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Median arcuate ligament syndrome (MALS), also known as Dunbar syndrome, is a rare but significant cause of chronic abdominal pain resulting from the extrinsic compression of the celiac trunk. This condition typically manifests with symptoms such as postprandial pain, nausea, vomiting, and weight loss, often leading to a diagnostic challenge due to its mimicry of other abdominal disorders. Diagnosis is based on exclusion and requires a high index of suspicion combined with precise imaging findings. This case report presents a 44-year-old female patient presenting with chronic abdominal pain, diaphoresis, and nausea, underscoring the complexity and diagnostic challenge of MALS, highlighting the significance of early intervention to mitigate morbidity and novelty treatment utilizing robotic-assisted surgical techniques. This report aims to contribute to the understanding of clinical presentations, diagnostic challenges, and treatment modalities of Dunbar syndrome, especially the option of minimally invasive robotic-assisted surgery for the treatment of this condition.

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OBJECTIVES: Chronic abdominal pain is occasionally caused by an abdominal wall entity such as anterior cutaneous nerve entrapment syndrome (ACNES). This syndrome is thought to occur due to intercostal nerve branches (T7-12) that are entrapped in the rectus abdominis muscles. The diagnosis is largely based on subjective clues in patient history and physical examination. A test referred to as the scratch collapse test (SCT) is used as an additional diagnostic tool in peripheral nerve entrapment syndromes such as the carpal tunnel syndrome. The aim of the present study is to investigate whether an SCT was positive in patients with suspected ACNES. If so, this finding may support its hypothesized neuropathic character. METHODS: A prospective, case-control study was performed among patients with ACNES (n = 20) and two control groups without ACNES (acute intra-abdominal pathology n = 20; healthy n = 20), all were consecutively included. ACNES was diagnosed based on previously published criteria. The SCT test was executed at the painful abdominal area in both patient groups and at a corresponding area in healthy controls. Predictive values, sensitivity, and specificity were calculated. Videos of tests were evaluated by blinded observers. RESULTS: SCT was judged positive in 19 of 20 ACNES patients but not in any of the 40 controls. A 95% sensitivity (confidence interval [CI]: 75-99) and optimal specificity (100%; CI: 83-100) were calculated. CONCLUSIONS: The positive SCT supports the hypothesis that ACNES is an entrapment neuropathy. A positive SCT should be considered a major diagnostic criterion for ACNES.

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BACKGROUND: Median arcuate ligament syndrome (MALS) is a neurovascular disorder characterized by gastrointestinal symptoms due to celiac artery and ganglion compression. Limited literature primarily focuses on adults. This study aims to characterize clinical and histopathologic findings in pediatric MALS. METHODS: Patients <18 years undergoing robotic MAL release, celiac ganglionectomy, and lymphadenectomy from 2020 to 2024 were evaluated. Clinical and histopathologic outcomes were analyzed. RESULTS: Twelve patients met inclusion criteria and were reviewed (15.7 ± 1.2 years, 75% female, BMI 20.9 [18.6-24.0] kg/m2). Comorbidities included depression/anxiety (83%), postural orthostatic tachycardia syndrome (POTS) (50%), gastroesophageal reflux disease (GERD) (50%), nutrition support (50%), mast cell activation syndrome (MCAS) (42%), hypermobile Ehlers-Danlos syndrome (hEDS) (42%), other vascular compression syndromes (33%). All patients who received preoperative celiac plexus block had temporary symptom relief (10/10). Mean operative time was 119.7 ± 22.4 min. No intraoperative complications, 30-day readmissions, reoperations, or complications occurred. Histopathologically, 92% had fibroadipose tissue, 100% had reactive lymph nodes, none had intraparenchymal nerves, and one had lipogranulomas. Median fibrosis scores were 1 [0.5-2] on H&E and 2 [1-2] on trichrome. Fibrosis score severity was not significantly associated with symptom improvement (χ2 = 3.67, p = 0.16). Median postoperative celiac artery velocity was 258.5 [192.5-350.5] cm/s with a median change of -80.5 [-106.1-+82.8] cm/s from preoperative 308.0 [229.3-344.0] cm/s (S = -5.0, p = 0.55). Those with lower preoperative velocities were more likely to have symptom improvement postoperatively (S = 19, p = 0.04). MALS symptoms improved in 83%; however, despite reporting "MALS pain" was improved, 64% (all female) had other comorbidities such as POTS, MCAS, hEDS, and colonic dysmotility contributing to other ongoing symptoms. CONCLUSION: Robotic MALS surgery is safe and effective in pediatrics. Clinical improvement rates and fibrosis scoring are comparable to adults; however, findings reveal challenges with multiple comorbidities contributing to separate symptoms that may continue postoperatively, particularly in females. We recommend a multidisciplinary team approach in addressing comorbidities and optimizing medical and surgical care. LEVEL OF EVIDENCE: IV.

