Is abdominal wall tenderness a useful sign in the diagnosis of non-specific abdominal pain?

Pain arising from the abdominal wall has been implicated as a cause of non-specific abdominal pain (NSAP), and the presence of abdominal wall tenderness (AWT) has been proposed as an accurate diagnostic test for NSAP. One hundred and fifty eight patients admitted to hospital with abdominal pain were tested for the presence of positive AWT. In 53 patients the final diagnosis was appendicitis and positive AWT was found in five. Thirty eight patients were found to have a variety of other recognised pathological diagnoses, none of whom had a positive AWT. In 67 patients a diagnosis of NSAP was made in the absence of other pathological diagnosis, 19 of whom had positive AWT, which was significantly different from the other diagnostic groups. This study confirms the presence of AWT in up to 28% of patients with NSAP, and suggests that testing for AWT is of value in patients with abdominal pain, although a positive AWT is not as accurate a predictor of NSAP as previously reported.     

A differential diagnosis in chronic lower abdominal pain

INTRODUCTIONSpigelian hernias represent 0.12–2.4% of all abdominal wall hernias. Its diagnosis is elusive and requires a high level of conjecture given the disease rarity, vague associated abdominal complaints and frequent lack of consistent physical findings.PRESENTATION OF CASEA 60-year-old woman presented with a history of chronic pain in the left lower side of the abdomen. The patient was treated for several diseases with no relief of symptoms. Abdominal ultrasound showed a Spigelian hernia in the lower left abdomen and surgery was scheduled for treatment.DISCUSSIONA SH is generally an inter-parietal hernia, meaning that the pre-peritoneal fat and the hernia sac penetrate the trasnversus abdominis and internal oblique muscles but remain behind the external oblique aponeurosis. In most of the patients the lack of clinical signs demands radiological investigation. That's the importance of the high grade of suspicious of the disease during the physical exam. The surgical repair is necessary due to the high risk of incarceration-related complications which can occur in up to 21% of cases.CONCLUSIONIt's important to think in the Spigelian hernia as cause of lower abdominal pain to prompt indicate surgical repair and provide the patient's symptom relief. Also the type of repair is dependent on the surgeon's choice and also the means available in each center.     

Evaluation of plain abdominal radiographs in the diagnosis of abdominal pain.

In an effort to develop referral criteria for the ordering of abdominal radiographs for patients presenting with abdominal symptoms, we prospectively studied the relation between clinical data and radiographic abnormalities. Of 1780 examinations, 179 (10.0%) showed some radiographic abnormality. If abdominal radiographs would have been limited to those patients who had moderate or severe abdominal tenderness, or to patients with a high clinical suspicion of bowel obstruction, renal or ureteral calculi, trauma, ischemia, or gallbladder disease, regardless of the degree of tenderness, 956 (53.7%) examinations would not have been done. All radiographic abnormalities reflecting a serious pathologic process would have been identified. Only 33 (3.5%) abnormalities of limited significance, almost all localized or generalized ileus, would have been undetected. The adoption of these referral criteria would result in minimal loss of clinically useful information, large financial savings, and a reduction in radiation exposure.     

Perforated jejunal divertikula - a rare differential diagnosis of acute abdominal pain

DIAGNOSTIC FINDINGS: We report about a 83 years old female with persisting abdominal pain for 3 days. Abdominal x-ray, as well as abdominal ultrasound examination were unsuccessful. CT scan revealed a 7 cm tumor, suspicious for abscess. OPERATION: Diagnostic laparotomy showed a 6 cm inflammatory tumor with covered perforation of a jejunal diverticula at the 4th intestinal loop distal the ligament of Treitz. We performed a segmental resection. FOLLOW UP: Clinical follow-up was uneventful, the patient was without any symptoms within the first 6 months. Pre- and intraoperative pathology will be explained and discussed referring to the literature.     

Laparoscopy for diagnosis and treatment of acute abdominal pain

PURPOSE: To evaluate the role of laparoscopy in the diagnosis and treatment of unexplained acute abdominal pain. PATIENTS AND METHODS: Fifty-six patients with acute abdominal pain (41 women, 15 men; median age 27) who attended our hospital between July 1996 and July 1999 and in whom a definite diagnosis could not be made by conventional methods underwent diagnostic laparoscopy. RESULTS: The laparoscopic procedure was performed under general anesthesia in 43 patients and local anesthesia in 13 patients. The median duration of laparoscopy was 16 minutes. The sensitivity and specificity of diagnostic laparoscopy were found to be 98% and 96%, respectively. The most frequent diagnosis was acute appendicitis (38%). Laparoscopic treatment of the surgical pathology was possible in 36 patients; in seven patients, conversion to laparotomy was necessary. The median postoperative hospital stay was 1 day in the diagnostic laparoscopy group. The median treatment cost was lower in the diagnostic laparoscopy group than in the therapeutic laparoscopy or laparotomy groups. There was no mortality or morbidity in the laparoscopy groups. CONCLUSIONS: Laparoscopy is an effective method for the diagnosis and treatment of surgical pathologies in patients in whom the diagnosis cannot be made with physical examination and noninvasive methods.     

