective was to determine the diagnostic utility of serial CRP measurements (to determine CRP velocity [CRPv]) in patients with right iliac fossa (RIF) pain., Methods: A single-centre prospective observational study was conducted on adult patients admitted with RIF pain. CRP was measured on admission, at midnight, and the following morning. Appendicitis was diagnosed on histopathology, or diagnostic imaging in non-operatively managed patients. Therapeutic interventions included all appropriate operative procedures and effective non-operative treatment with antibiotics. Logistic regression was used to generate predictors of therapeutic intervention, and then used to create a new risk score incorporating CRPv., Results: 98 of 112 (87.5%) participants had complete CRP data. 58 patients met the criteria for appendicitis (59.2%). Most patients presented with intermediate Modified Alvarado Scores (MAS) 5-6 (40.8%) or Appendicitis Inflammatory Response Scores (AIRS) 5-8 (49%). Our risk score had an AUROC of 0.88 (95% CI 0.81-0.96) in predicting therapeutic intervention. This score was superior to MAS, AIRS, and single admission biomarker measurements. Patients with an increasing CRPv had 14 times the odds (OR 14.07, 95% CI 0.63-315.2) of complicated appendicitis, and no cases of complicated appendicitis were observed in patients with a flat CRPv., Conclusions: CRP velocity is superior to single CRP at predicting intervention. Our v-Score shows promise as a decision making-aide by predicting the need for surgical intervention in RIF pain. A flat CRPv identifies a group of patients with a very low risk of complicated appendicitis., (Copyright © 2018 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. All rights reserved.)

Objective: To compare the effects of two different intraoperative CO 2 pressures (8 and 15 mmHg) during laparoscopic hysterectomy for benign uterine pathologies in terms of postoperative abdominal and shoulder pain, laparoscopy-mediated vegetative alterations, pain medication requirement, arterial CO 2 pressure (pCO 2 ), surgical parameters, and safety., Design: Prospective randomised controlled study., Setting: German university hospital., Population: Female patients undergoing laparoscopic hysterectomy for benign uterine pathologies., Methods: Patients were randomised to a standard pressure (SP; 15 mmHg, control) or low-pressure (LP; 8 mmHg, experimental) group., Main Outcome Measures: Primary outcomes were postoperative abdominal and shoulder pain intensities, measured via numeric rating scale (NRS) and vegetative parameters (fatigue, nausea, vomiting, bloating) at 3, 24, and 48 hours postoperatively. Secondary outcomes were pain medication requirement (mg) and arterial pCO 2 (mmHg). Surgical parameters and intra- and postoperative complications were also recorded., Results: In total, 178 patients were included. Patients in the LP group (n = 91) showed significantly lower postoperative abdominal and shoulder pain scores, fewer vegetative alterations, lower pain medication requirements, a shorter postoperative hospitalization, and lower intra- and postoperative arterial pCO 2 values compared with the SP group (n = 87; P ≤ 0.01). No differences in intra- and postoperative complications were observed between groups., Conclusions: Low-pressure laparoscopy seems to be an effective and safe technique for the reduction of postoperative pain and laparoscopy-induced metabolic and vegetative alterations following laparoscopic hysterectomy for benign indications., Tweetable Abstract: Low-pressure laparoscopy seems to be an effective and safe technique for reduction of pain following laparoscopic hysterectomy., (© 2019 Royal College of Obstetricians and Gynaecologists.)

Serum lipase and amylase are commonly requested in individuals presenting with abdominal pain for investigation of acute pancreatitis. Pancreatic hyperenzymaemia is not specific for acute pancreatitis, occurring in many other pancreatic and non-pancreatic conditions. Where persistent elevation of serum lipase and amylase occurs in the absence of a diagnosed cause or evidence of laboratory assay interference, ongoing radiological assessment for pancreatic disease is required for 24 months before a diagnosis of benign pancreatic hyperenzymaemia can be made. We report a case of a 71-year-old man with epigastric pain and elevated serum lipase levels. He was extensively investigated, but no pancreatic disease was detected. He is asymptomatic, but serum lipase levels remain elevated 18 months after his initial presentation., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Opioids are commonly required for abdominal pain in hospitalized patients with acute pancreatitis (AP). The factors associated with increased opioid requirements are unknown., Methods: The medical records of adult inpatients with AP from 2006 to 2016 were reviewed. Patients with chronic pancreatitis, psychiatric comorbidities, intubation, chronic opioid, and illicit drug use were excluded. The total quantity of opioids required during the first 7 days of hospitalization was converted to oral morphine equivalents (OME), divided by the number of days opioids were required to obtain the mean OME per day(s) of treatment (MOME). Multiple regression analysis was performed to identify factors associated with MOME., Results: A total of 267 patients were included. The mean (standard deviation) age was 46.9 (13.9) years and 56% were males. The most common etiology was alcohol (55.4%). The mean (standard deviation) MOME was 59.1 (54.5) mg. Although age (P = 0.008), black race (P = 0.004), and first episode of AP (P = 0.049) were associated with a lower MOME, early hemoconcentration (hematocrit ≥44%) (P < 0.001) was associated with an increased MOME., Conclusions: Early hemoconcentration is associated with an increased opioid requirement in hospitalized patients with AP. The impact of fluid therapy in these patients merits prospective study.