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Abdominal pain is a common symptom with a spectrum of causes. Anterior cutaneous nerve entrapment syndrome (ACNES) is a commonly overlooked and underdiagnosed cause for anterior abdominal pain. Among the patients of chronic abdominal wall pain, the incidence of ACNES is 10-30% and the most common cause is nerve entrapment at the lateral border of the rectus muscle. We describe two cases covering varied location of entrapment, one at the medial border of rectus and another at lateral border explaining the need of ultrasound for successful management of both. This case report illustrates the difficulty of making this diagnosis, utility of ultrasound and a brief review of literature.

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Colonic inertia is a gastrointestinal disorder characterized by a significant delay in colon transit, resulting in chronic constipation that impedes an undisclosed percentage of individuals in the United States. This article aims to delve into the intricate mechanisms underlying the hindered transit observed in colonic inertia, focusing on multifactorial etiology and treatment. By gaining a better understanding of the pathophysiology of colonic inertia, we can improve the quality of life for individuals affected by this condition. Our study employs a comprehensive approach, combining clinical observation during pancolectomy, histopathological analyses performed by pathologists, and detailed investigation to unravel the complex interplay of factors affecting colonic motility.

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Collagenous gastritis is a rare and chronic inflammatory condition of undetermined etiology characterized histologically by thickened subepithelial collagen bands and increased intraepithelial lymphocytes. Here, we present a collagenous gastritis case in a 16-year-old female with chronic abdominal pain, persistently elevated fecal calprotectin (507 and 796 mcg/g), and resolved iron deficiency anemia. The patient's history, laboratory tests, endoscopy, and magnetic resonance imaging ruled out common causes of elevated fecal calprotectin, including Helicobacter pylori and gastrointestinal infections, medications, celiac disease, and inflammatory bowel disease, as well as less common causes such as collagenous colitis. Esophagogastroduodenoscopy revealed significant antral nodularity. Gastric biopsies showed thickened subepithelial collagen band and surface epithelium damage with increased intraepithelial lymphocytes. The ileocolonoscopy was normal. This is among the first reported cases of collagenous gastritis with elevated fecal calprotectin levels that could solely be attributed to this condition.

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Crohn's disease is a chronic inflammatory bowel disease that primarily affects the terminal ileum and proximal colon. The exact cause is unknown but likely involves genetic factors, environmental triggers, and immune dysregulation. This case report delineates the choice of diagnostics for a 70-year-old patient presenting with symptoms indicative of small bowel obstruction. Initial assessments and imaging suggested a common clinical scenario, yet further investigation uncovered an unexpected diagnosis of Crohn's disease, a condition infrequently encountered in this age demographic.

