Assessment Of Acute Abdominal Pain Research Articles

Abdominal Pain and Abdominal Mass

Acute abdominal pain and abdominal mass are intimately connected; therefore, the diagnostic process for evaluating abdominal pain and abdominal masses is largely the same and has been preserved since ancient times. The primary goals in the management of patients with abdominal pain and/or abdominal mass are to establish a differential diagnosis by obtaining a clinical history, to refine the differential diagnosis with a physical examination and appropriate studies, and to determine the role of operative intervention in the treatment or refinement of the working diagnosis. This review describes the process of diagnosing abdominal pain, including taking a clinical history and performing a physical examination. Investigative studies, including laboratory tests, imaging, and pathology are reviewed. Management, including surgical treatment, is discussed. Tables describe intraperitoneal and extraperitoneal causes of acute abdominal pain, frequency of specific diagnoses in patients with acute abdominal pain, and common abdominal signs and findings noted on physical examination. Figures show abdominal pain in specific locations, a data sheet, the differential diagnosis of an abdominal mass by quadrant or region, characteristic patterns of abdominal pain, acute appendicitis with associated appendicolith, bilateral adrenal masses, adrenocortical carcinoma, retroperitoneal leiomyosarcoma, pancreatic mass, a sagittal ultrasonogram of the pancreas, ultrasonograms of the liver, a dark and well circumscribed abdominal mass, gastroesophageal junction adenocarcinoma, and percutaneous biopsy of a large abdominal mass. An algorithm outlines the assessment of acute abdominal pain and abdominal mass. This review contains 16 figures, 5 tables, and 164 references. Keywords: anatomy, swellings, inflammatory, opioid, palpatation, PET, COVID 19

Abdominal Pain and Abdominal Mass

Acute abdominal pain and abdominal mass are intimately connected; therefore, the diagnostic process for evaluating abdominal pain and abdominal masses is largely the same and has been preserved since ancient times. The primary goals in the management of patients with abdominal pain and/or abdominal mass are to establish a differential diagnosis by obtaining a clinical history, to refine the differential diagnosis with a physical examination and appropriate studies, and to determine the role of operative intervention in the treatment or refinement of the working diagnosis. This review describes the process of diagnosing abdominal pain, including taking a clinical history and performing a physical examination. Investigative studies, including laboratory tests, imaging, and pathology are reviewed. Management, including surgical treatment, is discussed. Tables describe intraperitoneal and extraperitoneal causes of acute abdominal pain, frequency of specific diagnoses in patients with acute abdominal pain, and common abdominal signs and findings noted on physical examination. Figures show abdominal pain in specific locations, a data sheet, the differential diagnosis of an abdominal mass by quadrant or region, characteristic patterns of abdominal pain, acute appendicitis with associated appendicolith, bilateral adrenal masses, adrenocortical carcinoma, retroperitoneal leiomyosarcoma, pancreatic mass, a sagittal ultrasonogram of the pancreas, ultrasonograms of the liver, a dark and well circumscribed abdominal mass, gastroesophageal junction adenocarcinoma, and percutaneous biopsy of a large abdominal mass. An algorithm outlines the assessment of acute abdominal pain and abdominal mass. This review contains 14 figures, 5 tables, and 143 references.

Point-of-care ultrasound for evaluating intra-abdominal calcification in the pediatric emergency department: case series and review of literature

