Central mechanisms of visceral pain

Deep pain arising from muscle, joints, connective tissue, and the viscera is different in character and quality from pain arising from cutaneous structures. Deep pains, particularly visceral pain, are poorly localized, typically referred or transferred to a cutaneous site, and generally produce strong emotional and autonomic responses and tonic muscle contractions. Despite the prevalence and clinical importance of deep pains, it is only relatively recently that investigative efforts have begun to focus on the mechanisms of deep pain. The present report briefly reviews the development and use of a model of visceral pain that employs constant pressure distension of the colon and rectum as a noxious stimulus. Converging behavioral, pharmacological, and physiological evidence that colorectal distension is a valid, reliable, noxious, visceral stimulus is presented.     

后腹腔镜肾囊肿去顶减压术治疗成人型多囊肾的疗效观察

目的评价后腹腔镜肾囊肿去顶减压术治疗多囊肾的临床疗效。方法2005年1月至2009年12月期间,行后腹腔镜肾囊肿去顶减压术的ADPKD患者17例,于术后1月、6月进行随访,观察患者的腰腹部胀痛情况、血压、血清肌酐、GFR的变化。结果腰腹部胀痛、血压明显低于术前,但随着时间推移,效果有所减弱;血清肌酐、GFR无变化。结论对于单侧症状明显的多囊肾患者,行后腹腔镜肾囊肿去顶减压术能改善腰腹部胀痛及血压。     

老年男性腹股沟疝与肌肉质量、肌力及腹内压的相关性

摘要 目的：探讨老年男性腹股沟疝与肌肉质量、肌力及腹内压力（IAP）的相关性。方法：选取2021年1月-2023年1月在眉山市人民医院普外一科就诊的 86例老年男性腹股沟疝患者作为研究组,选取同期100名老年体检者作为对照组,对两组研究对象的腹部肌肉质量、肌力及IAP进行检测,并探讨其与腹股沟疝发病风险的相关性。结果：研究组患者腹部骨骼肌肉面积值（SMA）、骨骼肌指数（SMI）水平及右手握力、左手握力均低于对照组,腹内脂肪面积、SMI异常比例及直立加压时腹内压（OVIAP）、直立加压前后腹内压差（OVIAPD）、平卧与直立加压时腹内压差（OSVIAPD）均高于对照组,差异均有统计学意义（P<0.05）。Logistic多元回归模型分析结果显示,老年腹股沟疝的发生与SMI水平、SMI异常、右手握力、OVIAPD、OSVIAPD具有相关性（P<0.05）。结论：老年男性腹股沟疝患者存在腹部肌肉质量和肌力的下降,患者在直立做加压动作时可出现IAP水平的升高,上述指标均与腹股沟疝的发生具有相关性,临床可采用针对性的综合干预措施以降低老年男性人群腹股沟疝的发病风险。     

Recognition and management of embolism to the superior mesenteric artery

Two cases of superior mesenteric arterial embolism are presented. The diagnosis should be suspected when severe abdominal pain develops suddenly in a patient with a cardiac arrhythmia or a recent history of myocardial infarction. Further support for the diagnosis is given by the finding of a poor peripheral circulation and a paucity of abdominal physical signs. The value of arteriography is questionable except to distinguish between thrombosis and embolism. The importance of early laparotomy as a diagnostic and life-saving measure is emphasized.     

