Approach to the acute abdomen

As our population ages, more patients will be presenting with acute abdominal problems which require attention. Unlike younger patients, the aged present later in the course of their disease and also often have concomitant underlying diseases. The diagnosis of an acute abdomen is further complicated by the relative lack of physical findings which is due to the elderly's lack of pain perception. The surgical problems in the elderly also tend to be more rapidly life-threatening than in younger patients. This further emphasizes the need for rapid diagnosis should an elderly patient present with abdominal pain. Methods to decrease the mortality from acute surgical problems are limited, but are potentially very effective. The first is to arrange for elective correction of the problem should it be known, and the second is to refer the patients promptly for operative consideration before sepsis becomes firmly established. Exact diagnosis before referral, while intellectually satisfying, is often contributory to a poor outcome in these patients.     

Peptic ulcer disease

Peptic ulcer disease (PUD) is due mostly to the widespread use of low-dose aspirin and nonsteroidal anti-inflammator drugs. It occurs mostly in older patients and those with comorbidities. Pain awakening the patient from sleep between 12 and 3 a.m. affects two-thirds of duodenal ulcer patients and one-third of gastric ulcer patients. Older adults (>80 years old) with PUD often do not present with abdominal pain; instead, epigastric pain, nausea and vomiting are among their most common presenting symptoms.     

腹主动脉瘤破裂的误诊误治

腹主动脉瘤的主要威胁是突发破裂,病情危重,病死率极高。腹痛、休克、腰背痛、腹部博动性肿块是腹主动脉瘤破裂最常见的表现,螺旋CT、彩超是主要辅助检查手段。腹主动脉瘤破裂症状富于变化,极易引起误诊,误诊疾病包括肾绞痛、胃肠道出血及破裂、肠梗阻、乙状结肠憩室炎、胆囊炎、胰腺炎、嵌顿性腹股沟疝、心肌梗死、腹部钝性外伤等。误诊的主要原因是临床医生对该病不熟悉,思维局限。救治办法是紧急开腹手术切除或行腔内治疗。误诊患者的病死率明显增高,不恰当的辅助检查和术前准备均造成手术延误,错误的手术止血方式也可能导致灾难性的后果。     

Epiploic appendagitis: the emergency department presentation.

We performed a structured retrospective chart review to describe clinical characteristics of Emergency Department (ED) patients diagnosed by history, physical examination, and abdominal computed tomography (CT) scan with epiploic appendagitis (EA). EA is a disease caused by inflammation of the appendix epiploica, subserosal adipose tissue along the colon. It may mimic surgical causes of acute abdominal pain, but is treated conservatively with pain management. There were 19 patients diagnosed with EA, with follow-up performed on 85%. All had focal, nonmigratory symptoms. Common findings included left lower quadrant pain and guarding, and a normal temperature and white cell count. No patient required operation. This preliminary work characterizes some common clinical features of ED patients diagnosed with EA. As use of emergency CT scan for abdominal pain increases, clinicians will encounter this more often. These features should also prompt the clinician to consider CT scan in patients with similar signs and symptoms. Accurate diagnosis may avoid unnecessary surgery.     

Mesenteric venous thrombosis.

BACKGROUND: Mesenteric venous thrombosis is an uncommon but often lethal form of intestinal ischemia. METHODS: We reviewed pertinent literature on mesenteric venous thrombosis using MEDLINE search. RESULTS: We found that previous abdominal surgery and hypercoagulable states are the most common conditions associated with mesenteric venous thrombosis. The symptoms and signs related to mesenteric venous thrombosis are not specific. In the majority of cases, the diagnosis is established by a high index of clinical suspicion and noninvasive imaging techniques. Immediate operation is indicated if signs of peritonitis or intestinal infarction are present. Administration of heparin is beneficial for reducing recurrence and mortality. CONCLUSION: Clinicians should consider the possibility of acute mesenteric venous thrombosis when faced with a patient having abdominal pain out of proportion to the physical findings and with a negative workup for the common causes of abdominal pain.     

Does Gender Influence Emergency Department Management and Outcomes in Geriatric Abdominal Pain?