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Acute intermittent porphyria (AIP) is a rare autosomal dominant metabolic disorder with low penetrance, often presenting with a broad spectrum of clinical manifestations. Acute neurovisceral attacks commonly occur in young women, mimicking signs and symptoms of other medical and psychiatric conditions, thus delaying the diagnosis. We present the case of an 18-year-old female college student with recurrent hospitalizations for intractable abdominal pain, now again with pain and new subjective hematuria. The patient had previously undergone an endoscopy/colonoscopy with negative biopsies and serologies for acute pathology, including celiac disease. Celiac studies were repeated, given the possibility of inadvertent gluten exposure before the onset of the latest symptoms, but were negative. Basic labs and repeat imaging, including contrast-enhanced CT, MRI, and magnetic resonance (MR) enterography of the abdomen, continued to be unremarkable, and the patient's symptoms were felt to be functional in etiology. The patient's urinalysis was normal, and pregnancy was also ruled out. The patient continued to have pain despite receiving opiate analgesics, thus prompting a psychiatry consultation. She was diagnosed with acute adjustment disorder with anxiety and was started on hydroxyzine. Due to persistent symptoms, serum and urine samples were sent, revealing low levels of porphobilinogen deaminase (PBGD) and hydroxymethylbilane synthase (HMBS) gene mutation, confirming the diagnosis of AIP. She was treated with oral glucose and outpatient IV hemin infusions with the resolution of symptoms. AIP presents a nonspecific and highly variable clinical picture, often making it a challenging diagnosis due to such a broad differential. While our patient was thought to have acute adjustment disorder due to an unremarkable initial workup, further testing revealed otherwise. This case demonstrates how clinicians must have a high suspicion of AIP when caring for young females, manifesting with neurovisceral and psychiatric signs and symptoms. Timely diagnosis improves a patient's quality of life and can decrease overutilization of healthcare resources.

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Background and aims: Spinal cord injury (SCI) affects roughly 300,000 Americans with 17,000 new cases added annually. In addition to paralysis, 60% of people with SCI develop neurogenic bowel (NB), a syndrome characterized by slow colonic transit, constipation, and chronic abdominal pain. The knowledge gap surrounding NB mechanisms after SCI means that interventions are primarily symptom-focused and largely ineffective. The goal of the present studies was to identify mechanism(s) that initiate and maintain NB after SCI as a critical first step in the development of evidence-based, novel therapeutic treatment options. Methods: Following spinal contusion injury at T9, we observed alterations in bowel structure and function reflecting key clinical features of NB. We then leveraged tissue-specific whole transcriptome analyses (RNAseq) and fecal 16S rRNA amplicon sequencing in combination with histological, molecular, and functional (Ca2+ imaging) approaches to identify potential mechanism(s) underlying the generation of the NB phenotype. Results: In agreement with prior reports focused on SCI-induced changes in the skin, we observed a rapid and persistent increase in expression of calcitonin gene-related peptide (CGRP) expression in the colon. This is suggestive of a neurogenic inflammation-like process engaged by antidromic activity of below-level primary afferents following SCI. CGRP has been shown to disrupt colon homeostasis and negatively affect peristalsis and colon function. As predicted, contusion SCI resulted in increased colonic transit time, expansion of lymphatic nodules, colonic structural and genomic damage, and disruption of the inner, sterile intestinal mucus layer corresponding to increased CGRP expression in the colon. Gut microbiome colonization significantly shifted over 28 days leading to the increase in Anaeroplasma, a pathogenic, gram-negative microbe. Moreover, colon specific vagal afferents and enteric neurons were hyperresponsive after SCI to different agonists including fecal supernatants. Conclusions: Our data suggest that SCI results in overexpression of colonic CGRP which could alter colon structure and function. Neurogenic inflammatory-like processes and gut microbiome dysbiosis can also sensitize vagal afferents, providing a mechanism for visceral pain despite the loss of normal sensation post-SCI. These data may shed light on novel therapeutic interventions targeting this process to prevent NB development in patients.

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In median arcuate ligament syndrome (MALS), the median arcuate ligament compresses the celiac trunk and surrounding nerves leading to chronic functional abdominal pain and vague gastrointestinal symptoms. MALS can be effectively treated by dividing the arcuate ligament through open surgery or laparoscopy. This is a rare vascular condition and mostly encountered in adult patients. We hereby report a case of a pediatric patient diagnosed with MALS and treated successfully by laparoscopic approach. An 11-year-old girl presented with severe abdominal cramps for 3 months, accompanied by nonbilious vomiting. Computed tomography (CT) angiography demonstrated clear images of celiac trunk compression suggesting MALS. Laparoscopic surgery to cut the ligament and decompress the celiac artery was performed. The patient was discharged on day 7 postoperative with no recurrence of symptoms after 12 months of follow-up. This report suggested the diagnostic value of CT scan, and the safety and the feasibility of laparoscopic surgical techniques to treat MALS in children.