Relative strengths of the chest wall muscles

We hypothesized that during maximal respiratory efforts involving the simultaneous activation of two or more chest wall muscles (or muscle groups), differences in muscle strength require that the activity of the stronger muscle be submaximal to prevent changes in thoracoabdominal configuration. Furthermore we predicted that maximal respiratory pressures are limited by the strength of the weaker muscle involved. To test these hypotheses, we measured the pleural pressure, abdominal pressure (Pab), and transdiaphragmatic pressure (Pdi) generated during maximal inspiratory, open-glottis and closed-glottis expulsive, and combined inspiratory and expulsive maneuvers in four adults. We then determined the activation of the diaphragm and abdominal muscles during selected maximal respiratory maneuvers, using electromyography and phrenic nerve stimulation. In all subjects, the Pdi generated during maximal inspiratory efforts was significantly lower than the Pdi generated during open-glottis expulsive or combined efforts, suggesting that rib cage, not diaphragm, strength limits maximal inspiratory pressure. Similarly, at high lung volumes, the Pab generated during closed-glottis expulsive efforts was significantly greater than that generated during open-glottis efforts, suggesting that the latter pressure is limited by diaphragm, not abdominal muscle, strength. As predicted, diaphragm activation was submaximal during maximal inspiratory efforts, and abdominal muscle activation was submaximal during open-glottis expulsive efforts at midlung volume. Additionally, assisting the inspiratory muscles of the rib cage with negative body-surface pressure significantly increased maximal inspiratory pressure, whereas loading the rib cage muscles with rib cage compression decreased maximal inspiratory pressure. We conclude that activation of the chest wall muscles during static respiratory efforts is determined by the relative strengths and mechanical advantage of the muscles involved.     

Perforated ascending colon cancer presenting as colocutaneous fistula with abscess to the anterior abdominal wall at the site of a cholecystectomy scar treated with biologic mesh

Ascending colon cancer as a colocutaneous fistula to the abdominal wall at the site of a previous postoperative scar is extremely rare. A 69 year old male presented with five day history of pain and foul smelling discharge from right subcostal scar from elective cholecystectomy performed 8 years ago. Last three days, he had fever up to 39 degrees C, with mild pain in right upper abdominal quadrant without vomiting, diarrhea, bloody stools or weight loss. Computed tomography, with peroral contrast, revealed extralumination into abdominal wall with several fistulas reaching the skin. Emergency median laparotomy found infiltrating tumor of ascending colon into abdominal wall. A right hemicolectomy and complete thickness abdominal wall excision (7 x 10 cm) was performed. The abdominal wall defect was too extensive for primary closure and two 20 x 20 cm moist gauzes were placed to cover the defect and were fixed with stitches to the skin. On second postoperative day, due to contamination, porcine dermal collagen implant was placed intraperitoneally. Such emergency presentations and therapeutic options are discussed.     

Low-grade appendiceal mucinous neoplasm and endometriosis of the appendix

Background

A distended, mucous-filled appendix is known as an appendiceal mucocele. They are a rare form of an appendiceal mass and develop from both benign and malignant processes. Mucoceles can develop secondarily to an obstruction, such as from a fecalith, scarring or, rarely, endometriosis. Only 12 cases of non-neoplastic appendiceal mucoceles caused by endometriosis have been previously described. The association between neoplastic appendiceal mucoceles in the presence of endometriosis is described for the first time in this report.

Case presentation

A 57-year-old woman presented with a chief complaint of worsening abdominal pain over the past 3 months. Imaging studies revealed an appendiceal mass. Laparoscopic evaluation confirmed an appendiceal mucocele, and the patient underwent complete appendectomy. No evidence of mucinous or endometrial deposits were present within the abdominal cavity. Pathological diagnosis revealed low-grade appendiceal mucinous neoplasm (LAMN) with evidence of endometriosis within the muscularis propria of the appendix. The patient recovered without complications and her abdominal pain completely resolved.

Conclusions

Endometriosis of the appendix is a rare manifestation and is most often identified as an incidental finding. Endometriosis leading to an obstructive mucocele of the appendix is an exceedingly rare finding, having only been described 12 times in the medical literature. LAMN in the presence of endometriosis of the appendix is described for the first time in this report. The association between appendiceal neoplasms in the presence of endometriosis requires further research in order to optimize operative treatment.

