Early analgesia for children with acute abdominal pain

OBJECTIVES

The objectives of this study were to determine whether the administration of morphine to children with acute abdominal pain would impede the diagnosis of appendicitis and to determine the efficacy of morphine in relieving the pain.

METHODS

This was a double-blind, randomized, placebo-controlled trial involving 5- to 16-year-old children who presented to the emergency department of a children's hospital with a chief complaint of acute abdominal pain that was thought by the pediatric emergency attending physician to require a surgical consultation. Subjects were randomized to receive intravenously administered morphine or normal saline solution. Clinical data and the emergency physician's confidence in his or her clinical diagnosis (0-100%) were recorded systematically with a standardized form. This was repeated 15 minutes after administration of the study medication. The surgeon assessed the child within 1 hour and completed a similar data collection sheet. Pain was assessed, with a color analog scale, before and after study medication administration. Each subject was monitored for 2 weeks after enrollment.

RESULTS

One hundred eight children were enrolled; 52 received morphine and 56 received a placebo saline solution. There were no differences between groups in demographic variables or the degree of pain. There were no differences between groups in the diagnoses of appendicitis or perforated appendicitis or the number of children who were observed and then underwent laparotomy. The reduction in the mean pain score was significantly greater in the morphine group (2.2 vs 1.2 cm). The emergency physicians' and surgeons' confidence in their diagnoses was not affected by the administration of morphine.

CONCLUSIONS

Our data show that morphine effectively reduces the intensity of pain among children with acute abdominal pain and morphine does not seem to impede the diagnosis of appendicitis.

Acute abdomen: an unusual case of ruptured tuberculous mesenteric abscess

BACKGROUND

Abdominal tuberculosis is an uncommon extra-pulmonary manifestation of tuberculosis.

METHODS

Case report and literature review.

RESULTS

Herein, we report an unusual case of ruptured tuberculous mesenteric cold abscess, which was managed by laparotomy for diagnosis and drainage, and post-operative chemotherapy.

CONCLUSIONS

Peritoneal tuberculosis may present to surgeons as ascites, an abdominal mass, or peritonitis. Preoperative diagnosis of abdominal tuberculosis is notoriously difficult. Acute peritonitis provoked by rupture of tuberculosis mesenteric cold abscess is exceedingly rare. Surgical intervention is warranted for diagnosis and drainage.

Neurological manifestations of an acute abdomen in children

The acute abdomen in the pediatric age group is not infrequently fraught with diagnostic pitfalls. The younger the patient, the more problematic the presentation can be. Among the more unusual manifestations of an acute abdomen is an apparent encephalopathic picture. We present 2 cases which serve to illustrate the diagnostic difficulties encountered.

Approach to the acute abdomen

Acute abdomen is a common clinical complaint identified in small animal patients. Success results from a proactive approach to management,including rapid stabilization of major body systems, early identification of the inciting problem(s), attention to comorbid conditions, and timely definitive therapy.

[Acute abdominal surgical pathology complicated with haemorrhagic shock in elderly patients treated in intensive care unit]

Elderly patients suffering from acute surgical pathology and severe medical comorbidities present serious "mix-cases" and their multiple organ detorioration requires perioperative intensive care.

GOAL OF THE STUDY

analysis of outcome of elderly patients, aged 65 years and over, suffering from acute abdominal surgical pathology associated with haemorrhagic shock.

MATERIALS AND METHODS

17,573 patients were treated in the 2nd Chair and Department of Surgery in Jagiellonian University Hospital within 01.07.1997 and 30.06.2003. 365 patients, aged >65 yrs underwent surgery because of acute abdominal pathology; 86 cases out of this group presented haemorrhagic shock, 69 of them had bleeding into the gastrointestinal tract, and in 17 there was diagnosed ruptured abdominal aortic aneurysm. The principles of the diagnosis and the therapy were common for both groups. The analysis included: mortality rate, duration of hospital and intensive care unit (ICU) stay, continuous assessment based on APACHE II (Acute Physiology And Chronic Health Evaluation) and TISS-28 (Therapeutic Intervention Scoring System).

RESULTS

Mortality rate was 71.01% in the group of 69 patients with gastrointestinal bleeding (there is no comparative data based on relevant cases in the literature), and 58.8% in the group with ruptured abdominal aneurysm. The difference in those values was caused by prolonged time (i.e. days), which elapsed from the onset of symptoms of pathology and commencing surgery and intensive therapy. In the group with ruptured aneurysm, the dramatic onset of symptoms reduced the time between commencing of pathology and the intensive treatment and procedure.

