Radiological manifestations of benign mesenteric lipoma that presented with acute intestinal obstruction: A case report

Background Intestinal obstruction is a common surgical emergency that is presented to the hospital with various aetiologies. Among all, mesenteric lipoma is one of the uncommon extraluminal causes of intestinal obstruction. In such conditions, bowel volvulus, compression or even adhesion are the underlying pathologies. Case presentation We report a 69-year-old gentleman who presented with a triad of intestinal obstruction which required exploratory laparotomy. Preoperative computed tomography revealed multiple coalescing lobulated hypoattenuating lesions encircling part of a small bowel forming transitional zone. These lesions are comparatively more hypoattenuating in comparison with the surrounding mesenteric fat. Intraoperatively, a giant ileal mesenteric lipoma was identified causing compression and folding to the adjacent small bowel, leading to proximal bowel dilatation. Excision of the lipoma with a few mesenteric lymphadenectomy was done, revealing a benign mesenteric lipoma and reactive lymph nodes. Despite ileus, he made a good postoperative recovery and was discharged well. Conclusions Patients with recurrent abdominal pain must have a thorough endoscopic and imaging assessment. Besides common or malignant aetiology, rarities should be considered and actively sought. Mesenteric lipoma is a relatively indolent tumour for which early detection can alter clinical presentation.

Irritable bowel syndrome – a common problem, individual approach

Irritable bowel syndrome is a recurrent abdominal pain that occurs at least once a week for 3 months, with symptoms at least 6 months associated with at least two features: bowel movements, change in bowel frequency, change in the appearance of stools. According to the Rome IV Diagnostic Criteria, the disease is diagnosed on the basis of clinical symptoms. This does not apply to people over 50 years of age (and in the case of first-degree relatives of patients with colorectal cancer after 45 years of age) and patients with alarm symptoms. Due to the lack of a single etiological factor, the treatment of irritable bowel syndrome consists in reducing symptoms and improving the patient’s quality of life. Non-pharmacological treatment includes a high-fiber diet and modification of the microbiota. The most effective drugs are antispasmodics directly affecting the smooth muscle, inhibiting the influx of calcium, i.e. drotaverine, mebeverine and alverine. There has been proven effectiveness of antidepressants. This confirms that functional disorders of the gastrointestinal tract are a manifestation of the dysfunction of the brain–gut–microbiota axis.

Congenital cyst in female accessory spleen: a case report

Cysts found in splenic stores, of parasitic or non-parasitic origin, are rare causes of recurrent abdominal pain, but with a significant increase in the number of diagnoses in recent years. This condition is caused by the derivation of the mesothelial cell lining of the spleen capsule, occurring in 0.5 - 2% of the world population. Clinically, patients tend to remain asymptomatic for years and usually have an incidental diagnosis by imaging exams or during the investigation of diffuse and recurrent abdominal pain, rarely found in females. The treatment of splenic cysts is performed through video laparoscopic splenic resection.

Parental experiences of psychological interventions for recurrent abdominal pain in childhood

Active components of psychological intervention for RAP remain unclear. This study involved completing interviews about parental experience of psychological intervention for RAP to ascertain how and why psychological intervention can be effective. Difficulty making sense of RAP and barriers to treatment were identified as struggles. Acceptance and containment were key overlapping mechanisms, which allowed families to develop a changed relationship with the pain and manage the impact of pain. To further develop interventions, the role of containment should be considered and acceptance-based interventions explored, given the growing evidence base in this area. Practical implications of this research are also discussed.

Abdominal hereditary angio-oedema caught on magnetic resonance imaging

A 17-year-old woman presented with a 3-year history of recurrent, severe abdominal pain with spontaneous resolution within a few days. An ultrasound revealed nothing more than free fluid within the pelvis. An MRI of the small bowel was done within 24 hours of abdominal pain onset, which revealed extensive submucosal oedema associated with moderate volume ascites. A repeat MRI of the small bowel after 72 hours showed near-complete resolution of these changes. Checking C1 inhibitor levels confirmed a diagnosis of hereditary angio-oedema with an abdominal presentation. This is a rare cause of recurrent abdominal pain and, to our knowledge, the first case in which MR images have been obtained during and after an acute attack.