     

ROENTGEN DIAGNOSIS OF INTRA-ABDOMINAL HERNIA

The primary radiologic evidence of intra-abdominal hernia is disturbance of normal small intestine arrangement. Loops of intestine are crowded together as if in a bag, giving the appearance of clumping or sacculation. Dilatation and loss of mobility may occur with varying degrees of stasis. Displacement of viscera or pressure deformity may be observed.Studies of the small bowel are necessary to demonstrate these conditions and must be made with the patient in the erect as well as the horizontal position. Repeated studies may be required, and the best time to make them is during an acute attack, as the hernia may be temporarily reduced during a remission.The clinical symptoms are sufficiently characteristic to suggest the diagnosis in most cases. The usual history is of repeated attacks of abdominal pain or discomfort, usually accompanied by distention, varying in periodicity and intensity, with or without nausea or vomiting, and not accompanied by laboratory data or clinical signs indicative of inflammatory disease.Similar or identical clinical and roentgenologic evidence may be produced by torsion of the small bowel or by peritoneal adhesions.The hernia or torsion may reduce spontaneously before or at the time of operation. Therefore, a careful search for abnormal fossae, mesenteric defects or adhesive bands is necessary if herniation or torsion is not found.     

Spontaneously ruptured gastrointestinal stromal tumor (GIST) of the jejunum mimicking acute appendicitis

Gastrointestinal stromal tumors (GISTs) are characterized with diverse clinical presentations, including acute and chronic gastrointestinal bleeding, abdominal pain, presence of an intra-abdominal mass, anorexia, and intestinal obstruction. A 60-year-old obese woman presented as an acute abdominal emergency with right lower quadrant (RLQ) pain and tenderness, nausea and leukocytosis, all mimicking acute appendicitis. Laparotomy revealed a spontaneously ruptured GIST of the jejunum, which was localized to the RLQ due to postoperative adhesions following previous two cesarean sections and cholecystectomy. Complete surgical resection was performed, followed by an uneventful early postoperative course.     

The conservative treatment of longstanding adductor-related groin pain syndrome: a critical and systematic review

Longstanding (chronic) adductor-related groin pain syndrome is a widely common problem for athletes in many sports activities which often drastically reduces player activity and performance. The first choice in therapeutic treatment is conservative therapy. The objective of this study is to provide a systematic review regarding conservative treatment for longstanding adductor-related groin pain syndrome present in literature today. Furthermore, this study aims to give a critical vision of the current state of the art of the considered topic. After screening 234 articles, 19 studies following the inclusion criteria were included and summarized in this current systematic review and seven different types of therapeutic interventions were described. Compression clothing therapy, manual therapy together with strengthening exercise and prolotherapy were the therapeutic interventions which showed both the greatest level of strength of evidence (Moderate) and grade of recommendation (D). The remaining four types of therapeutic interventions i.e.: corticoid injection, platelet rich plasma therapy, intra-tissue percutaneous electrolysis and pulse-dose radiofrequency, showed both lower levels of strength of evidence (Conflicting) and grade of recommendation (C). In conclusion the literature available on the conservative treatment for longstanding adductor-related groin pain syndrome is limited and characterized by a low level of evidence. Therefore, our recommendation is to refer only to the few studies with higher level of evidence and at the same time to encourage further research in this area. The intervention showing the greater level of strength of evidence, and the greater grade of recommendation are compression clothing therapy, manual therapy and strengthening exercise, and prolotherapy. Other therapeutic interventions such as intra-tissue percutaneous electrolysis and pulse-dose radiofrequency seem promising but require further studies to confirm their efficacy.     

A rare cause of chronic mesenteric ischemia from fibromuscular dysplasia: a case report

Introduction

Chronic mesenteric ischemia is a condition that is classically associated with significant atherosclerosis of the abdominal arteries, causing postprandial abdominal pain out of proportion to physical examination. The abdominal pain is exacerbated after meals due to the shunting of blood away from the intestines to the stomach, causing relative ischemia. More than 95% of chronic mesenteric ischemia cases are due to atherosclerosis. We report the first known case of chronic mesenteric ischemia from fibromuscular dysplasia. To the best of our knowledge, this is also the first known case in the literature where postprandial abdominal pain was the presenting symptom of fibromuscular dysplasia.