Polymicrobial bacteremia caused by Escherichia coli, Edwardsiella tarda, and Shewanella putrefaciens

Edwardsiella tarda, a member of Enterobacteriaceae, is found in freshwater and marine environments and in animals living in these environments. This bacterium is primarily associated with gastrointestinal diseases, and has been isolated from stool specimens obtained from persons with or without clinical infectious diseases. Shewanella putrefaciens, a saprophytic gram-negative rod, is rarely responsible for clinical syndromes in humans. Debilitated status and exposure to aquatic environments are the major predisposing factors for E. tarda or S. putrefaciens infection. A 61-year-old woman was febrile with diarrhea 8 hours after ingesting shark meat, and two sets of blood cultures grew Escherichia coli, E. tarda and S. putrefaciens at the same time. She was successfully treated with antibiotics. We present this rare case of polymicrobial bacteremia caused by E. coli, E. tarda and S. putrefaciens without underlying disease, which is the first found in Taiwan. This rare case of febrile diarrhea with consequent polymicrobial bacteremia emphasizes that attention should always be extended to these unusual pathogens.

Epiploic appendagitis

This case report describes epiploic appendagitis in an elderly lady who presented with acute abdomen. The condition was diagnosed on CT scan and the patient treated conservatively.

Therapeutic impact of abdominopelvic computed tomography in patients with acute abdominal symptoms

PURPOSE

To determine the diagnostic and therapeutic impact of abdominopelvic computed tomography (CT) in patients with acute abdominopelvic pain.

MATERIAL AND METHODS

Referring clinicians completed pre-CT and post-CT questionnaires for 50 patients in whom CT had been requested because of acute abdominopelvic pain. Clinicians recorded their leading diagnosis, confidence in this, and intended management. Following CT, clinicians again recorded these responses in the light of CT findings. Responses pre-CT and post-CT were compared in order to determine diagnostic and therapeutic impact.

RESULTS

Diagnostic confidence rose significantly following CT (mean score 6.8 pre-CT versus 8.3 post-CT; P<0.0001). Intended management changed because of CT findings in 29 (58%) patients: 14 (28%) subjects whose intended management was surgical were treated medically and an additional 2 were transferred to gynecological care; 4 patients whose intended management was medical were treated surgically; 2 patients whose intended management was medical were treated by percutaneous drainage; a patient whose intended management was percutaneous drainage was treated by surgery. Of 6 patients with uncertain management pre-CT, 2 were treated surgically and 4 medically. The leading diagnosis also changed as a consequence of CT in 7 (33%) of 21 patients in whom intended management did not alter.

CONCLUSION

CT in patients with acute abdominopelvic pain has considerable diagnostic and therapeutic impact, altering management in 58% of patients studied. The major effect is to avert intended laparotomy.

Dehydration related abdominal pain (DRAP)

OBJECTIVE

To describe the frequency of dehydration as a medical cause of acute abdomen.

DESIGN

Cross-sectional analytical study.

PLACE AND DURATION OF STUDY

The study was conducted at Combined Military Hospital, Malir Cantonment Karachi between March 1, 2000 to March 1, 2002.

SUBJECTS AND METHODS

All the patients reporting with abdominal pain to the surgical outpatient department or the emergency department, were reviewed in the study. The clinical findings in all these cases were studied along with the mode of their management and outcome.

RESULTS

Of all the patients presenting with abdominal pain, 303% (n=68) were suffering from dehydration related abdominal pain. They were predominantly males in a ratio of 8.7:1, mostly in the 2nd and 3rd decades of their lives. All these cases were suffering from acute or chronic dehydration were provisionally diagnosed by general practitioners as 'acute abdomen' and referred for surgical consultation. Associated symptoms included vomiting in 42.6% backache in 91.2%, headache in 95.6%, and pain in lower limbs in 97.1% of the cases. 83.8% required indoor management with intravenous fluids. All the patients became asymptomatic with rehydration therapy.

CONCLUSION

Dehydration is a possible cause of severe abdominal pain. There is a need to educate the general public about the benefits of adequate fluid intake.