Is the clinical pattern of pediatric celiac disease changing? A thirty-years real-life experience of an Italian center

Objectives Clinical presentation of pediatric celiac disease (CD) is heterogeneous and ever-evolving. Our aim is to highlight its changes throughout the years. Methods Data about clinical presentation of CD in children diagnosed between 1990 and 2020 at the CD Center of Maggiore Hospital, Bologna, were collected. Patients were stratified into groups based on the date [P1 (1990–2011), P2 (2012–2020)] and age [G1 (< 2 years), G2 (2–5), G3 (6–11), G4 (12–18)] at diagnosis, then investigated by comparing CD clinical presentation in different periods and ages. Results 1081 children were selected. Mean age at diagnosis increases from 5.9 to 6.6 years from P1 to P2. Gastrointestinal Symptoms (GIs) are predominant, with a decline of diarrhea (47%VS30%) and an increase of constipation (4%VS19%) (p < 0.001). Among Extraintestinal symptoms (EIs) a decrease of anemia (76%VS43%, p = 0,001) is observed. Failure to Thrive (FTT) is stable throughout the years (p = 0.03), while screenings show a trend of increment (19%VS23%). GIs’ frequency decline from G1 to G4 (p = 0,001), with reduction of diarrhea (p < 0.001), and rise of recurrent abdominal pain (p = 0,02). EIs are more frequent at older ages, FTT in younger patients. Conclusions Changes in clinical presentation of CD have occurred in the last 30 years. We observe a reduction of severe and classic gastroenterologic symptoms and a rise of atypical ones, together with a growth of serological screenings and higher age at diagnosis. Awareness about CD clinical trends is crucial for a proper approach and early diagnosis.

Predictors of Positive Video Capsule Endoscopy Findings for Chronic Unexplained Abdominal Pain: Single-Center Retrospective Study and Meta-Analysis

Video capsule endoscopy (VCE) is an effective diagnostic modality for detecting small bowel lesions. However, the value of VCE for patients with chronic recurrent abdominal pain (CAP) of unknown etiology remains obscure. We retrospectively analyzed factors that could predict enteropathy based on the medical records of 65 patients with unexplained chronic recurrent abdominal pain (CAP) who were assessed using VCE between 2001 and 2021. We also conducted a systematic review and meta-analysis of the literature to validate our results. The positive findings of 27 (41.5%) of the 65 patients were mostly ulcerative lesions including stricture (n = 14, 60.9%) and erosion (n = 8, 29.7%). Multivariate analysis identified elevated ESR (OR, 1.06, 95% CI, 1.02–1.1, p = 0.004) as a significant risk factor for enteropathy predicted by VCE. Three eligible studies in the meta-analysis included 523 patients with CAP. Elevated C-reactive protein (CRP) (OR, 14.09; 95% CI, 2.81–70.60; p = 0.001) and erythrocyte sedimentation rate (ESR) (OR, 14.45; 95% CI, 0.92–227.33; p = 0.06) indicated VCE-positive findings in patients with unexplained abdominal pain. Elevated levels of the inflammatory markers ESR and CRP can thus predict positive VCE findings in patients with CAP.

1250. Development of Linezolid and Daptomycin Resistance in Vancomycin Resistant Enterococcus faecium (VRE) during prolonged treatment for Intraabdominal Abscess

Background Vancomycin-resistant enterococci (VRE) are nosocomial pathogens with extensive intrinsic and acquired antimicrobial resistance (AMR) mechanisms. We report a case in which intraabdominal (IA) and blood cultures grew linezolid and daptomycin resistant VRE (DLVRE). Methods We report a case of DLVRE bacteremia after prolonged treatment with linezolid and daptomycin. Results The patient was a 65-year-old female with a history of multiple abdominal surgeries who presented for elective incisional hernia repair. Her post-operative course was complicated by the development of loculated IA abscesses. A drain was placed into the largest abscess, and aspiration cultures were polymicrobial containing vancomycin-resistant E. faecium (Isolate 1). The patient was treated meropenem, fluconazole and linezolid for 6 weeks. Clinical and radiographic improvement was achieved. However, 4 days after competing antibiotics she developed recurrent abdominal pain and a leukocytosis. Daptomycin was chosen out of concern for long-term linezolid toxicity and IA cultures demonstrated new linezolid resistance (Isolate 2, LVRE). After an additional three weeks of therapy, she developed a catheter-associated bloodstream infection (CLABSI). Blood cultures revealed daptomycin-resistant LVRE bacteremia (Isolate 3, DLVRE). She was started empirically on a combination of ceftaroline and daptomycin, her PICC line removed, and her blood cultures cleared. Her antibiotic course is presented in Figure 1 and resistance patterns of the VRE in Table 1. Conclusion In this patient, an IA abscess known to harbor VRE developed resistance to both linezolid and daptomycin during prolonged treatment with both agents. Ultimately, the patient experienced an episode of CLABSI DLVRE. Limited data exists on appropriate antibiotic choice in such challenging situations. Based on prior clinical and experimental data, we elected to use daptomycin in conjunction with ceftaroline for synergy, and the patient achieved the desired clinical response, clearance of her blood cultures and diminishing size of her IA abscess. Further work is needed to elucidate the best course of treatment for patients with VRE requiring long-term antibiotic therapy and for those who have developed extensively drug-resistant E. faecium. Disclosures All Authors: No reported disclosures