Case presentation

A 44-year-old Caucasian woman with a history of hypertension and preeclampsia, who had taken oral contraceptive pills for 15 years, presented with an intractable, colicky abdominal pain of two weeks duration. This abdominal pain worsened with oral intake. It was also associated with diarrhea and vomiting. Physical examination revealed stage III hypertension out of proportion to her risk factors and diffuse abdominal pain without peritoneal signs. An abdominal computed tomography scan, completed in the emergency room, revealed nonspecific colitis. Laboratory work revealed leukocytosis with a left shift, an erythrocyte sedimentation rate of 79 and a C-reactive protein level of 100. She was started on intravenous flagyl and intravenous ciprofloxacin. However, all microbial cultures were negative including three cultures for clostridium difficile. Urine analysis revealed nephritic range proteinuria. The laboratory profile was within normal limits for perinuclear-anti-neutrophil cytoplasmic antibody, cytoplasmic-anti-neutrophil cytoplasmic antibody, anti-saccharomyces cerevisiae antibody, antinuclear antibody test, celiac profile, lactate, carbohydrate antigen-125 and thyroid stimulating hormone. A colonoscopy was completed, which revealed diffuse colonic lymphoid reactive hyperplasia. A small bowel series was negative for any inflammation. An indium scan, pan-computed tomography scan and transvaginal ultrasound were also negative. Magnetic resonance angiography of her abdomen revealed proximal superior mesenteric artery stenosis, which was confirmed by computed tomography angiogram findings of severe proximal and distal superior mesenteric artery stenosis, consistent with the appearance of fibromuscular dysplasia on angiography in the absence of vasculitis or atherosclerotic disease. The patient's superior mesenteric artery stenosis was subsequently angioplastied suboptimally and had to be stented with an Angioplus stent. One month after she was admitted, her abdominal pain and tolerance to oral feeds improved tremendously.

Conclusion

Fibromuscular dysplasia most commonly presents with renal artery stenosis, which rarely causes abdominal pain. This case illustrates how fibromuscular dysplasia can present as a rare cause of chronic mesenteric ischemia, similar to chronic mesenteric ischemia from atherosclerosis.     

Fever, rash, and blindness in a previously healthy young male

A 31-year-old male presented to the emergency room with a sudden onset of blindness and a rash after a five-day history of myalgia, abdominal pain, and fever. The diagnostic approach and the patient''s clinical course are presented. Indications for surgical intervention in staphyloccal endocarditis are discussed. Surgical and autopsy findings are reviewed.     

腹内压值对外科急腹症患者的检测价值研究

目的:评估膀胱压力(BP)测量作为急腹症诊断工具的临床价值。方法:选取在我院外科治疗的患者,根据病情分为两组:一组为325例急腹症患者,对照组为50例进行腹腔镜手术的患者。在治疗前测量患者腹内压力。患者采用仰卧位,将50 m L无菌生理盐水缓慢注射到膀胱中,待排光后检测BP。将导管同水压计连接,以耻骨联合处为参考点。将BP值大于10 cm H2O,作为诊断急腹症的标准。结果:BP诊断急腹症的灵敏度为94.4%,特异性为79%,阳性预测值为95.9%,阴性预测值为71.7%,精确度为92.3%。结论:腹内压(IAP)升高可以作为急性腹痛的诊断工具。BP检测有助于临床医生在试验室检查或影像学检查结果有限时对患者病情进行评估。     

Primary leiomyosarcoma of the inferior vena cava: report of a case diagnosed by fine needle aspiration cytology and confirmed by histopathologic examination