Laktatacidose und akutes Abdomen bei Biguanidintoxikation

Metformin, an anti-hyperglycaemic drug, reduces mortality in obese patients with a non-insulin-dependent diabetes mellitus type II (United Kingdom Prospective Diabetes Study) and is therefore recommended as the first line therapy. A metformin-associated lactic acidosis due to accumulation or intoxication is a rare but severe complication with a mortality rate of up to 50%. The main clinical symptoms are unspecific and the patient may present with acute abdominal pain and reduced consciousness. This can easily be misinterpreted and may lead to a wrong diagnosis. Only a thorough clinical examination and exact analysis of laboratory values in combination with the medical history and chronic medication will allow a correct diagnosis. We report a case of a 79-year-old female patient whose clinical symptoms were initially interpreted as an acute intestinal ischemia. A progressively deteriorating haemodynamic state led to an exploratory laparotomy. Postoperatively, the correct diagnosis of a metformin-associated lactic acidosis due to acute renal failure was made. In the course of the ICU stay the condition improved after bicarbonate haemodialysis and the patient was discharged 11 days after admission.

[Intraabdominal focal fat infarction]

BACKGROUND

Intraabdominal focal fat infarction is an acute abdominal condition unfamiliar to many doctors. Until recently it has only been diagnosed perioperatively, but since 1985 several authors report the use of imaging modalities and a spontaneous regression of this disorder.

MATERIAL AND METHODS

Report of two cases and a review of the literature.

RESULTS

Intraabdominal focal fat infarction presents characteristic imaging findings with ultrasonography and computer tomography. A well-defined lesion of fat with oedema is found in the location of maximum tenderness.

INTERPRETATION

Doctors dealing with the acute abdomen, particularly radiologists and surgeons, should be aware of this condition. With a confident diagnosis, unnecessary surgery may be avoided.

Surgical complications of selected gastrointestinal emergencies: pitfalls in management of the acute abdomen

Complaints referable to the abdomen are common emergency department presentations. Many of these conditions prove to be benign and self-limited, whereas others are potentially catastrophic. Because serious and benign intra-abdominal conditions share many relatively nonspecific symptoms, it is often difficult to identify patients who have life-threatening problems early in the course of their disease. Apart from relieving the patient's symptoms, the emergency physician's primary role is to detect and stabilize life-threatening conditions in a rapid and cost-effective manner.

Study of the clinical effects of postoperative parenteral nutrition in 15 horses

Several clinical variables were compared in two groups of 15 horses recovering from resection and anastomosis of a strangulated small intestine; 15 were treated with parenteral nutrition and 15 were starved routinely. There was some evidence that parenteral nutrition had a short-lived adverse effect on both the catheter sites and gastric emptying, but there were no marked adverse clinical effects and no evidence of any improvement in the horses' condition.

[Osler's hereditary angioneurotic edema as rare but possible cause of false surgical acute abdomen]

The authors are presenting one case of Osler's hereditary angioneurotic oedema, rare genetic disease with dominant autosomal transmission linked to the 11-th chromosome, with clinical aspects resembling to those of surgical acute abdomen, with difficult diagnostic problems. The treatment consist in: fresh plasma administration, antihistaminic drugs and anabolic steroids. The simple laparotomy under general anaesthesia by orotraheal intubation being very dangerous. The patients with Osler's hereditary angioneurotic oedema must be followed-up by the allergology services and educated regarding the disease and it's risks to avoid diagnostic errors with following negative consequences.

[Prospective observation of abdominal ultrasound in radiological emergency services: approaches to cost saving]

PURPOSE

To analyze prospectively abdominal ultrasound in an emergency department (ED) with special emphasis on different routes of obtaining radiology service, reasons for consultation and ordering diagnosis, and to identify strategies for realizing cost savings.

MATERIALS AND METHODS

Over a three-month period, the course of events of 295 patients, who entered the ED and underwent on-call sonography, was recorded from the initial presentation to the commencement of treatment, and the results were subsequently evaluated.