BackgroundThe presence of intra-abdominal calcification in the pediatric population can be due to a wide range of conditions. Calcification in the abdomen can be seen in normal or abnormal anatomical structures. In some patients, abnormal calcification points towards the pathology; whereas in others, calcification itself is the pathology. After a thorough history and clinical examination, point-of-care ultrasound (POCUS) would complement the assessment of acute abdominal pain, based on the list of differentials generated as per the abdominal region. The main objective of this article is to review commonly encountered causes of intra-abdominal calcifications in the pediatric population and help in clinical decision-making in a Pediatric Emergency Department.Case presentationWe describe a series of pediatric patients who presented to the Pediatric Emergency Department with acute abdominal pain, in whom point-of-care ultrasound helped expedite the diagnosis by identifying varying types of calcification and associated sonological findings. For children who present to the Pediatric Emergency Department with significant abdominal pain, a rapid distinction between emergencies and non-emergencies is vital to decrease morbidity and mortality.ConclusionsIn a child presenting to the Pediatric Emergency Department with abdominal pain, POCUS and the findings of calcifications can narrow or expand the differential diagnosis when integrated with history and physical exam, to a specific anatomic structure. Integrating these findings with additional sonological findings of an underlying pathology might raise sufficient concerns in the emergency physicians to warrant further investigations for the patient in the form of a formal radiological ultrasound and assist in the patient's early disposition. The use of POCUS might also help to categorize the type of calcification to one of the four main categories of intra-abdominal calcifications, namely concretions, conduit wall calcification, cyst wall calcification, and solid mass-type calcification. POCUS used thoughtfully can give a diagnosis and expand differential diagnosis, reduce cognitive bias, and reduce physician mental load. By integrating the use of POCUS with the history and clinical findings, it will be possible to expedite the management in children who present to the Pediatric Emergency Department with acute abdominal pain.

Towards remote assessment and screening of acute abdominal pain using only a smartphone with native accelerometers

Smartphone-based telehealth holds the promise of shifting healthcare from the clinic to the home, but the inability for clinicians to conduct remote palpation, or touching, a key component of the physical exam, remains a major limitation. This is exemplified in the assessment of acute abdominal pain, in which a physician’s palpation determines if a patient’s pain is life-threatening requiring emergency intervention/surgery or due to some less-urgent cause. In a step towards virtual physical examinations, we developed and report for the first time a “touch-capable” mHealth technology that enables a patient’s own hands to serve as remote surrogates for the physician’s in the screening of acute abdominal pain. Leveraging only a smartphone with its native accelerometers, our system guides a patient through an exact probing motion that precisely matches the palpation motion set by the physician. An integrated feedback algorithm, with 95% sensitivity and specificity, enabled 81% of tested patients to match a physician abdominal palpation curve with <20% error after 6 attempts. Overall, this work addresses a key issue in telehealth that will vastly improve its capabilities and adoption worldwide.

Overview of point-of-care abdominal ultrasound in emergency and critical care.

Point-of-care abdominal ultrasound (US), which is performed by clinicians at bedside, is increasingly being used to evaluate clinical manifestations, to facilitate accurate diagnoses, and to assist procedures in emergency and critical care. Methods for the assessment of acute abdominal pain with point-of-care US must be developed according to accumulated evidence in each abdominal region. To detect hemoperitoneum, the methodology of a focused assessment with sonography for a trauma examination may also be an option in non-trauma patients. For the assessment of systemic hypoperfusion and renal dysfunction, point-of-care renal Doppler US may be an option. Utilization of point-of-care US is also considered in order to detect abdominal and pelvic lesions. It is particularly useful for the detection of gallstones and the diagnosis of acute cholecystitis. Point-of-case US is justified as the initial imaging modality for the diagnosis of ureterolithiasis and the assessment of pyelonephritis. It can be used with great accuracy to detect the presence of abdominal aortic aneurysm in symptomatic patients. It may also be useful for the diagnoses of digestive tract diseases such as appendicitis, small bowel obstruction, and gastrointestinal perforation. Additionally, point-of-care US can be a modality for assisting procedures. Paracentesis under US guidance has been shown to improve patient care. US appears to be a potential modality to verify the placement of the gastric tube. The estimation of the amount of urine with bladder US can lead to an increased success rate in small children. US-guided catheterization with transrectal pressure appears to be useful in some male patients in whom standard urethral catheterization is difficult. Although a greater accumulation of evidences is needed in some fields, point-of-care abdominal US is a promising modality to improve patient care in emergency and critical care settings.