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In this article, we propose a new diagnostic paradigm known as Chronic Abdominal Discomfort Syndrome (CADS). Patient's presentation centers around chronic abdominal pain not explained by acute pathology with or without accompanying dyspepsia, bloating, nausea and vomiting among other symptoms. The pathophysiology is noted to be neurogenic, possibly stemming from visceral sympathetic nerves or abdominal wall afferent nerves. Diagnosis is supported by signs or symptoms traversing clinical, diagnostic and functional criteria. Included is a tool which can assist clinicians in diagnosing patients with CADS per those domains. We hope to facilitate primary care physicians' and gastroenterologists' utilization of our criteria to provide guidance for selecting which patients may benefit from further interventions or evaluation by a pain physician. The pain physician may then offer interventions to provide the patient with relief.

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The irritable bowel syndrome (IBS) is a functional gastrointestinal disorder (FGID), whose prevalence has widely increased in pediatric population during the past two decades. The exact pathophysiological mechanism underlying IBS is still uncertain, thus resulting in challenging diagnosis and management. Experts from 4 Italian Societies participated in a Delphi consensus, searching medical literature and voting process on 22 statements on both diagnosis and management of IBS in children. Recommendations and levels of evidence were evaluated according to the grading of recommendations, assessment, development, and evaluation (GRADE) criteria. Consensus was reached for all statements. These guidelines suggest a positive diagnostic strategy within a symptom-based approach, comprehensive of psychological comorbidities assessment, alarm signs and symptoms' exclusion, testing for celiac disease and, under specific circumstances, fecal calprotectin and C-reactive protein. Consensus also suggests to rule out constipation in case of therapeutic failure. Conversely, routine stool testing for enteric pathogens, testing for food allergy/intolerance or small intestinal bacterial overgrowth are not recommended. Colonoscopy is recommended only in patients with alarm features. Regarding treatment, the consensus strongly suggests a dietary approach, psychologically directed therapies and, in specific conditions, gut-brain neuromodulators, under specialist supervision. Conditional recommendation was provided for both probiotics and specific fibers supplementation. Polyethylene glycol achieved consensus recommendation for specific subtypes of IBS. Secretagogues and 5-HT4 agonists are not recommended in children with IBS-C. Certain complementary alternative therapies, antispasmodics and, in specific IBS subtypes, loperamide and rifaximin could be considered.

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Eosinophilic gastroenteritis (EoGE) is a group of infrequent conditions that arise from the accumulation of eosinophils in the gastrointestinal (GI) tract without any secondary causes of eosinophilia. Most cases of EoGE cases show involvement of different parts of the GI tract. Herein, we report a case of EoGE with the sole involvement of Jejunum. A 57-year-old male patient presented to our center with a chief complaint of acute abdominal pain. The patient had experienced chronic abdominal pain and intermittent diarrhea for several years, but he presented to the emergency department with severe acute flank pain. The patient was first diagnosed with renal stone and treated accordingly. However, the computed tomography (CT) scan also showed other incidental findings related to his chronic abdominal pain from several years ago, including mesenteric infiltration which shows fluid appearance in some areas, mild wall thickening, and mucosal edema of the duodenum and jejunal loops with normal appearance of the ileum. Complete blood count (CBC) showed increased eosinophil (15.5%) and decreased lymphocytes (13.1%) percent. Pathological examination of enteroscopy samples of jejunum showed a mild increase in the number of eosinophils in lamina propria. Neither parasites nor granuloma was detected. However, no such changes were found in other parts of the GI tracts. Based on pathological examination, the patient was diagnosed with eosinophilic enteritis of the jejunum. EoGE does not typically involve a specific part of the GI and generally affects both the stomach and intestine. This study reported the first case of EoGE where only the jejunal part of the intestine was involved and other parts of the GI tract were spared.