RESULTS

Of all patients sonographically examined in the ED, 60 % had no prior contact to ambulatory medical services (self-referred, S), 15 % had been sent by a physician (physician-referred, P), and 25 % were inpatients. The most frequent reason for consultation was acute abdominal pain in self-referred patients (70 %) and blunt abdominal trauma in physician-referred patients (70 %). Sonography for acute abdominal pain was considered indicated by the examining radiologist prior to the examination in 90 % (P) and 70 % (S). Sonography contributed to the diagnosis in 44 % (P) and 22 % (S). Patients had to be hospitalized in 80 % (P) and 40 % (S), and needed immediate treatment in 78 % (P) and 43 % (S). Sonography after blunt abdominal trauma was considered appropriate in 90 % (P) and 65 % (S). Diagnostic information was obtained in 90 % (P) and 88 % (S), and therapeutic interventions were required in 10 % (P) and 0 % (S). The admission rate was 97 % (P) and 29 % (S), respectively.

CONCLUSIONS

In the ED, sonography was performed with significantly lower clinical effectiveness on self-referred than on physician-referred patients. Substantial cost-savings could be achieved by more selective use of abdominal sonography for self-referred patients.

Acute abdomen due to Brucella melitensis

A case of acute abdomen caused by a Brucella melitensis is reported. The patient presented with biliary involvement in the form of acute acalculous cholecystitis and developed acute appendicitis that resulted in his surgical treatment.

[Small bowel intussusception in childhood]

BACKGROUND

Intussusception is the most common cause of abdominal emergency in early childhood. The majority of cases are ileocolic type of intussusception. Only few reports concerning small bowel intussusception have been reported.

PATIENTS AND METHOD

We retrospectively reviewed the clinical records and imaging findings of all patients with the diagnosis of intussusception (comparing small bowel intussusception with ileocolic type of intussusception), which were documented by ultrasound in the period April 1997 to January 2001. The routine ultrasound scans included an evaluation of the entire abdomen using sector and linear transducers of high frequency (5 - 7.5 MHz) and power doppler ultrasound.

RESULTS

A total of 22 patients with small bowel intussusception (9 female, 13 male) and 29 patients diagnosed to suffer from ileocolic intussusception (10 female, 19 male) were identified and treated. Children with small bowel intussusception were significant older in comparison to children with ileocolic type of intussusception (median age 50 vs. 11 months). In our series the presenting symptoms of patients with small bowel intussusception consisted of abdominal pain (86 %) and vomiting (36 %). The initial clinical symptoms of patients with ileocolic intussusception were abdominal pain (100 %), vomiting (72 %) and/or rectal fresh blood (35 %). Small bowel intussusception was an incidental finding in 3 asymptomatic patients (14 %). Hydrostatic reduction was attempted in 14 % of children with small bowel intussusception (vs. 93 % of children with ileocolic intussusception), one patient needed operative treatment (vs. 21 %). Outcome in all patients was favorable.

CONCLUSION

The high percentage of patients with small bowel intussusception observed may relate to increased use of abdominal ultrasound in children presenting with abdominal pain and improvements in resolution and quality of the images. Small bowel intussusceptions in our series were in the majority of cases short-segmented, self-limited and without a lead point. In comparison to patients with ileocolic intussusception the presenting symptoms of small bowel intussusception are less acute.

Triage and approach to the acute abdomen

The presentation of a patient with acute abdominal pain often is both a diagnostic and therapeutic challenge for the veterinary practitioner. Rapid physical examination and assessment of the patient's cardiovascular status are critical to initiating appropriate and often aggressive medical management as diagnostic tests are being performed. A number of diagnostic tests can be performed, including complete blood count, serum biochemistry profile, serum amylase and lipase, abdominal radiographs, abdominal ultrasound, abdominal paracentesis or diagnostic peritoneal lavage, cytology, and fluid analysis. In some cases, surgical exploration may be indicated, depending on each patient's clinical signs and response to therapy. Of the most important aspects of medical management of the patient with acute abdominal pain is to maintain oxygen delivery to tissues and to treat aggressively for pain or discomfort. The initial triage and approach to the patient with acute abdomen are discussed.

[Ogilvie's syndrome: a rare cause of the acute abdomen]

Ogilvie's syndrome (acute colonic pseudo-obstruction) is a rare clinical disease characterized by segmental distension of the proximal colon caused by a paralysis without mechanic obstruction. It may be a sequel of underlying neurological, medical or surgical disease. Risk factors are respiratory decompensation, electrolyte disturbances and different drugs. A special kind is the primary idiopathic pseudoobstruction with a high risk of perforation or necrosis. Especially elderly patients (> 70 years) with cardiovascular or neurologic diseases and accordant drugs are concerned. Clinical symptoms are progressive abdominal distension and abdominal pain like an acute abdomen. The differential diagnosis of a mechanic ileus is important for further treatment. This case report should draw attention to this rare disease.