Abdominal wall pain (AWP) is a common and underrecognized cause of chronic abdominal pain. The etiology of AWP varies. History and physical examination are critical to an accurate diagnosis of AWP. Trigger point injection using either a corticosteroid, a local anesthetic, or a combination of both often gives relief of pain and is of diagnostic and therapeutic value. Increased awareness of AWP as a cause of chronic, nonvisceral abdominal pain can prevent fruitless searches for intra-abdominal pathology and reduce medical costs., (Copyright © 2018 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background: Serum lactate is frequently tested in the emergency department (ED) setting to diagnose visceral ischemia and as a marker of end-organ perfusion. It is highly nonspecific, and levels can be affected by both kidney and liver function. In this retrospective chart review, we aim to demonstrate that serum lactate is overused in the ED setting and predicts resource utilization but not the need for surgical intervention., Methods: ED records with a chief complaint of "abdominal pain" were queried for the preceding 12 mo. We excluded pregnant patients, patients aged less than 18 years, and patients for whom a blood count and chemistry were not obtained. Vital signs, laboratory values, resource utilization, and outcome of the visit were obtained. Logistic regression models were developed to correct for confounding associations., Results: A total of 1003 records were obtained initially with 753 patients (75%) included in the study. Serum lactate was drawn in 118 patients (15%) and was elevated in 19 patients (16% of those drawn). Utilization of computed tomography imaging was associated with lactate utilization (P < 0.001). Patients in whom lactate was drawn were more likely to have a general surgery consult (51% versus 34%, P < 0.001) and to be admitted to the hospital (P < 0.001)., Conclusions: The use of serum lactate in the workup of patients with abdominal pain should be targeted at patients who have signs of sepsis and based on the index of suspicion for specific disease processes such as mesenteric ischemia., (Published by Elsevier Inc.)

Abdominal pain is one of the key symptoms of irritable bowel syndrome (IBS). Studies have indicated an increase in the incidence of IBS in Asia. However, yet the pathophysiology of this disease remains unknown. Women are more likely to develop the condition than men, especially the constipation-predominant type. Essential fatty acid (EFA) malnutrition is one of several theories discussing the mechanism of IBS.The authors hypothesized that significant EFA deficiency may cause abdominal pain in patients with IBS. However, because patterns in the oral intake of EFAs differ between cultures, the authors narrowed this study to examine the nutritional status of Asian female patients with IBSThe authors investigated Asian female patients with IBS and compared them with a group of healthy controls. Thirty patients with IBS and 39 healthy individuals were included in this study. The participants' age, height, weight, and waist size were recorded. The 24-item Hamilton Depression Rating Scale was documented. Both erythrocyte and plasma fatty acid content were analyzed through gas-liquid chromatography.The authors found that patients with IBS exhibited significantly higher scores for depression, higher proportions of plasma saturated fatty acids and monounsaturated fatty acids, and lower proportions of docosahexaenoic acid and total omega-3 polyunsaturated fatty acids in plasma are associated with IBS in Asian female patients. Further study is indicated to confirm the causality of this association.