MR Imaging of Acute Abdomen and Pelvis

Magnetic resonance imaging (MRI), although not usually the first diagnostic study in assessment of acute abdominal pain, can offer a radiation-free high tissue-contrast resolution alternative to CT. MRI can be particularly useful in assessment of young or pregnant patients, or patients with renal insufficiency precluding administration of intravenous contrast. In this article, we review MRI appearance of a number of acute abdominal and pelvic processes, including hemorrhage and various ischemic, inflammatory, and infectious conditions.

Importance of a Physical Examination for Efficient Differential Diagnosis of Abdominal Pain: Diagnostic Usefulness of Carnett's Test in Psychogenic Abdominal Pain

Abdominal pain can be a challenging complaint for both primary care and specialist physicians because it is frequently a benign complaint, but it can also herald a serious acute clinical condition. An epidemiologic assessment of acute abdominal pain is classified in outpatients complaining of abdominal pain on their first visit to primary care physicians including the following: whole abdominal, epigastric, right subcostal, left subcostal, right flank, left flank, periumbilical, right-lower, mid-lower, and left lower pain (1). Abdominal pain can be categorized as follows: intra-abdominal pain, abdominal wall pain, and referred pain. Patients are often subjected to a variety of procedures in an attempt to find a cause for the abdominal pain. Failure to find a visceral cause for the pain may prompt the physician to apply a functional or psychosomatic label to the patient, with any treatment directed along those lines. However, awareness that abdominal pain may have a non-visceral origin can forestall a fruitless search for intra-abdominal pathology. Abdominal wall pain is most commonly diagnosed on the basis of a patient’s history and a physical investigation. A careful history and examination, and noticing symptoms arising from abdominal wall pain, might lead to an accurate diagnosis and appropriate treatment, and it could avoid negative examinations (2-5). Carnett’s test is a clinical test in which abdominal tenderness is evaluated. It is useful for differentiating abdominal wall pain from intra-abdominal pain. While supine, the patient is asked to perform a straight-leg-raising maneuver while the examiner’s hand touches the painful site. Raising only the head while in the supine position achieves the same purpose. These maneuvers tighten the rectus abdominis muscles, increasing the pain from the entrapped nerve. True visceral sources of pain are associated with less tenderness when abdominal muscles are tense (2, 6). A previous study reported that Carnett’s test has a sensitivity of 81% and a specificity of 88%. The constant site of tenderness has the highest sensitivity (97%) but the lowest specificity (54%), whereas superficial tenderness has the highest specificity (90%) with a sensitivity of 84%. Another study, proposed criteria for diagnosing abdominal wall pain, and tested 33 patients with abdominal wall pain compared with 62 patients with intra-abdominal pain; they found a sensitivity of 85% and specificity of 97%, which appeared to be better than those for the Carnett’s test alone (9). This suggests that clinical methods are sufficient to diagnose abdominal wall pain in most cases and can be used to rule out other possible diagnoses (Table 1) (7-11). If Carnett’s test is positive, pain relief after an accurately placed nerve block or trigger point anesthesia injection can lead to diagnostic therapy. Pain relief with anesthesia injection affords excellent reassurance to the patient when effective (3, 12, 13). Carnett’s test may not be interpretable in patients who cannot adequately comply with leg or head-raising maneuvers. False positive results may occur from visceral causes of pain that involve the local parietal peritoneum (14). Psychogenic abdominal pain is inextricably linked to the origin of pain. The pain is often described as severe and persistent, having been experienced for several years and being constantly present. The pain is consistent with the anatomy of the nervous system, and no organic pathological or pathophysiological mechanism can be classified to the physical findings. Patients usually appear well compared with intra-abdominal patients (15, 16). In this issue of Internal Medicine, Takada et al evaluated the diagnostic usefulness of Carnett’s test for psychogenic abdominal pain, which was established by a retrospective study in 5,399 outpatients with abdominal pain. The differentiation of psychogenic abdominal pain from intra-abdominal pain has not yet