Percutaneous removal of retained calculi from the abdomen

With rising pressure placed on health service resources minimally invasive techniques requiring only short hospital admissions are increasing in importance. We describe the techniques used to remove calculi from the peritoneal cavity which had been retained after surgery and continued to cause clinical problems. In both cases described the calculi lay within abscess cavities associated with fistulous tracks to the skin. The fistulae were dilated to allow passage of therapeutic radiologic and endoscopic equipment enabling manipulation and subsequent extraction of the stones. In both cases removal of the calculi allowed complete resolution of the fistulae and the patients made a full clinical recovery. Removal of gallstones which have escaped into the peritoneum at laparoscopic cholecystectomy leading to sepsis has been described; we describe the novel management of a patient in whom extraction had already been attempted, at another hospital, without success. Removal of an appendicolith, described here in another patient, does not appear to have been reported previously.

[Treatment results in geriatric patients with acute abdomen in the intensive care unit]

Presented is material of 277 patients, who were treated due to acute abdomen illness in Intensive Therapy Unit at 2nd Department General Surgery Collegium Medicum Jagiellonian University during the time: from 01.07.1997 till 30.06.2002. This material regards only geriatric patients (patients > 65 years old). Patients analysis was divided into two main groups: patients with haemorrhagic shock caused by gastrointestinal bleeding (49 patients--group A) and by ruptured abdominal aneurysm (16 patients--group B), patients with hypovolemic and/or septic shock owing to diffuse peritonitis (150 patients--group C), and intestinal obstruction (62 patients--group D). The other principles of therapeutic procedures were described for every main group. In every illness group was showed: multiorgan dysfunction (acute myocardial ischemia with enzymatic and/or electrocardiographic changes, pulmonary oedema as acute left ventricular failure, respiratory and renal failure and metabolic dysfunction), actual punctuation into two scoring systems: APACHE II (28.8 points) and TISS-28 (44.5 points), time of hospitalization in the intensive therapy unit (mean 7.1 days), hospital's time of treatment (mean 17.5 days), mortality (for all patients 57.8%). These dates compared with dates from publications.

[Errors and difficulties in the diagnosis and management of acute and chronic abdomen in children]

The authors are reviewing on a lot of 2844 cases between 1996 and 2000 the difficult problems of differential diagnosis between acute surgical abdomen in children and intestinal tuberculosis, abdominal tumors and inflammatory diseases such as acute osteomielitis. They are presenting 13 particular cases in which the acute abdomen diagnosis was difficult or even omitted.

Effect of contrast-enhanced computed tomography on diagnosis and management of acute abdomen in adults

AIM

To determine the impact of computed tomography (CT) on the diagnosis and treatment plan in patients with acute abdominal pain.

MATERIALS AND METHODS

A prospective study was undertaken in 125 adult patients presenting with acute abdominal pain (74 men and 51 women; 40.2 +/- 19.3 years; range, 18-92). Changes in diagnosis, gain in percentage diagnostic certainty and changes of treatment plan of the surgeons in the emergency department before and after CT were evaluated. Pre- and post-CT diagnoses were compared with the final diagnoses.

RESULTS

CT findings changed the initial diagnosis in 40 (32.0%) patients. The diagnostic certainty was 58.3 +/- 22.9% before CT, and its gain after CT was 21.9 +/- 18.5 points (P < 0.0001). Post-CT diagnoses were consistent with the final diagnosis in 116 patients (92.8%), while pre-CT diagnoses were correct in 89 patients (71.2%; P < 0.0001). Initial treatment plans were changed in 31 (24.8%) patients after CT. In 57 (45.6%) patients, CT information changed diagnoses and/or treatment plans. No significant differences were observed in the diagnosis, diagnostic certainty and treatment plan among four surgeons.

CONCLUSION

Contrast-enhanced CT frequently changed the clinical diagnoses with increased diagnostic certainty and the initial treatment plans.

The therapeutic impact of abdominal ultrasound in patients with acute abdominal symptoms

AIM

The technical performance of abdominal ultrasound in the investigation of acute abdominal pain has been thoroughly investigated but its therapeutic effects are less well understood. We aimed to determine the therapeutic effect of abdominal ultrasound in the investigation of acute abdominal pain.