We report a case of ileo-colonic Histoplasmosis without apparent respiratory involvement in a patient who had previously undergone an orthotopic liver transplant (OLT) for primary biliary cholangitis 15 years earlier. The recipient lived in the United Kingdom, a non-endemic region for Histoplasmosis. However, she had previously lived in rural southern Africa prior to her OLT. The patient presented with iron deficiency anaemia, diarrhoea, abdominal pain and progressive weight loss. She reported no previous foreign travel, however, it later became known that following her OLT she had been on holiday to rural southern Africa. On investigation, a mild granulomatous colitis primarily affecting the right colon was identified, that initially improved with mesalazine. Her symptoms worsened after 18 mo with progressive ulceration of her distal small bowel and right colon. Mycobacterial, Yersinia, cytomegalovirus and human immunodeficiency virus infections were excluded and the patient was treated with prednisolone for a working diagnosis of Crohn's disease. Despite some early symptom improvement following steroids, there was subsequent deterioration with the patient developing gram-negative sepsis and multi-organ failure, leading to her death. Post-mortem examination revealed that her ileo-colonic inflammation was caused by Histoplasmosis., Competing Interests: Conflict-of-interest statement: No conflict of interests are declared by any authors.

We describe 2 patients with diabetes mellitus, presenting with upper abdominal pain. Although imaging findings were consistent with acute pancreatitis (AP), serum amylase and lipase levels were within normal limits. In both the cases, the only identifiable diagnostic culprit was vildagliptin. This is the first reported case of vildagliptin causing AP clinically and radiographically without elevated serum pancreatic enzymes. In conclusion, even when serum amylase and lipase levels are normal, AP should be kept in mind when making a differential diagnosis of patients with diabetes mellitus who present with abdominal pain and take dipeptidyl peptidase-4 (DPP-4) inhibitors.

A 23-year-old Japanese woman presented with abdominal distention following fever, diarrhea, and abdominal pain during a stay in Taiwan. Serology for the detection of amebic-antibodies and stool microscopic examination were both negative. A computed tomography scan showed a 13 cm diameter abscess spreading from the lower abdominal wall to the pelvic retroperitoneal space. Needle aspiration of the abscess was done under computed tomography guidance, and microscopy of the aspirated fluid revealed trophozoites of Entamoeba. The patient was diagnosed as amebiasis with negative serologic markers that caused intra-abdominal abscess. Intravenous metronidazole treatment for two weeks did not result in any improvement of the abscess. After irrigation and drainage of the abscess, her symptoms resolved. This case report highlights that amebiasis should be considered when indicated by patient history, including travelers returning from endemic areas, and that further evaluation is necessary for diagnosis, even if the serology and stool test are negative., (Copyright © 2017 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Background: The endocannabinoid system plays a substantial role in analgesia., Aim: To analyze N-arachidonoylethanolamine (AEA), N-oleoylethanolamine (OEA), linoleoyl ethanolamide (LEA), α-linoleoyl ethanolamine (α-LNEA), N-palmitoylethanolamine (PEA) and N-stearoyl ethanolamine (SEA) in two groups of patients having chronic pancreatic diseases., Patients and Methods: Twenty-six patients with chronic pancreatitis, 26 patients with pancreatic ductal adenocarcinoma and 36 healthy subjects were studied. The visual analogic scale (VAS) was used for assessing pain immediately before the venipuncture to obtain blood in all subjects. Six endocannabinoids were measured in serum of the patients enrolled., Results: Only OEA, LEA and PEA serum levels were significantly higher in patients with pain as compared to those without. Using the cutoff values, the sensitivity and specificity of the various endocannabinoids in evaluating pain in patients with chronic pancreatitis and in those with pancreatic ductal adenocarcinoma were: 44.2% and 95.6% for AEA, 83.7% and 73.3% for LEA, 88.4% and 91.1% for LNEA, 81.4% and 82.2% for OEA, 81.4% and 88.9% for PEA, 86.0% and 88.9% for SEA, respectively., Conclusion: Endocannabinoids are not useful in assessing pain in patients with chronic pancreatic diseases and they cannot replace a simple method such as VAS for assessing the pain and its intensity.