Computer-aided diagnosis of lower abdominal pain in women.

This paper describes the use of a system of computer aided diagnosis in an unselected, prospective survey of 393 women suffering from lower abdominal pain of less than 1 week's duration. An accurate diagnosis was made by clinicians at first patient contact in 68-5 per cent of the group of patients. The computer's diagnostic prediction (based on the same data) matched the final diagnosis in 81-6 per cent of the patients. During this survey a marked improvement in diagnostic accuracy was observed amongst the junior clinicians. It is suggested that this is because of the discipline of data collection imposed and the intermittent feedback received, and also that this educational aspect of computer usage may be of wider benefit.     

Methadone is safe for treating hospitalized patients with severe pain

PURPOSE: Methadone is still regarded as a second line opioid for patients suffering from severe pain, and is rarely used in hospitalized patients. The infrequent use of methadone is probably due to its long plasma half-life that could lead to accumulation and toxicity. In the present study we report that clinically effective analgesic doses of methadone, given either epidurally or orally, can be used safely for prolonged treatment in hospitalized patients. Clinical features: Over a five-year period we administered methadone at Hadassah Hospital in Jerusalem to 3,954 in-patients with severe pain, 12% of whom were younger than 17 yr. Satisfactory pain relief was recorded in more than 85% of the patients. None of the patients treated with oral methadone developed serious side effects. Three patients, treated with epidural methadone (0.09%), developed a clinically significant respiratory depression. In all three cases, epidural pump failure or pump misprogramming resulted in methadone overdose. None of the children or adults treated with methadone developed addiction during hospitalization. CONCLUSION: Based on its analgesic properties and marked safety profile, we suggest that methadone could be added to the analgesic armamentarium of in-hospital health-care providers. Moreover, methadone could serve as the opioid of first choice in some in-patient populations.     

Open abdomen during extracorporeal membrane oxygenation is a safe and effective treatment for abdominal compartment syndrome

Background/PurposeDecompressive laparotomy and open abdomen for abdominal compartment syndrome have been historically avoided during Extracorporeal Membrane Oxygenation (ECMO) due to seemingly elevated risks of bleeding and infection. Our goal was to evaluate a cohort of pediatric respiratory ECMO patients who underwent decompressive laparotomy with open abdomen at a single institution and to compare these patients to ECMO patients without open abdomen.MethodsWe reviewed all pediatric respiratory ECMO (30 days-18 years) patients treated with decompressive laparotomy with open abdomen at Riley Hospital for Children (1/2000–12/2019) and compared these patients to concurrent respiratory ECMO patients with closed abdomen. We excluded patients with surgical cardiac disease. We assessed demographics, ECMO data, and outcomes and defined significance as p = 0.05.Results6 of 81 ECMO patients were treated with decompressive laparotomy and open abdomen. Open and closed abdomen groups had similar age (p = 0.223) and weight (0.286) at cannulation, but the open abdomen group had a higher reliance on vasoactive medications (Vasoactive Inotropic Score, p = 0.040). Open abdomen group survival was similar to closed abdomen patients (66.7%, vs 62.7%, p = 1). Open abdomen patients had lower incidence of ECMO complications (33.3% vs 83.6%, p = 0.014), but the groups had similar bleeding complications (p = 0.412) and PRBC transfusion volume (p = 0.941).Conclusion/ImpactPediatric ECMO patients with open abdomen after decompressive laparotomy had similar survival, blood products administered, and complications as those with a closed abdomen. An open abdomen is not a contra-indication to ECMO support in pediatric respiratory patients and should be considered in select patients.     

Chronic right-lower-quadrant abdominal pain: is there a role for elective appendectomy?

BACKGROUND/PURPOSE: Chronic right-lower-quadrant abdominal pain is a frequent problem in the pediatric population. The purpose of this report is to detail the outcome of management of these patients with appendectomy. METHODS: Appendiceal colic was judged to be present if the history showed cramping abdominal pain in association with McBurney's point tenderness. This is a retrospective review of 50 consecutive pediatric patients experiencing pain for greater than 1 year. All patients were evaluated at a single institution by one surgeon and underwent elective appendectomies from April 1985 through April 1997. RESULTS: Seventy-five percent of the patients were girls. One hundred forty-nine imaging and endoscopic studies were performed with 135 negative findings. Twenty-three patients had a minimum of one previous emergency room visit or hospitalization for the same abdominal complaints. The pathological findings were distinctly different from those of incidental appendectomies. Three patients had undergone previous diagnostic explorations for abdominal pain, the appendix was not removed, and a subsequent appendectomy relieved the discomfort. Forty-nine of the 50 patients were pain free at 1 year. CONCLUSIONS: Appendiceal colic is a clinical diagnosis. It is anticipated that patients with cramping abdominal pain associated with McBurney's point tenderness could undergo less preoperative workup and expedited resolution of the problem in the future.     