Prior studies have suggested gender-based differences in the care of elderly patients with acute medical conditions such as myocardial infarction and stroke, but it is unknown whether these differences are seen in the care of abdominal pain. The objective of this study was to examine differences in evaluation, management, and diagnoses between elderly men and women presenting to the Emergency Department (ED) with abdominal pain. For this observational cohort study, a chart review was conducted of consecutive patients aged 70 years or older presenting with a chief complaint of abdominal pain. Primary outcomes were care processes (e.g., receipt of pain medications, imaging) and clinical outcomes (e.g., hospitalization, etiology of pain, and mortality). Of 131 patients evaluated, 60% were women. Groups were similar in age, ethnicity, insurance status, and predicted mortality. Men and women did not differ in the frequency of medical (56% vs. 57%, respectively), surgical (25% vs. 18%, respectively), or non-specific abdominal pain (19% vs. 25%, respectively, p = 0.52) diagnoses. Similar proportions underwent abdominal imaging (62% vs. 68%, respectively, p = 0.42), received antibiotics (29% vs. 30%, respectively, p = 0.85), and opiates for pain (35% vs. 41%, respectively, p = 0.50). Men had a higher rate of death within 3 months of the visit (19% vs. 1%, respectively, p < 0.001). Unlike prior research in younger patients with abdominal pain and among elders with other acute conditions, we noted no difference in management and diagnoses between older men and women who presented with abdominal pain. Despite a similar predicted mortality and ED evaluation, men had a higher rate of death within 3 months.     

The use of abdominal computed tomography in older ED patients with acute abdominal pain

The objectives of this study were to determine the prevalence of use of abdominal computed tomography (CT) in older ED patients with acute nontraumatic abdominal pain, describe the most common diagnostic CT findings, and determine the proportion of diagnostic CT results. This was a prospective, observational, multicenter study of 337 patients 60 years or older. History was obtained prospectively; charts were reviewed for radiographic findings, dispositions, diagnoses, and clinical course, and patients were followed up at 2 weeks for additional information. The prevalence of use of abdominal CT was 37%. The most common diagnostic findings were diverticulitis (18%), bowel obstruction (18%), nephrolithiasis (10%), and gallbladder disease (10%). Eight percent of patients had findings suggestive of neoplasm. Overall, 57% of CT results were diagnostic (95% confidence interval [CI], 49%-66%), 75% (95% CI, 63%-84%) for patients requiring acute medical or surgical intervention, and 85% (95% CI, 62%-97%) for patients requiring acute surgical intervention. CT use is highly prevalent in older ED patients with acute abdominal pain. CT results are often diagnostic, especially for patients with emergent conditions.     

Is all pain is treated equally? A multicenter evaluation of acute pain care by age

Pain is highly prevalent in health care settings; however, disparities continue to exist in pain care treatment. Few studies have investigated if differences exist based on patient-related characteristics associated with aging. The objective of this study was to determine if there are differences in acute pain care for older vs younger patients. This was a multicenter, retrospective, cross-sectional observation study of 5 emergency departments across the United States evaluating the 2 most commonly presenting pain conditions for older adults, abdominal and fracture pain. Multivariable adjusted hierarchical modeling was completed. A total of 6,948 visits were reviewed. Older (⩾65 years) and oldest (⩾85 years) were less likely to receive analgesics compared to younger patients (<65 years), yet older patients had greater reductions in final pain scores. When evaluating pain treatment and final pain scores, differences appeared to be based on type of pain. Older patients with abdominal pain were less likely to receive pain medications, while older patients with fracture were more likely to receive analgesics and opioids compared to younger patients. Differences in pain care for older patients appear to be driven by the type of presenting pain.     

Abdominal pain in the HIV infected patient

The objectives of this study were to describe the clinical presentations and outcomes of all HIV+ patients who presented to the Emergency Department (ED) with a chief complaint of abdominal pain and to compare the outcomes of those with advanced disease (CD4 < 200/mm(3)) to those with early or middle stage disease (CD4 >or= 200/mm(3)). We conducted a retrospective chart review in an urban municipal hospital ED and included subjects if they were HIV+ and had a chief complaint of abdominal pain. Demographic and clinical data were entered into a standardized database; patients with advanced disease were compared with those with early or middle stage disease. One hundred eight patient visits were reviewed. The mean age was 37 +/- 7.6 years with mean CD4 count of 263/mm(3); 44% had CD4 counts <200/mm(3). Abdominal pain of unknown etiology, gastroenteritis/diarrhea, and ulcer disease/gastritis/dyspepsia were the three most common diagnostic categories for all patients. With the exception of disseminated mycobacterial disease, there were no statistically significant differences between the two groups. AIDS-associated opportunistic infections represented only 10% of the ED diagnosis of those patients with advanced disease. Only 8% of patients required intra-abdominal surgical procedures, however, 37% were admitted compared with 18% of patients without HIV disease (p < 0.001). Patients infected with HIV presenting with abdominal pain most often have a non-HIV related cause of abdominal pain and infrequently require surgery. However, HIV+ patients are admitted at twice the rate of the non-HIV infected population.     

Exercise-induced bilateral rectus sheath hematomas presenting as acute abdominal pain with scrotal swelling and pressure: case report and review

Rectus sheath hematoma (RSH) is an uncommon but significant cause of acute abdominal pain in patients presenting to the Emergency Department. RSHs are often misdiagnosed as other more common causes of abdominal pain. This case describes a 23-year-old male presenting with acute abdominal pain, scrotal swelling, and associated scrotal pressure. The case highlights the uniqueness of this particular presentation and the clinical features, risk factors, diagnosis, and treatment of RSH.     