Background and Objective: The glucagon-like peptide-1 (GLP-1) analog, ROSE-010, plays a critical role in alleviating abdominal pain in patients with irritable bowel syndrome (IBS); however, the underling mechanism is unclear. In the present study, we determined the serum GLP-1 level in patients with constipation-predominant IBS (IBS-C). The relationship between GLP-1 and abdominal pain was investigated. In addition, the expression of the GLP-1 receptor in the colon was determined., Methods: Rectosigmoid biopsies were gathered from 38 patients with IBS-C who met the Rome III criteria, and 22 healthy controls. Abdominal pain was quantified by a validated questionnaire. Serum GLP-1 was measured by ELISA and correlated with abdominal pain scores. The presence of the GLP-1 receptor in the colonic mucosa was assessed by immunohistochemistry., Results: Serum GLP-1 was substantially decreased in patients with IBS-C. Decreased serum GLP-1 had a negative correlation with the abdominal pain scores. Biopsies from patients with IBS-C revealed a significant down-regulation of the GLP-1 receptor in colonic mucosa compared with control subjects., Conclusions: Decreased serum GLP-1 correlates with abdominal pain in patients with IBS-C. Decreased expression of GLP-1 and GLP-1 receptor may be the basis for alleviation of abdominal pain in patients with IBS-C by ROSE-010., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Zollinger-Ellison syndrome (ZES) results from an ectopic gastrin-secreting tumor leading to peptic ulcer disease, reflux, and chronic diarrhea. While early recognition portends an excellent prognosis with >80% survival at 15 years, symptoms are often nonspecific making the diagnosis difficult to establish. Diagnosis involves a series of tests, including fasting gastrin, gastric pH, chromogranin A, and secretin stimulation. Performing these tests in the correct sequence and at the proper time is essential to avoid inaccurate results. Tumor localization is equally nuanced. Although providers have classically used 111 indium-radiolabeled octreotide with somatostatin receptor scintigraphy to evaluate tumor size and metastases, recent studies have shown superior results with newer imaging modalities. In particular, 68 gallium ( 68 Ga)-labeled somatostatin radiotracers (i.e., 68 Ga-DOTATOC, 68 Ga-DOTANOC and 68 Ga-DOTATATE) used with positron emission tomography/computed tomography can provide excellent results. Endoscopic ultrasound is another useful modality, particularly in patients with ZES in the setting of multiple endocrine neoplasia type 1. This review aims to provide clinicians with an overview of ZES with a focus on both clinical presentation and the proper utilization of the various biochemical and imaging tests available.

Objective: To assess the diagnostic usefulness of leucine-rich alpha-2-glycoprotein-1 in female patients with acute abdominal pain on right lower-quadrant and acute appendicitis., Methods: The prospective, cross-sectional study was conducted at the emergency department of Kecioren Training and Research Hospital, Ankara, Turkey, during a two-month period in 2014, and comprised patients with acute abdominal pain in right lower-quadrant, and control subjects. Female patients aged 18-60 years who were admitted to the hospital's emergency department were included. The control group consisted of healthy females without acute or chronic diseases. Venous blood was obtained from all the subjects to measure leucine-rich alpha-2-glycoprotein-1., Results: Of the 160 participants, 80(50%) were patients and 80(50%) were control subjects. The mean value of leucine-rich alpha-2-glycoprotein-1 level in the patient and control groups were 6.78±2.21mg/ml and 6.59±2.37mg/ml, respectively (p>0.05). Among the cases, 32(40%) patients were diagnosed with acute appendicitis, whereas 48(60%) with non-acute appendicitis. The mean leucine-rich alpha-2-glycoprotein-1level was 6.96±2.76mg/ml in patients diagnosed with acute appendicitis, and 6.66±1.78mg/ml in those diagnosed with non-acute appendicitis (p>0.05)., Conclusions: Plasma leucine-rich alpha-2-glycoprotein-1 levels were not useful in diagnosing acute appendicitis in female patients with acute abdominal pain in right lower-quadrant.

Ayurveda is a traditional medicine native to India but is used in many parts of the world as an alternative or adjunct to standard medicine. Preparation can involve incorporation of heavy metals, including lead. We report the case of a 64-year-old man presenting with malaise, abdominal pain, anaemia and very high lead levels. He was found to be taking ayurvedic medicines to help his diabetic control. Analysis of the ayurvedic medications showed several with very high lead content. Following treatment with an oral chelating agent, the patient's symptoms and blood abnormalities resolved. This case highlights the need to be aware of potentially toxic alternative medications patients take and the efficacy of oral treatment choices in lead poisoning., (© 2017 Royal Australasian College of Physicians.)

We describe the case of a 55-year old women admitted at night to the emergency department (ED), complaining for acute abdominal pain lasting for nearly 5 hours. A first blood testing, performed immediately after admission, revealed mild anaemia. A second blood sample, drawn two hours after admission, revealed a considerable decrease of haemoglobin, haematocrit, total white blood cell and platelet counts (between 10-15% reduction). Abdominal ultrasonography was normal and the patient had no signs or symptoms of internal or external haemorrhage. Pre-analytical and analytical errors were accurately excluded. No infusion therapy was administered. After thoughtful discussing the sequence of events, it was ascertained that the first set of blood samples was drawn with the patient in seated position, immediately after ED admission ( i.e., approximately 1 min passed from standing to seated position before venipuncture), whereas the second set of blood samples was drawn with the patient lying for two hours in supine position. This case report highlights the importance of standardizing patient position before venous blood collection, along with the crucial role played by cooperation and communication between laboratory and clinical wards for identifying and troubleshooting potential causes of spurious results of in vitro diagnostic testing., Competing Interests: Potential conflict of interest: None declared.