Abdominal intercostal nerve pain. A contribution to differential diagnosis of acute abdominal pain

Intercostal nerves and their vascular supply can be impinged in a fascial gap of the m.rectus abdominalis and cause neural pain simulating visceral symptoms. The diagnosis is based on clinical symptoms and proven by histological demonstration of cicatricial impingement of an intercostal nerve. The disease can be cured by simple resection of the impinged nerve.     

Presentation and diagnosis of acute abdominal pain in Finland: a computer aided study

326 patients presenting with acute abdominal pain to a hospital in Tampere were compared with others in England and Norway, and with a large series of 6097 cases collected under the auspices of the World Organization of Gastro-Enterology. The distribution of disease in these 326 Finnish patients bore remarkable similarities to the distribution in other countries. When subjected to a computer-aided diagnostic analysis, comparing Finnish patients with UK and world-wide data, as regards appendicitis, cholecystitis and nonspecific pain, the computer performed roughly as well as the clinicians diagnosing the same cases. It is concluded that these diseases therefore have a common presentation in Finland with that elsewhere. As regards small bowel obstruction however, the computer diagnosed only 22% of cases correctly, (compared with the accuracy of clinical diagnosis 73%). This leads us to conclude that this disease presents unusually in Scandinavia, and possible reasons are discussed.     

Fishbone perforation through a Meckel's diverticulum: a rare laparoscopic diagnosis in acute abdominal pain.

The use of diagnostic laparoscopy in acute abdominal pain, especially when patients have been admitted for acute pain in the lower abdominal quadrants, improves the accuracy of diagnosis and leads to improvements in treatment procedures. A case is reported of a 24-year-old woman admitted under suspicion of appendicitis. The appendix was found to be normal, and a perforation caused by a fishbone was discovered in a Meckel's diverticulum. The diverticulum was resected by a combined laparoscopic and open procedure. Diagnostic laparoscopy should be performed routinely in cases of acute abdominal pain in the lower quadrants of suspected appendiceal origin to avoid overlooking other causes of the symptoms.     

Single-port laparoscopic colectomy is safe and feasible in patients with previous abdominal surgery

Background

The aim of this study was to assess the impact of previous abdominal surgery (PAS) on single-port laparoscopic colectomy (SPLC).

Methods

We studied 429 consecutive patients who underwent SPLC in our department from May 2009 to December 2013. Patients were divided into 2 groups: those with PAS (PAS group) and those with NPAS (NPAS group). Operative parameters and outcomes were analyzed between the 2 groups retrospectively.

Results

SPLC was performed in 152 PAS patients and 277 NPAS patients. Eight patients in the PAS group and 6 patients in the NPAS group were converted to multiport laparoscopic colectomy (5.3% vs 2.2%, respectively; P = .077). Three patients in the PAS group and 2 patients in the NPAS group had inadvertent enterotomy (2.0% vs .7%, respectively; P = .352). No patients were converted to open surgery. There were no significant differences between the 2 groups in terms of blood loss, operative time, and postoperative outcomes.

Conclusion

Our experience has demonstrated the safety and feasibility of SPLC in patients with PAS.     

Laparoscopic diagnosis and treatment of nontraumatic acute abdominal pain in women

PURPOSE: We reviewed the records of 77 women treated for nontraumatic acute abdomen by the principal author between June 1991 and June 1996. All patients presented to either the surgeon's office or the emergency room at Northwest Hospital, which is an urban community hospital in North Seattle. Our objectives in the study were to determine the effectiveness of diagnostic laparoscopy for nontraumatic acute abdomen and the percentage of cases managed using laparoscopic technique exclusively. PATIENTS AND METHODS: The mean patient age was 36.5 (range 12-65) years. The majority of these women (92%) were premenopausal. Seventy-two (93.5%) were Caucasian, and the remaining 5 (6.5%) were Asian. Thirty-eight of the women (49%) had undergone at least one prior pelvic or abdominal operation, and 28 (36%) had undergone more than one. The principal author performed preoperative clinical evaluations, then diagnostic laparoscopy for all 77 patients. RESULTS: Laparoscopy provided a definitive diagnosis in 76 of the 77 cases. In 70% of the cases (54 of 77) the preoperative diagnosis was confirmed by diagnostic laparoscopy, and in 29% (22 of 77), the diagnosis was confirmed, yet augmented or clarified, by diagnostic laparoscopy. In the remaining case, diagnostic laparoscopy ruled out any acute etiology. Ninety-five percent of the patients (72 of 76) were treated exclusively by laparoscopy (70 cases) or a laparoscopy-assisted procedure (2 cases). Four patients (5%) required conversion to laparotomy. The remaining patient required no therapeutic surgery. Mortality was 0 and morbidity 4%. CONCLUSION: A high proportion of women presenting with acute abdominal pain can be managed using a laparoscopic technique exclusively.