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OBJECTIVES: Functional dyspepsia (FD) includes postprandial distress and epigastric pain syndrome. Percutaneous electrical nerve field stimulation (PENFS) in addition to behavioral interventions (BI) has shown benefits in children with functional abdominal pain but not specifically in FD. We aimed to assess the efficacy of PENFS for treating FD and compare the outcomes with those who received the combination of PENFS + BI. MATERIALS AND METHODS: Charts of patients with FD who completed four weeks of PENFS were evaluated. A subset of patients received concurrent BI. Demographic data, medical history, and symptoms were documented. Outcomes at different time points included subjective symptom responses and validated questionnaires collected clinically (Abdominal Pain Index [API], Nausea Severity Scale [NSS], Functional Disability Inventory [FDI], Pittsburgh Sleep Quality Index [PSQI], Children's Somatic Symptoms Inventory [CSSI], Patient-Reported Outcomes Measurement Information Systems [PROMIS] Pediatric Anxiety and Depression scales). RESULT: Of 84 patients, 61% received PENFS + BI, and 39% received PENFS alone. In the entire cohort, API (p < 0.0001), NSS (p = 0.001), FDI (p = 0.001), CSSI (p < 0.0001), PSQI (p = 0.01), PROMIS anxiety (p = 0.02), and depression (p = 0.01) scores improved from baseline to three weeks and at three months. Subjective responses showed nausea improvement (p = 0.01) and a trend for improvement in abdominal pain (p = 0.07) at week three. Abdominal pain subjectively improved at week three and three months (p = 0.003 and 0.02, respectively), nausea at week three and three months (p = 0.01 and 0.04, respectively), and a trend for improvement in sleep disturbances at week three and three months (p = 0.08 and p = 0.07, respectively) in the PENFS + BI group vs PENFS alone. CONCLUSION: Abdominal pain, nausea, functioning, somatization, sleep disturbances, anxiety, and depression improved at three weeks and three months after PENFS in pediatric FD. Subjective pain and nausea improvement were greater in the PENFS + BI group than in the group with PENFS alone, suggesting an additive effect of psychologic therapy.

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PURPOSE: Anterior cutaneous nerve entrapment (ACNES) is characterized by neuropathic pain in a predictable, circumscript abdominal area. The diagnostic delay is long, with half of ACNES-affected individuals reporting nausea, bloating, or loss of appetite mimicking visceral disease. The aim of this study was to describe these phenomena and to determine whether treatment could successfully reverse the visceral symptoms. METHODS: This prospective observational study was conducted between July 2017 and December 2020 at SolviMáx, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven. Adult patients who fulfilled published criteria for ACNES and reported at least one visceral symptom at intake were eligible for the study. A self-developed Visceral Complaints ACNES Score (VICAS) questionnaire that scores several visceral symptoms (minimum 1 point, maximum 9 points) was completed before and after therapy. The success of treatment was defined as at least 50% reduction in pain. RESULTS: Data from 100 selected patients (86 females) aged 39 ± 5 years were available for analysis. Frequently reported symptoms were abdominal bloating (78%), nausea (66%) and altered defecation (50%). Successful treatment significantly reduced the number of visceral symptoms, with a VICAS before of 3 (range 1-8) and after of 1 (range 0-6) (p < 0.001). A low baseline VICAS was associated with successful treatment outcome (OR 0.738, 95% CI 0.546-0.999). CONCLUSION: Patients with ACNES may report a variety of visceral symptoms. Successful treatment substantially reduces these visceral symptoms in selected patients.