Background: Elevated levels of circulating plasma and urine leucine-rich-2-glycoprotein-1 (LRG1) protein has been found in patients with acute appendicitis (AA) and may be useful for diagnosis. This study aimed to investigate whether combined tests including circulating LRG1 mRNA levels improve the early diagnosis of AA., Methods: Between December 2011 and October 2012, a prospective study was conducted on patients aged 18years or older presenting to the ED with acute abdominal pain (<7days of symptom onset). Levels of whole blood LRG1 mRNA and plasma LRG1 protein taken from these patients within 24h of arrival (mean 12.4h) were analyzed. The primary outcome was AA., Results: Eighty-four patients (40 (47.6%) with AA and 44 (52.4%) without AA; mean age 35years; 41.6% males) were recruited. Median whole blood LRG1 mRNA and plasma LRG1 levels were higher in AA patients than in non-AA. Of 40 AA patients, 13 (32.5%) were diagnosed as complicated AA. In ROC analysis of LRG1 mRNA (normalized to GAPDH), LRG1 protein and Alvarado score for discriminating AA and non-AA, the areas under the curve (AUC) were 0.723, 0.742 and 0.805 respectively. The AUC of combination of normalized LRG1 mRNA, LRG1 protein and Alvarado score was 0.845., Conclusion: A combination of modified whole blood LRG1 mRNA levels, plasma LRG1 protein and Alvarado score at the ED may be useful to diagnose simple and complicated AA from other causes of abdominal pain., (Copyright © 2017 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.)

Authors and clinicians advocate lipase as the preferred serological test for the diagnosis for acute pancreatitis. While acute pancreatitis is among the differential diagnosis for elevated lipase levels, several other causes of elevated lipase levels have been identified including several reports Salmonella species as a causative agent. There also have been retrospective studies that have reported clinical pancreatitis associated with Salmonella infection. These studies concluded that clinical pancreatitis should be considered as a complication of Salmonella infections. However, Salmonella infections may induce elevated pancreatic enzyme levels without clinical pancreatitis or morphological pancreatic abnormalities through a variety of proposed mechanisms. The following is a case that describes a patient who developed Salmonella colitis and demonstrated elevated serum lipase levels without clinical pancreatitis., (Published by Elsevier Inc.)

IgA vasculitis is primarily a pediatric disease that is rarely encountered in adults. With adults, gastrointestinal manifestations are quite common, yet are nonspecific and may overlap with other diseases, particularly Crohn's disease, which can make the diagnosis a challenging task. Treatment is controversial given the disease course is usually self-limited with few serious complications. We present a case of IgA vasculitis in an adult patient with limited extraintestinal findings illustrating the complexity of arriving at the correct diagnosis.

Background: Manual acupuncture (MA) manipulations are one of the key factors influencing acupuncture effects in traditional Chinese medicine theory. Different MA manipulations contain different stimulating parameters, thus generating different acupuncture responses or effects. Evidence has demonstrated that acupuncture is effective for functional dyspepsia (FD). However, the effects of different stimulating parameters of MA manipulations on FD remain unclear., Methods/design: This study is a randomized controlled trial with a four-arm, parallel-group structure. Patients with FD with epigastric pain syndrome (EPS) will be included and randomly allocated into four groups: three MA manipulation groups (separately treated with a frequency of 1 Hz, 2 Hz, or 3 Hz) and a control group. All groups will receive omeprazole as a basic treatment and acupuncture: in the MA manipulation groups, the needles will be manipulated manually with three different frequencies on the basis when de qi is reached, while in the control group, the needles will be inserted without any manipulation. All patients will receive acupuncture treatment of five consecutive sessions per week for 2 weeks and be followed up at 4, 8, and 12 weeks. The primary outcomes of the study include patients' response to the treatment. The secondary outcomes include dyspeptic symptoms, quality of life, mental status, fasting serum gastrin, motilin, and ghrelin concentrations, and adverse events. The protocol was approved by the Ethics committee of the First Affiliated Hospital of Zhejiang Chinese Medical University (2016-K-057-01)., Discussion: The aim of this study is to evaluate the efficacy and safety of MA manipulations with different stimulating parameters (different frequencies) on EPS in patients with FD., Trial Registration: Chinese Clinical Trial Registry, ChiCTR-IOR-16008189 . Registered on 30 March 2016.