BACKGROUND: Leiomyosarcoma is a malignant neoplasm and can originate within major abdominal veins, including the inferior venacava (IVC). CASE: A 45-year-old woman presented with upper abdominal pain and a mass lesion in the liver and within the lumen of the IVC. A diagnosis of primary leiomyosarcoma of the IVC was made by using imaging techniques,fine needle aspiration cytology and histopathologic examination of the resected specimen. CONCLUSION: In patients presenting with vague upper abdominal pain and radiologic features of a hepatic mass extending to major veins, the rare possibility of primary leiomyosarcoma of the IVC shoald he considered and investigated by both fine needle aspiration cytology and intraoperative histology. Early surgical intervention and/or postoperative chemotherapy and radiotherapy are associated with improved survival.     

An Imported Case of Cystic Echinococcosis in the Liver

A 25-year-old Uzbek male presented with right upper abdominal pain for 20 days. On radiologic studies, a huge cystic mass was noticed in the right liver which was suspected as parasitic. The patient received right hepatic segmentectomy (segment 7), and the surgically resected mass was confirmed as cystic echinococcosis (CE), measuring 10.5 cm in its diameter. The inner surface of the cyst was bile-stained. The patient was discharged on the 8th hospital day, and was rechecked 6 months after the surgical intervention without any evidence of recurrence. The present report describes findings of an imported case of CE which represented ultrasound images of the ''ball of wool''.     

Behavioural responses of juvenile Steller sea lions to abdominal surgery: Developing an assessment of post-operative pain

Marking and tracking of marine mammals is required to gain a better understanding of life history traits; however, some marking procedures used are likely painful. Recent technological advances include intra-abdominally implanted archival telemetry devices for the life-long monitoring of individual animals. No research to date has assessed any aspect of post-operative pain in marine mammals. This study specifically evaluated behavioural responses in nine juvenile Steller sea lions to the abdominal surgery required for insertion of telemetry devices. Behaviours predicted to reflect post-operative pain, including posture and body movements, were assessed during 3-day pre-, 3-day post-, and days 10–12 post-surgery. The proportion of time sea lions spent on land standing increased from 0.00 to 0.07 and then decreased to 0.04, for pre-, post-, and late post-surgery respectively. Similarly, the proportion of land time spent with the back arched increased from 0.01 to 0.57, and then decreased to 0.33. The time sea lions spent on land with pressure on their ventral side while sitting or lying down declined from 1.0 pre-surgery to 0.17 post-surgery, and increased to 0.20 late post-surgery. The time sea lions spent in locomotion on land and in the water decreased from 0.05 in pre-surgery to 0.01 post-surgery, and returned to 0.06 by late post-surgery. These results suggest that behaviours such as back arch, standing, time spent with pressure on the ventral side, and locomotion may be useful in the assessment of pain following abdominal surgery in sea lions. The presence of these behaviours and their persistence for up to 12 days after surgery suggest that more work is required to further develop safe and effective analgesic methods for this procedure.     