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BACKGROUND: Many patients suffer from abdominal and thoracic pain syndromes secondary to numerous underlying etiologies. Chronic abdominal and thoracic pain can be difficult to treat and often refractory to conservative management. In this systematic literature review, we evaluate the current literature to assess radiofrequency ablation's (RFA) efficacy for treating these debilitating chronic pain conditions in the thoracic and abdominal regions. OBJECTIVES: The objective of this study is to determine the pain relief efficacy of RFA on chronic thoracic and chronic abdominal disease states. STUDY DESIGN: This study is a systematic literature review that uses the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) method to gather academic literature articles through a methodical approach. The numbers obtained from each academic manuscript were then used to calculate the percent efficacy of radiofrequency ablation on thoracic and abdominal pain relief. METHODS: Articles from 1992 through 2022 were gathered using PRISMA guidelines. The search terms "Radiofrequency Ablation Thoracic Pain" and "Radiofrequency Ablation Abdominal Pain" were used to identify articles to include in our study. Our search yielded a total of 575 studies, 32 of which were included in our study. The articles were then categorized into pain causes. The efficacy of RFA for each qualitative study was then quantified. Risk of bias was also assessed for articles using the Cochran Risk of Bias tool, as well as a tool made by the National Institutes of Health. RESULTS: The PRISMA search yielded a total of 32 articles used for our study, including 16 observational studies, one cohort study, 6 case reports, 6 case series, and 3 clinical trials. Twenty-five articles were labeled good quality and one article was labeled fair quality according to the risk of bias assessment tools. The studies examined RFA efficacy on chronic abdominal and chronic pain syndromes such as spinal lesions, postsurgical thoracic pain, abdominal cancers, and pancreatitis. Among these etiologies, RFA demonstrated notable efficacy in alleviating pain among patients with spinal osteoid osteomas or osteoblastomas, lung cancer, and pancreatic cancer. The modes of RFA used varied among the studies; they included monopolar RFA, bipolar RFA, pulsed RFA, and RFA at different temperatures. The average efficacy rate was 84% ranging from 55.8% - 100%. A total of 329 males and 291 females were included with ages ranging 4 to 90 years old. LIMITATIONS: Limitations of this review include the RFA not being performed at the same nerve level to address the same pathology and the RFA not being performed for the same duration of time. Furthermore, the efficacy of RFA was evaluated via large case series and single cohort observational studies rather than control group observational studies and clinical trial studies. CONCLUSION: A systematic review of the literature supports RFA as a viable option for managing abdominal and thoracic pain. Future randomized controlled trials are needed to investigate the efficacy of the various RFA modalities to ensure RFA is the source of pain relief as a large body of the current literature focuses only on observational studies.

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Background  Opioids, which have well-known adverse effects such as drowsiness paralytic ileus and respiratory depression, were mostly utilised to treat postoperative pain in the past. The increased incidence of side effects has led to a rise in interest in pain management techniques that spare opioids. Persistent abdominal pain following surgery has a major detrimental effect on patients' quality of life. While epidural analgesia is widely regarded as the gold standard to combat the pain that is present post abdominal surgeries, it is not devoid of drawbacks. The transversus abdominis plane (TAP) block has developed as a potentially effective treatment for severe abdominal pain. The TAP block acts on the neuro-fascial plane between the internal oblique and transversus abdominis muscles, which is innervated by spinal nerves from T6 to L1. Studies reveal that the addition of corticosteroids to bupivacaine in TAP blocks provides pain relief and improves the quality of life of the patient. Aims and objectives  In this study, the effects of bupivacaine and corticosteroids, particularly dexamethasone and methylprednisolone, on chronic abdominal pain following surgery are examined. Assessing the quality of pain relief is the primary objective. Methodology  Thirty patients who had undergone abdominal surgery and had been having persistent abdominal pain for six to eight months thereafter and had attempted unsuccessfully to treat the pain with alternative pain relief methods participated in the study. They were divided into two groups at random. Dexamethasone and bupivacaine were given to patients in Group D while methylprednisolone and bupivacaine were given to patients in Group M for ultrasonography (USG)-guided bilateral TAP blocks. At various intervals up to 12 weeks after injection, the patient's pain levels were measured using the visual analogue score (VAS), and their quality of life was assessed using the quality-of-life score. Results  Patients in Group M experienced significantly less pain than those in Group D at the fourth, sixth, and 12th weeks of treatment. Furthermore, in the fourth, sixth, and 12th weeks, patients in Group M reported a superior quality of life in comparison to those in Group D. Conclusion  Patients with persistent postoperative abdominal pain receiving bupivacaine and methylprednisolone in an ultrasonography-guided TAP block experience more effective and long-lasting pain relief than those who receive bupivacaine and dexamethasone. The quality of life for patients may be enhanced by using corticosteroids to optimise postoperative pain management strategies and lessen the need for opioids, as this study highlights.

