Abdominal Pain ============== þ Murphy Sign - LR 2.8 but CI 1.0 (Joe Suyama) - Boas Sign: specific for GB pain Hyperesthesia 10+12 vertebra area - an area of hyperaesthesia at the site of radiation of the pain to the back, typically, below the scapula þ RUQ pain: US, CT, or HB? - Harvey, R. T. and W. T. Miller, Jr. (1999). "Acute biliary disease: initial CT and follow-up US versus initial US and follow-up CT." Radiology 213(3): 831-6. PURPOSE: To evaluate the utility of ultrasonography (US) versus that of computed tomography (CT) for assessment of acute biliary disease. MATERIALS AND METHODS: Radiologic reports and clinical charts were reviewed in all patients who underwent US and CT within 48 hours of each other for evaluation of acute right upper quadrant pain. Radiologic findings and clinical outcome were correlated. RESULTS: CT was the initial imaging study in 57 patients, and CT findings resulted in underdiagnosis or misdiagnosis of acute biliary disease in eight of 11 patients. Follow-up US results were suggestive of the correct diagnosis and provided additional clinical information in seven of these eight patients. US findings resulted in altered clinical treatment in six of 11 patients with acute biliary disease. US was the initial study in 66 patients, and US findings were suggestive of biliary disease or the correct diagnosis in seven of seven patients with acute biliary disease. Follow-up CT did not result in changes in clinical treatment in any patient with acute biliary disease. CONCLUSION: Initial US is better than initial CT in patients suspected of having acute biliary disease. Follow-up CT provides no additional information regarding the biliary system, and its use should be limited to those patients with a wider differential diagnosis or with confusing clinical symptoms and signs. þ Labs: - Singer: no combination of labs predictive of + HIDA GB HB scan - Singer: A stepwise analysis failed to identify any combination of clinical variables that was associated with a higher probability of a positive HBS. [Singer, A. J., G. McCracken, et al. (1996). "Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis." Ann Emerg Med 28(3): 267-72. STUDY OBJECTIVE: To assess the ability of various clinical and laboratory parameters to predict the results of hepatobiliary scintigraphy (HBS) in patients with suspected acute cholecystitis. METHODS: This was a retrospective chart review of all patients referred from the emergency department for an HBS in 1993 to exclude acute cholecystitis. The setting was a university-affiliated tertiary care hospital with an annual census of approximately 42,000. The participants were 100 consecutive patients who were seen in the ED and had an HBS and obtainable medical records. Medical records of all patients referred from the ED for an urgent HBS in 1993 were retrospectively reviewed for the following information: demographics, historical information, physical findings, laboratory findings, biliary scintigraphic findings, and surgical pathologic findings. Comparisons were made between patients with a positive or negative HBS. Sensitivities, specificities, and positive and negative predictive values were calculated for dichotomous variables with a positive HBS as a control standard. A separate analysis was performed for patients with pathologically confirmed acute cholecystitis. RESULTS: Fifty-three patients had a positive HBS, and 47 had a negative HBS. A history of fever had a positive predictive value of 100% and a sensitivity of 14.6%. The presence of Murphy's sign was both sensitive (97.2%) and highly predictive (93.3%) of a positive HBS yet was not documented in 35 cases. All other variables were not found to be helpful in predicting the results of HBS. Pathologic diagnoses were available in 44 patients. Of 40 patients with pathologically confirmed acute cholecystitis, fever and leukocytosis were absent at the time of presentation in 36 (90%) and 16 (40%) of the cases, respectively. Murphy's sign was absent in 3 (10%) of 29 of these patients. A stepwise analysis failed to identify any combination of clinical variables that was associated with a higher probability of a positive HBS. CONCLUSION: No single or combination of clinical or laboratory findings at the time of ED presentation identified all patients with a positive HBS. Murphy's sign had the highest sensitivity and positive predictive value yet was poorly documented. Liberal use of biliary scintigraphy or ultrasound is encouraged to avoid underdiagnosis of acute cholecystitis.] þ Obturator Hernia - rare cause of abdominal pain, SBO; often discovered in OR for SBO. - can sometimes see on CT and Xray can be suggestive. - can mimic renal colic with pain to the flank or hip - Pressure on the obturator nerve causes pain in the medial thigh that is relieved by thigh flexion. This same pain may be exacerbated by extension or external rotation of the hip (Howship-Romberg sign). þ How to reduce a hernia (eMedicine) - The spontaneous reduction technique requires adequate sedation/analgesia, Trendelenburg positioning, and padded cold packs applied to the hernia for a duration of 20-30 minutes. This can be attempted prior to manual reduction attempts. - Provide adequate sedation and analgesia to prevent straining or pain. The patient should be relaxed enough to not increase intra-abdominal pressure or to tighten the involved musculature. - Place the patient supine with a pillow under his or her knees. - Place the patient in a Trendelenburg position of approximately 15-20ø for inguinal hernias. - Apply a padded cold pack to the area to reduce swelling and blood flow while establishing appropriate analgesia. - Place the ipsilateral leg in an externally rotated and flexed position resembling a unilateral frog leg position. - Place 2 fingers at the edge of the hernial ring to prevent the hernial sac from riding over the ring during reduction attempts. - Firm steady pressure should be applied to the side of the hernia contents close to the hernia opening, guiding it back through the defect. - Applying pressure at the apex, or first point, that is felt may cause the herniated bowel to "mushroom" out over the hernia opening instead of advancing through it. - Consult with a surgeon if reduction is unsuccessful after 1 or 2 attempts; do not use repeated forceful attempts. þ Strangulated Hernia - Strangulated hernias are differentiated from incarcerated hernias by the following: + pain out of proportion to examination findings + Fever or toxic appearance + Pain that persists after reduction of hernia (ischemic necrotic bowel) þ Pediatric Abdominal Pain þ Mesenteric Ischemia - may have elevated phosphate as well as lactate - angiogram is study of choice, but up to 80% sensitivity for arterial occlusion with spiral CT and large doses of IV contrast. (Per Kaveh Ilkanipour, February 2002) þ Testicular Torsion - often causes abdominal pain without testicular pain - every male with abdominal pain needs a testicular exam þ LLQ pain: - AAA tends to rupture down and left, mimicking diverticulitis þ Abdominal Exam in the Elderly þ Analgesics for Abdominal Pain þ Mesenteric Ischemia þ Ogilvie's Syndrome: - pseudo-obstruction of the large bowel from decreased motility þ Referred pain: small bowel refers to peri-umbilical area, but large bowel refers to suprapubic area; rectal and uterine refers to sacrum. þ Appendicitis: þ Biliary Colic þ Peritonitis: vs. Obstruction: constant pain crampy pain decreased sounds inreased sounds guarding no guarding tender nontender þ X-rays for free air - use L decubitus (L side down) so free air is silhouetted by liver. þ Abdominal pain with polycystic kidneys - A patient with polycystic kidney disease and renal failure presents with sudden onset of severe abdominal pain. What intestinal catastrophes are seen more commonly in patients with polycystic kidney disease? Diverticulitis and bowel perforation are commonly seen in these patients. Tintinalli 3rd ed. p 375 þ Abdominal Aortic Aneurysm (AAA):