Infected urachal cyst initially misdiagnosed as an incarcerated umbilical hernia

Background

Urachal abnormalities are a rare cause of lower abdominal pain. They are often initially mistaken for more common causes of lower abdominal pain, and the diagnosis is usually made during evaluation for one of these more common conditions.

Case Report

We report a case of a painful periumbilical mass ultimately diagnosed as an infected urachal cyst. Although the cyst was evident sonographically, it was misidentified as an umbilical hernia, and the correct diagnosis was not made until the patient underwent computed tomography of the abdomen and pelvis before surgery.

Conclusion

Emergency physicians should consider urachal disease in patients presenting with lower abdominal pain and should also be familiar with both the clinical and radiologic findings characteristic of this disease.     

Acute diverticulitis in patients 40 years of age and younger

Acute colonic diverticulitis typically occurs in patients older than 60 years of age but is uncommon in patients under the age of 40, which may lead to a delay in diagnosis. Because abdominal pain is a very common presenting symptom in emergency department patients, we retrospectively analyzed the cases of 21 patients 40 years of age and younger diagnosed with acute diverticulitis and characterized the presenting signs and symptoms, laboratory and radiographic findings, treatment, and outcome. There were 17 men and 4 women with a mean age of 34.1 +/-5.9 years. All patients had abdominal pain, with 14 (67%) patients noting pain in the left lower quadrant (LLQ) and 5 (24%) patients noting right lower quadrant (RLQ) pain. Nausea was present in 18 (86%) patients and fever in 15 (71%) patients. The mean pulse rate was 103 +/- 16 and the mean temperature was 100.7 +/- 1.4 F. Leukocytosis was present in 19 (90%) patients. Plain abdominal radiographs were obtained in 19 (91%) patients and were normal in 15 (79%) of these cases. Computed tomographic (CT) scans were obtained in 15 (71%) patients which revealed findings consistent with acute diverticulitis in 14 (93%) patients. The admitting diagnosis was diverticulitis in 10 of the 12 patients with LLQ tenderness and appendicitis in 4 of the 6 patients with RLQ tenderness. Overall, six patients were taken to surgery: three patients had cecal diverticulitis and three patients had perforated colonic diverticulitis. General treatment measures included bowel rest in 18 (86%) patients, and intravenous fluids and antibiotics in all patients. All patients survived. In conclusion, acute diverticulitis is uncommon in patients under 40 years of age; however, this condition may be confused with other conditions, usually acute appendicitis. As a result, clinicians should consider acute diverticulitis in young patients with acute abdominal pain, especially if they are male with nausea, fever, tachycardia, and leukocytosis, and consider obtaining a CT scan to aid in the diagnosis.     

Etiology of non-traumatic acute abdomen in pediatric emergency departments

Acute abdominal pain is a common complaint in pediatric emergency departments. A complete evaluation is the key factor approaching the disease and should include the patient’s age, any trauma history, the onset and chronicity of the pain, the related symptoms and a detailed physical examination. The aim of this review article is to provide some information for physicians in pediatric emergency departments, with the age factors and several causes of non-traumatic acute abdominal pain. The leading causes of acute abdominal pain are divided into four age groups: infants younger than 2 years old, children 2 to 5, children 5 to 12, and children older than 12 years old. We review the information about acute appendicitis, intussusception, Henoch-Schönlein purpura, infection, Meckel’s diverticulum and mesenteric adenitis. In conclusion, the etiologies of acute abdomen in children admitted to the emergency department vary depending on age. A complete history and detailed physical examination, as well as abdominal imaging examinations, could provide useful information for physicians in the emergency department to narrow the differential diagnosis of abdominal emergencies and give a timely treatment.     

Bowel obstruction and hernia

Bowel obstruction and abdominal hernia are commonly observed in patients seeking emergency care for abdominal pain. This article discusses bowel obstruction, adynamic ileus, acute colonic pseudo-obstruction, and abdominal hernias, with particular emphasis on the management of patients in the emergency department (ED). Although the diagnostic approach to bowel obstruction often requires imaging, abdominal hernia may be identified in most circumstances by history and physical examination alone. Urgent surgical consultation is indicated when there is a concern for bowel ischemia, strangulation, or complete obstruction. This article reviews an ED-based approach to the patient presenting with symptoms of bowel obstruction or hernia.     