Eosinophilia in a patient with cyclical vomiting: a case report

BACKGROUND: Eosinophilic gastritis is related to eosinophilic gastroenteritis, varying only in regards to the extent of disease and small bowel involvement. Common symptoms reported are similar to our patient's including: abdominal pain, epigastric pain, anorexia, bloating, weight loss, diarrhea, ankle edema, dysphagia, melaena and postprandial nausea and vomiting. Microscopic features of eosinophilic infiltration usually occur in the lamina propria or submucosa with perivascular aggregates. The disease is likely mediated by eosinophils activated by various cytokines and chemokines. Therapy centers around the use of immunosuppressive agents and dietary therapy if food allergy is a factor. CASE PRESENTATION: The patient is a 31 year old Caucasian female with a past medical history significant for ulcerative colitis. She presented with recurrent bouts of vomiting, abdominal pain and chest discomfort of 11 months duration. The bouts of vomiting had been reoccurring every 7-10 days, with each episode lasting for 1-3 days. This was associated with extreme weakness and cachexia. Gastric biopsies revealed intense eosinophilic infiltration. The patient responded to glucocorticoids and azathioprine. The differential diagnosis and molecular pathogenesis of eosinophilic gastritis as well as the molecular effects of glucocorticoids in eosinophilic disorders are discussed. CONCLUSIONS: The patient responded to a combination of glucocorticosteroids and azathioprine with decreased eosinophilia and symptoms. It is likely that eosinophil-active cytokines such as interleukin-3 (IL-3), granulocyte macrophage colony stimulating factor (GM-CSF) and IL-5 play pivotal roles in this disease. Chemokines such as eotaxin may be involved in eosinophil recruitment. These mediators are downregulated or inhibited by the use of immunosuppressive medications.     

Clinical Presentation of Acute Abdomen: Study of 600 Patients

This paper presents the clinical features of 600 patients suffering from abdominal pain of acute onset and admitted to either the General Infirmary or St. James''s Hospital, Leeds. The survey was initially retrospective, but later put on a prospective basis. Roughly two-thirds of these 600 patients presented a “typical” picture of the disease with which they presented, while the remaining third presented one or more atypical features. Since other prospective studies have indicated that the diagnostic accuracy of a group of clinicians in respect of the acute abdomen is roughly 65% it is tentatively suggested (a) that clinical diagnosis contains a large element of “pattern-matching,” and (b) that such a policy can be expected to be ineffective in roughly one-third of all cases of acute abdominal pain.     

Severe recurrent abdominal pain: an anatomical variant of Chilaiditi's syndrome

A patient who presented to the emergency department with severe, recurrent abdominal pain demonstrated Chilaiditi's sign, a radiographic term for interposition of the hepatic flexure of the colon between the liver and right hemidiaphragm. Workup of this clinical case revealed anomalous colonic anatomy, which led to successful laparoscopic corrective surgery. We call attention to the potential importance of this sign when associated with clinically recurrent abdominal pain (Chilaiditi's syndrome).     

Epidemiology of Pediatric Functional Abdominal Pain Disorders: A Meta-Analysis

ObjectiveWe aimed to review the literature regarding epidemiology of functional abdominal pain disorders in children and to assess its geographic, gender and age distribution including associated risk factors of developing functional abdominal pain.MethodsThe Cochrane Library, MEDLINE, EMBASE, CINAHL and PsychInfo databases were systematically searched up to February 2014. Study selection criteria included: (1) studies of birth cohort, school based or general population samples (2) containing data concerning epidemiology, prevalence or incidence (3) of children aged 4-18 years (4) suffering from functional abdominal pain. Quality of studies was rated by a self-made assessment tool. A random-effect meta-analysis model was used to estimate the prevalence of functional abdominal pain in childhood.ResultsA total of 58 articles, including 196,472 children were included. Worldwide pooled prevalence for functional abdominal pain disorders was 13.5% (95% CI 11.8-15.3), of which irritable bowel syndrome was reported most frequently (8.8%, 95% CI 6.2-11.9). The prevalence across studies ranged widely from 1.6% to 41.2%. Higher pooled prevalence rates were reported in South America (16.8%) and Asia (16.5%) compared to Europe (10.5%). And a higher pooled prevalence was reported when using the Rome III criteria (16.4%, 95% CI 13.5-19.4). Functional abdominal pain disorders are shown to occur significantly more in girls (15.9% vs. 11.5%, pooled OR 1.5) and is associated with the presence of anxiety and depressive disorders, stress and traumatic life events.ConclusionFunctional abdominal pain disorders are a common problem worldwide with irritable bowel syndrome as most encountered abdominal pain-related functional gastrointestinal disorder. Female gender, psychological disorders, stress and traumatic life events affect prevalence.