Assessment of the acute abdomen: role of the plain abdominal radiograph

Assessment of the acute abdomen: role of the plain abdominal radiograph Frances A Hampson, Ashley S ShawDepartment of Radiology, Addenbrooke&rsquo;s Hospital, Cambridge, UKAbstract: &lsquo;The acute abdomen&rsquo; is one of the most frequent reasons for presentation to the emergency department. There are a multitude of potential causes. Imaging plays a vital role in making an accurate and timely diagnosis, which in turn reduces morbidity and mortality. Plain abdominal radiography has traditionally been considered a fundamental part of the initial assessment of acute abdominal pain. However, with the increasing availability of computed tomography, ultrasound, and magnetic resonance imaging, the role of the plain abdominal radiograph has been increasingly questioned and its use is dwindling. During the course of this review, we will describe the current guidelines for the use of the plain abdominal radiograph and assess its potential diagnostic yield. We will also discuss its current applications in the context of the acute abdomen both in general and in a number of frequently encountered conditions and illustrate when other imaging modalities would be better employed.Keywords: acute abdomen, abdominal radiograph

Severity of appendicitis correlates with the pediatric appendicitis score

The pediatric appendicitis score (PAS) has been used as a diagnostic tool for the assessment of acute abdominal pain. Our institution has utilized this scoring system as part of a clinical pathway for acute appendicitis. We sought to discover if the PAS could also serve as a prognostic indicator. Patients treated within the clinical pathway were divided into three groups (A, B, and C) based on the PAS assigned on admission. Data pertaining to intraoperative findings and length of hospital stay were collected prospectively. In 4 months, 112 patients were enrolled in the study (median age 10.5, range 1-18). 69 of these patients underwent early laparoscopic appendectomy. For group A, 75% had simple appendicitis and 5% were complex. For group B, 68.4% patients had simple appendicitis and 26.3% were complex. For group C, 27.3% were simple and 63.6% were complex. Mean length of hospital stay increased from 1.63 ± 0.34 for patients in group A to 5.9 ± 1.37 for patients in group C. Our observational data suggests that the PAS may be a prognostic tool for acute appendicitis. It thereby may impact on preoperative management and postoperative clinical pathways. A larger cohort is necessary to validate our findings.

Validity of tests performed to diagnose acute abdominal pain in patients admitted at an emergency department

To determine the real importance of anamnesis, physical examination, and various tests in the assessment of acute abdominal pain. A retrospective observational study with patients complaining of abdominal pain at the Emergency Department, Altiplano Health Area (Murcia) was performed. In our study we considered the following variables: socio-demographic data, history of previous surgery, symptoms, place and type of pain. Imaging tests were labeled as positive, negative, or inconclusive for assumed diagnoses, which were retrospectively assessed by an external radiologist who was unaware of the patient s final diagnosis. Our study includes 292 patients with a mean age of 45.49 years; 56.8% of these patients were women. Regarding the frequency of the different acute abdomen diagnoses, appendicitis was the main cause (approx. 25%), followed by cholecystitis (10%). We found a significant diagnostic correlation between pain location in the right hypochondrium (RHC) and a diagnosis with cholecystitis. This location was also significant for acute appendicitis (up to 74%). Regarding clinical signs, we only observed a significant correlation between fever and viscera perforation, and between Murphy s sign and cholecystitis. Sensitivity and specificity found in relation to the psoas sign were similar to those seen in other series, 16 and 95% respectively, and slightly lower than the Blumberg or rebound sign, which we found to be around 50 and 23%, respectively. a) Anamnesis and physical examination offer limited accuracy when assessing acute abdomen; b) ultrasound scans offer a low diagnostic agreement index for appendicitis; and c) laparoscopy may prove useful for diagnosis, and is also a possible treatment for acute abdominal pain despite its low diagnostic efficiency.