Torsion of a wandering spleen: acute abdominal presentation

Torsion of a wandering spleen is a rare but fulminant condition and is part of the differential diagnosis in patients presenting with acute abdominal pain. It results due to absence or laxity of the various ligaments supporting the spleen. Patients may be asymptomatic or may present with acute abdominal pain. It may occur in people of all ages, with a predilection for male patients under 10 years of age and for female patients in older age groups, being most common in multiparous women. Early intervention is necessary to reduce the risk of splenic infarction and other complications. An awareness of the condition together with use of appropriate medical imaging can lead to the correct diagnosis.     

Acute abdominal pain in children

Acute abdominal pain in children presents a diagnostic dilemma. Although many cases of acute abdominal pain are benign, some require rapid diagnosis and treatment to minimize morbidity. Numerous disorders can cause abdominal pain. The most common medical cause is gastroenteritis, and the most common surgical cause is appendicitis. In most instances, abdominal pain can be diagnosed through the history and physical examination. Age is a key factor in evaluating the cause; the incidence and symptoms of different conditions vary greatly over the pediatric age spectrum. In the acute surgical abdomen, pain generally precedes vomiting, while the reverse is true in medical conditions. Diarrhea often is associated with gastroenteritis or food poisoning. Appendicitis should be suspected in any child with pain in the right lower quadrant. Signs that suggest an acute surgical abdomen include involuntary guarding or rigidity, marked abdominal distention, marked abdominal tenderness, and rebound abdominal tenderness. If the diagnosis is not clear after the initial evaluation, repeated physical examination by the same physician often is useful. Selected imaging studies also might be helpful. Surgical consultation is necessary if a surgical cause is suspected or the cause is not obvious after a thorough evaluation.     

急诊腹痛症状早期预警方法研究进展

急诊科就诊患者较多、拥挤是普遍现象,其中需要紧急救治的患者常常被延误治疗。医师延误对病情的评估、疾病的诊断和治疗,将导致不良结局的出现。腹痛占急诊就诊的6.8%,是急诊患者的最常见临床症状,其诊断繁多,包括良性疾病和威胁生命的疾病〔1〕。由于不同的腹痛病因引起的临床特点不同,从而使急诊医师更多地依赖于实验室检查。一项对急诊的研究表明,65%的相同的非创伤性腹痛患者至少要接受一项影像学检查〔2〕。实验室检查不仅增加了开销,延长了留观时间,而且加重了急诊室的拥挤现象。有调查显示,在过去     

Approach to acute abdominal pain

Evaluation of the emergency department patient with acute abdominal pain may be challenging. Many factors can obscure the clinical findings leading to incorrect diagnosis and subsequent adverse outcomes. Clinicians must consider multiple diagnoses with limited time and information, giving priority to life-threatening conditions that require expeditious management to avoid morbidity and mortality. This article seeks to provide the clinician with the clinical tools to achieve these goals by reviewing the anatomic and physiological basis of abdominal pain and key components of the history and the physical examination. In addition, this article discusses the approach to unstable patients with abdominal pain.     

Mesenteric venous thrombosis presenting as gastrointestinal bleeding,a challenging diagnosis

Acute mesenteric venous thrombosis (MVT) is an uncommon cause of intestinal ischemia and is associated with high morbidity and mortality. Patients with acute MVT often present with gastrointestinal (GI) bleeding and other unspecific findings making the diagnosis challenging. This condition requires emergent treatment. The high rates of misdiagnosis of these patients and subsequently the delay in proper and quick management put patients at increased risk of having a negative outcome. Physicians should suspect acute MVT in patients with GI bleed while also considering other factors such as, a past medical history of pro-thrombotic conditions, past surgical history of splenectomy, symptoms of nausea, vomiting, abdominal pain, physical exam findings of abdominal tenderness and abdominal distention and a laboratory workup indicating leukocytosis and an increased plasma lactic acid level. An increase in the yield of accurate diagnosis of acute MVT is possible if physicians in the ED accurately interpret all these findings. The authors herein present a case of acute MVT in a patient whose initial complaint was GI bleeding and provide a thorough review of the literature of cases of acute MVT presenting with GI bleed.     

Prognosis of elderly patients with non-specific abdominal pain.

OBJECTIVE: To examine the long term outcome of patients over 65 years presenting with acute non-specific abdominal pain. SETTING: District general hospital. DESIGN: Retrospective cohort survey. SUBJECTS: 43 patients with non-specific abdominal pain, median age 75.5 years, presenting in 1985. METHODS: Case notes were reviewed and a questionnaire sent to the patients' general practitioners to assess long term outcome. RESULTS: There was little evidence that these patients subsequently developed or died from a disease requiring surgery. However, this patient group did have a significantly poorer five year survival than a representative control group because of cardiorespiratory disorders. CONCLUSIONS: Non-specific abdominal pain in elderly patients should not be regarded as harmless but may have medical rather than surgical implications.