MATERIAL AND METHODS

A pre- and post-intervention observational study design was used to determine the diagnostic and therapeutic effects of abdominal ultrasound for acute abdominal pain. Referring clinicians completed a pre-ultrasound questionnaire that detailed their leading diagnosis, confidence in this and intended management in 100 consecutive adult patients. Following ultrasound a second questionnaire was completed. This again detailed the leading diagnosis, confidence in this and their intended management. Clinicians quantified the management contribution of ultrasound both for the individual case in question and in their clinical experience generally.

RESULTS

The leading diagnosis was either confirmed or rejected in 72 patients and a new diagnosis provided where no prior differential diagnosis existed in 10. Diagnostic confidence increased significantly following ultrasound (mean score 6.5 pre-ultrasound vs 7.6 post-ultrasound, P < 0.001). Intended management changed following ultrasound in 22 patients; 15 intended laparotomies were halted and a further seven patients underwent surgery where this was not originally intended. Ultrasound was rated either 'very' or 'moderately' helpful in 87% of patients, with 99% of clinicians finding it either 'very' or 'moderately' helpful generally.

CONCLUSION

Abdominal ultrasound has considerable diagnostic and therapeutic effect in the setting of acute abdominal pain.

[Acute abdomen in primary care]

The author--using his 30 years practical medical experience, from the point of view of a family doctor giving the first diagnose, analyses the problem of acute abdomen. Gives an overview of anamnesis (heteroanamnesis) and the data and their significance investigated during the physical examination of patient (inspection, palpation, percussion, auscultation), and that of the usefulness for the right diagnose. The author orients the reader's attention to the fact, that the beginning of the third millennium in the world of instrumental and laboratory diagnostics, in case of certain illnesses--so in the case of acute abdomen--physical examinations have not lost a bit from their significance.

Capnocytophaga canimorsus sepsis presenting as an acute abdomen in an asplenic patient

Acute abdominal symptoms are frequently caused by surgical intra-abdominal problems. However, the differential diagnosis also includes several internal diseases. Overwhelming infections may present with acute abdominal signs, particularly in the immunocompromised host. Asplenic patients are highly susceptible to infections with encapsulated bacteria such as Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitidis. Severe infections due to Capnocytophaga canimorsus (DF2), are also common in this group. C. canimorsus is a Gram-negative rod, present as a commensal organism in cat and dog saliva. We describe the atypical presentation of a fatal C. canimorsus-sepsis in a 46-year-old man, who underwent traumatic splenectomy two decades earlier.

Abdominal actinomycosis with hydronephrosis in childhood

Two 11-year-old boys had similar clinical courses of abdominal actinomycosis complicating ruptured appendicitis and manifesting as abdominal masses causing hydronephrosis. Cure was effected by surgery and prolonged penicillin therapy.

Acute appendicitis in children: the importance of family history

BACKGROUND/PURPOSE

Acute appendicitis is common, frequently atypical, challenging, and still associated with significant morbidity. Despite major technologic advances, appendicitis remains a primarily clinical diagnosis. Therefore, no relevant anamnestic information should be overlooked. Surprisingly, the relationship between heredity and appendicitis is seldom considered. Because of the potential clinical importance of the family history, the authors addressed this question prospectively over a 52-month period in a practice that includes the majority of pediatric patients with appendicitis in the region.

METHODS

Family histories were obtained in a standardized manner, focusing on first-degree relatives. Children with incomplete family information were excluded. Patients (ages 2(1/2) to 19 years) were divided into 3 groups: group A, children who underwent an appendectomy (n = 166); group B (first control), children who presented with an acute abdomen and suspected appendicitis but did not undergo an appendectomy (n = 117); group C (second control), children who were seen in the practice for unrelated conditions (n = 141).

RESULTS

A positive parental history was obtained from 59 patients (36%) in group A, 24 patients (21%) in group B, and 20 patients (14%) in group C, and the odds ratios (ORs) were 2.0 (P =.035) and 2.9 (P <.001) for groups A versus B and A versus C, respectively. Of the 13 patients whose sibling had had acute appendicitis, 9 were in group A versus 2 each in groups B and C, and the OR for any family history (siblings, parents) in groups A versus B was 1.9 (P =.028) and for groups A versus C was 2.9 (P < 0.001). Appendicitis was histologically confirmed in 93% of children in group A.