Objectives: Carbohydrate intolerance or malabsorption has been suggested as a cause of chronic abdominal pain (CAP) in a subset of patients. We aimed to evaluate disaccharidase deficiencies in children with functional CAP and to correlate deficiencies with clinical features., Method: Patients presenting to the gastroenterology clinic at Children's Hospital of Wisconsin with abdominal pain prospectively completed a detailed demographic, history, and symptom questionnaire. The CAP cohort included those with at least 1 month of symptoms. Data on disaccharidase activity and histology of endoscopic biopsies were collected retrospectively. Only patients with normal histology were included in the study. The association between groups with low disaccharidases and clinical features was examined., Results: A total of 203 pediatric patients with CAP were included. The mean (SD) age was 11.5 (3.1) years, and 32.5% were male. The percentages of abnormally low disaccharidase levels using the standard laboratory cutoffs were lactase, 37%; sucrase, 21%; glucoamylase, 25%; and palatinase, 8%. Thirty-nine percent of the patients with low lactase also had low sucrase, and 67% of the patients with low sucrase had low lactase. There was no significant difference in the activities of any of the disaccharidases or sucrase/lactase ratio in relation to age. Also, no association was found between stool consistency, stool frequency, or location of pain and low disaccharidase activity., Conclusions: A large proportion of patients with CAP have deficiencies in disaccharidases. Bowel frequency, vomiting, or location of pain was no different between groups, suggesting that these clinical features cannot be used to predict disaccharidase deficiencies.

The aim of this study was to investigate the role of serum Interleukin-6 (IL-6) as a predictive value to make decision for surgical interventions when ovarian torsion (OT) is suspected. This study was performed on 284 women with lower abdominal pain. IL-6 levels were compared between OT (n = 67, 23.6%) and control groups (n = 217, 76.4%). For the purpose of diagnosis of OT, sensitivity and specificity of IL-6 at the cut-off point of 9.6 pg/ml were 41.79 and 82.49%, respectively. Patients with ovarian masses on ultrasound and IL-6 >9.6 pg/ml were found to be 24 times more likely to develop OT. Patients with serum IL-6 >9.6 pg/ml who lacked blood flow in ovarian Doppler ultrasound had 40.75 times higher risk of developing OT. It seems that simultaneous use of Doppler ultrasound and serum IL-6 levels can be helpful for early diagnosis of OT and making decision for surgical intervention.

Purpose: The study investigated the capability of clinical findings, temperature, C-reactive protein (CRP), and white blood cell (WBC) count to discern patients with acute colonic diverticulitis from all other patients admitted with acute abdominal pain., Methods: The probability of acute diverticulitis was assessed by the examining doctor, using a scale from 0 (zero probability) to 10 (100 % probability). Receiver operating characteristic (ROC) curves were used to assess the clinical diagnostic accuracy of acute colonic diverticulitis in patients admitted with acute abdominal pain., Results: Of 833 patients admitted with acute abdominal pain, 95 had acute colonic diverticulitis. ROC curve analysis gave an area under the ROC curve (AUC) of 0.95 (CI 0.92 to 0.97) for ages <65 years, AUC = 0.86 (CI 0.78 to 0.93) in older patients. Separate analysis showed an AUC = 0.83 (CI 0.80 to 0.86) of CRP alone. White blood cell count and temperature were almost useless to discriminate acute colonic diverticulitis from other types of acute abdominal pain, AUC = 0.59 (CI 0.53 to 0.65) for white blood cell count and AUC = 0.57 (0.50 to 0.63) for temperature, respectively., Conclusion: This prospective study demonstrates that standard clinical evaluation by non-specialist doctors based on history, physical examination, and initial blood tests on admission provides a high degree of diagnostic precision in patients with acute colonic diverticulitis., Competing Interests: Compliance with ethical standards The Regional Committee for Medical and Health Research Ethics (REC) gave permission for the study (2011/1782/REK midt). Only patients who gave written consent were included in the study. Conflict of interest The authors declare that they have no conflict of interest.