Assessment of Acute Abdominal Pain: Utility of a Second Cross-sectional Imaging Examination

To retrospectively determine how often a second cross-sectional imaging examination provides useful additional information or alters management of acute abdominal pain. The research ethics board approved this study; the informed consent requirement was waived. Authors assessed imaging reports and clinical charts of adult patients who presented to the emergency department and underwent both computed tomography (CT) and ultrasonography (US) of the abdomen within 72 hours. A total of 255 patients fulfilled study criteria. The second examination was categorized as providing additional useful information, providing no additional useful information, or providing contradictory information. It was also noted whether the second examination was recommended because of findings of the first and whether the results of the second altered clinical management. Follow-up was available in 149 patients, and a definitive diagnosis was established. For these patients, it was determined whether either examination favored the correct diagnosis. Fisher exact test, one- and two-sample tests for equality of proportions with continuity correction, and the chi(2) test were used, where appropriate. In 85 patients (33.3%), findings of the second examination agreed with those of the first examination and provided additional information. In 153 patients (60.0%), findings of the second examination agreed with those of the first examination and provided no additional information. In 17 patients (6.7%), findings of the second examination were contradictory to findings of the first examination. The percentage of follow-up CT examinations that provided no additional useful information was significantly lower when recommended by the radiologist (38%) than when recommended by someone else (72%, P < .001). The percentage of follow-up US examinations that provided no additional useful information was significantly lower when recommended by the radiologist (42%) than when recommended by someone else (74%, P = .003). In the 149 patients in whom a final diagnosis was available, both sets of scans were correct in 87 patients (58.4%); only the second set of scans was correct in 43 (28.8%). Overall, findings of the second examination led to a change or could have led to a change in treatment of 23 patients (9.0%). A second examination is significantly more likely to be useful when performed because of radiologist recommendation.

Role of fine catheter peritoneal cytology and laparoscopy in the management of acute abdominal pain

Laparoscopy and fine catheter peritoneal cytology (FCPC) have been advocated as aids in the assessment of acute abdominal pain. In all, 411 patients admitted to a district general hospital during a 10-month period were managed using a standard protocol incorporating these techniques. After initial assessment by a surgical registrar, 151 patients were excluded from further progress through the protocol (age less than 16 years, definite diagnosis made or contraindication to FCPC. The remaining 260 patients were placed in one of four management groups: (A) urgent operation (23 patients); (B) 'look and see' (40 patients); (C) 'wait and see' (59 patients); (D) urgent operation not indicated (138 patients). Eighty-eight of 99 patients (88 per cent) in groups B and C, where the need for operation was uncertain, underwent successful FCPC and 39 patients (39 per cent) underwent laparoscopy. In these patients the initial registrar management decision proved to be incorrect in 33 cases (33 per cent), but by following the protocol the number of management errors actually made was reduced to 13 (13 per cent, P less than 0.001). This would have been reduced to 8 per cent if the protocol had not been violated in five patients. This study demonstrates the effectiveness of a protocol using FCPC and laparoscopy to improve the management of patients with acute abdominal pain.

Do Plain Abdominal Radiographs Have Any Place in the Modern Accident and Emergency Department?

Study Objectives: Abdominal x-rays (AXRs) are widely used in the assessment of acute abdominal pain despite their poor diagnostic yield. An audit was performed to determine the usage of AXRs in the assessment of abdominal pain and to determine whether they contributed any information towards the diagnosis and eventual management of patients presenting to our emergency department (ED).

Reliability and validity of a visual analog scale for acute abdominal pain in the ED