CONCLUSIONS

Heredity is a significant factor in pediatric patients who have appendicitis. Children who have appendicitis are twice as likely to have a positive family history than are those with right lower quadrant pain (but no appendicitis) and almost 3 times as likely to have a positive family history than are surgical controls (without abdominal pain). Because of its potential value in changing the threshold for intervention, a careful family history should be obtained for every child in whom acute appendicitis is suspected.

The acute abdomen and its management

Emergency referrals represent nearly 50% of general surgical practice. The acute abdomen makes up the bulk of these emergency referrals. As in all branches of medicine a number of seemingly straightforward questions need to be answered.

Approach to the acute abdomen

Acute abdominal pain is a clinical sign associated with several underlying disease processes, many of which can be life threatening. Abdominal pain requires efficient diagnostic evaluation to determine the appropriate course of treatment. Definitive treatment involves medical and/or surgical management. The emergency clinician must be well versed in the diagnostic approach to these patients to facilitate appropriate therapy.

The acute abdomen and the obstetrician

An acute abdomen in pregnancy can be caused by pregnancy itself, be predisposed to by pregnancy or be the result of a purely incidental cause. These various conditions are discussed. The obstetrician often has a difficult task in diagnosing and managing the acute abdomen in pregnancy. The clinical evaluation is generally confounded by the various anatomical and physiological changes occurring in pregnancy itself. Clinical examination is further hampered by the gravid uterus. The general reluctance to use conventional X-rays because of the pregnancy should be set aside when faced with the seriously ill mother. A reluctance to operate during pregnancy adds unnecessary delay, which increases morbidity for both mother and fetus. Such mistakes should be avoided as prompt diagnosis and appropriate therapy are crucial. A general approach to acute abdominal conditions in pregnancy is to manage these problems regardless of the pregnancy.

Do patients with acute abdominal pain wait unduly long for analgesia?

A prospective audit of 100 emergency admissions was carried out to determine local surgical practice for analgesia administration in patients with acute abdominal pain. The main outcome measure investigated was waiting time for analgesia and how this was influenced by (i) severity of pain, (ii) clinical diagnosis, (iii) clinical setting. The data were correlated with the results of a questionnaire on timing of analgesia. Forty percent of patients received analgesia within 1 h, 17% between 1-2 h, and 43% 2-22 h after admission. Mean waiting time was 2.3 h with severe pain (n = 84) vs. 6.3 h with moderate pain (n = 16, p < 0.0001, Mann-Whitney). Clinical diagnosis did not influence timing of analgesia. Fifty-seven per cent received analgesia in the Accident and Emergency (A&E) department with a mean wait of 60 min, whereas 43% admitted to the ward without analgesia in the A&E department waited an average of 5.7 h for pain medication (p < 0.0001; Mann-Whitney U-test). This was at variance with local surgical opinion that favoured early analgesia administration (yes-88%), in the absence of a firm diagnosis (yes-79%), although 38% stated that analgesia might mask physical signs. In conclusion, a substantial cohort of patients with acute abdominal pain (43%) wait too long for analgesia. Delays are due to omission of analgesia in A&E, and reluctance of junior staff to administer analgesia for fear of masking physical signs. Clinical guidelines for pain medication in acute surgical emergencies are warranted.

Acute abdominal pain and eosinophilia, two cases of eosinophilic gastroenteritis

Two patients are presented who were admitted with acute abdominal pain for which they underwent laparotomy. No clear-cut diagnosis could be established during operation. Eventually, eosinophilic gastroenteritis was diagnosed and treated with corticosteroids. The heterogeneous presentation of eosinophilic gastroenteritis is discussed, ranging from mild non-specific gastrointestinal symptoms to an acute abdominal emergency prompting surgical intervention. The pathogenesis and treatment of eosinophilic gastroenteritis are discussed.

[NSAID-use delays the diagnosis of 'acute abdomen']

In three patients with abdominal pain, two men aged 63 and 18 years and a woman aged 46 years, the use of NSAIDs reduced the symptoms. They were in fact suffering from peritonitis due to gastrointestinal perforation, but the decision to operate was delayed because of the relatively mild presentation. The strong analgesic, antipyretic and anti-inflammatory properties of NSAIDs can reduce the symptoms, signs and laboratory findings of peritonitis.