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Legionnaires' disease is an atypical pneumonia caused by Legionella pneumophila (L. pneumophila) pneumonia that features slow onset, nonproductive cough, fatigue, headache, sore throat, myalgias, and malaise. It can be difficult to diagnose, as it presents with extrapulmonary symptoms, and delay in treatment can be fatal. Here, we present the case of a previously healthy 32-year-old Caucasian male with Legionnaires disease who only presented to the clinic with abdominal pain and diarrhea. The patient did not have any pulmonary symptoms at the initial presentation. This presentation did not fit the diagnostic tools available for Legionnaires' disease, including a validated clinical prediction rule, which ruled out L. pneumophila infection with a sensitivity of 97% and a negative predictive value of 99.4%. Due to the complaint of abdominal pain, a flat/upright abdominal X-ray was ordered, which includes a chest X-ray. Upon analyzing the chest X-ray, a right lower lobe consolidation was identified, prompting an L. pneumophila urinary test to be added to the lab orders. This case represents the difficulties in diagnosing Legionnaires' disease due to the diverse clinical complexities of presentations, which may solely involve abdominal complaints.

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A Meckel's diverticulum is one of the most common congenital causes of small bowel obstruction. The lack of a more common gastric-containing tissue and older age of symptom onset can lead to difficulties with preoperative diagnosis. This case demonstrates an adult with chronic abdominal pain with recurrent small bowel obstruction that was found to be a rare ectopic endometrial tissue containing a Meckel's diverticulum following a diagnostic laparotomy. The barriers to diagnostics and factors affecting the age of onset are discussed with a focus on demonstrating the importance of surgical intervention for small bowel obstruction due to a Meckel's diverticulum and on the significance of a rare histological finding.

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Background: The casual relationship between the role of cholecystectomy and functional gastrointestinal disorders (FGIDs) are a controversial clinical challenge. This study aimed to investigate: (1) the overlap of FGIDs before cholecystectomy and its long-term outcome after surgery in patients with symptomatic cholelithiasis, and (2) the incidence of new-onset FGIDs after cholecystectomy. Methods: Patients with symptomatic gallstone disease who underwent elective, laparoscopic cholecystectomy were prospectively enrolled. Healthy populations who underwent medical check-ups were selected as age- and sex-matched controls. Questionnaires regarding sociodemographic characteristics, gastrointestinal symptoms and a somatization symptom checklist (SSC) were completed at baseline and 12 months thereafter. Results: The prevalence of all FGID symptoms before cholecystectomy were significantly higher in the group of patients with symptomatic cholecystolithiasis compared to the control group. In cholecystectomy group, the preoperative FGID symptoms improved after surgery, except for chronic diarrhea. Compared to the controls, the new-onset FGIDs, including functional dyspepsia (14.8% vs. 6.9%; p = 0.040), functional diarrhea (6.6% vs. 0.2%; p < 0.001), and chronic abdominal pain (11.9% vs. 4.4%; p = 0.024), were more common at 1 year after cholecystectomy. Somatization was independent predictors of new-onset dyspepsia and abdominal pain, while newly occurring diarrhea was not realted to somatization. Conclusion: Overlap of FGIDs was common in patients with symptomatic cholelithiasis before surgery and at follow-up 1 year after cholecystectomy. Furthermore, new-onset FGIDs could be occurred after cholecystectomy. Therefore, a delicate diagnostic approaches and appropriate treatments about co-existent FGIDs should be given in patients with cholelithiasis before and after cholecystectomy.