The objective of the study was to assess the validity and reliability of the visual analog scale (VAS) in the measurement of acute abdominal pain, and to identify the minimum clinically significant difference in VAS scores among patients with acute abdominal pain. The study was undertaken in preparation for a randomized clinical trial of opioid use in acute abdominal pain. A prospective, observational cohort study of a convenience sample of patients presenting to 2 urban EDs with the chief complaint of acute abdominal pain was conducted. At time 0 and 1 minute later each subject indicated pain severity on a 100mm VAS. This was repeated every 30 minutes for 2 hours. Patients were also asked to contrast their current pain severity with their pain in the preceding 30 minutes using one of 5 graded verbal descriptors: “much less pain,” “little less pain,” “the same pain,” “little more pain,” and “much more pain.” Validity was assessed by performing an analysis of variance for linear trend on the association between the 5 categorical pain descriptors and change in VAS scores. Reliability was assessed using the intra-class correlation coefficient (ICC) between VAS scores taken 1 minute apart, supplemented by a Bland-Altman analysis. The minimum clinically significant difference in pain was defined as the mean difference between sequential VAS scores obtained 30 minutes apart when the patient noted a “little less” or “little more” pain. Differences in VAS scores increased linearly as pain descriptors escalated from “much less” to “much more” pain (P <.001). Reliability was high, ICC = 0.99 [95%CI 0.989 to 0.992] for 0 and 1 minute VAS scores. The minimum clinically significant difference in acute abdominal pain was 16 mm (95% CI 13, 18 mm). VAS measures of acute abdominal pain are valid and reliable. The 95% CI surrounding the minimum clinically significant difference of approximately 16mm overlaps with the 95% CI of minimum clinically significant difference of approximately 13mm reported previously in traumatic and other types of acute pain. We conclude that the VAS is a methodologically sound instrument for quantitative assessment of acute abdominal pain and for detecting clinically important changes in such pain. (Am J Emerg Med 2002;20:287-290. Copyright 2002, Elsevier Science (USA). All rights reserved.)

Acute abdomen in the child

The acute abdomen in childhood demands early diagnosis for the sake of appropriate and early therapy. A high number of differential diagnosis in the assessment of acute abdominal pain and problems, as well as different causes of diseases in different age of the children, make a partition with respect to the age of the children considerable. A partition in diseases, which are leading to acute abdominal pain in neonates, in toddlers and small infants and in schoolchildren makes sense. In older schoolchildren and adolescents also diseases of the grown up generation are possible as a cause of acute abdominal pain. The lack of compliance (cooperation and communication) in small children obstructs clinical and radiological assessment and elucidates the necessity of knowledge of causes of acute abdominal pain as much as possible. A lot of patience and experience are mandatory in the evaluation of small children and therefore make a dedicated, trained and experienced stuff necessary. A dedicated paediatric radiologist will find a safe and proper technique, and in cooperation with the referring clinician the necessary decision for therapy will be made.

Computers in medical education 2. Use of a computer package to supplement the clinical experience in a surgical clerkship: an objective evaluation.

Student teaching of surgery has been devolved from the university in an effort to increase and broaden undergraduate clinical experience. In order to ensure uniformity of learning we have defined learning objectives and provided a computer-based package to supplement clinical teaching. A study was undertaken to evaluate the place of computer-based learning in a clinical environment. Twelve modules were provided for study during a 6-week attachment. These covered clinical problems related to cardiology, neurosurgery and gastrointestinal haemorrhage. Eighty-four fourth-year students undertook a pre- and post-test assessment on these three topics as well as acute abdominal pain. No extra learning material on the latter topic was provided during the attachment. While all students showed significant improvement in performance in the post-test assessment, those who had access to the computer material performed significantly better than did the controls. Within the topics, students in both groups performed equally well on the post-test assessment of acute abdominal pain but the control group's performance was significantly lacking on the topic of gastrointestinal haemorrhage, suggesting that the bulk of learning on this subject came from the computer material and little from the clinical attachment. This type of learning resource can be used to supplement the student's clinical experience and at the same time monitor what they learn during clinical clerkships and identify areas of weakness.

Oral cholecystography in assessment of acute abdominal pain.

During one year, 77 patients had oral cholecystography within five days of the onset of acute upper abdominal symptoms. These patients were not severely ill, as evidenced by the fact that only 18 were hospitalized. The patients were unselected and the results were reviewed in retrospect. Accordingly, the data cannot be critically analyzed. Nonetheless, diagnostically useful information was obtained in 57 of these cases. In 44 patients, a normal gallbladder was visualized, and in 13 patients gallstones were seen. Three conclusions are derived from this study. First, oral cholecystography can be performed within five days of the onset of acute upper abdominal symptoms with a reasonable expectation of obtaining diagnostically useful information. Second, the usually recommended delay of four to six weeks is unnecessary. Finally, this diagnostic study should be performed in the acute situation when it is not precluded by nausea, vomiting, or a severely ill patient.