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Yale SH, Tekiner H, Yale ES. Fothergill and Carnett signs and rectus sheath hematoma. J Rural Med 2020; 15:130-131. [PMID: 32704339 PMCID: PMC7369406 DOI: 10.2185/jrm.2019-019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 03/08/2020] [Indexed: 11/27/2022] Open
Abstract
Fothergill and Carnett signs are used to distinguish intrabdominal from abdominal wall
diseases. These bedside techniques may be useful in distinguishing intrabdominal from an
abdominal wall cause of disease. Timely and accurate diagnosis of rectus sheath hematoma
in at risk patients in the appropriate clinical setting is important because of the
associated morbidity and mortality associated with this condition. Diagnosis requires an
accurate and thorough history and bedside physical examination and performance of these
maneuvers as originally described.
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Affiliation(s)
- Steven H Yale
- Department of Internal Medicine, University of Central Florida College of Medicine, USA
| | - Halil Tekiner
- Department of the History of Medicine and Ethics, Erciyes University School of Medicine, Turkey
| | - Eileen S Yale
- Division of General Internal Medicine, University of Florida, USA
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Rastogi V, Singh D, Tekiner H, Ye F, Mazza JJ, Yale SH. Abdominal Physical Signs and Medical Eponyms: Part III. Physical Examination of Palpation, 1926-1976. Clin Med Res 2019; 17:107-114. [PMID: 31308023 PMCID: PMC6886893 DOI: 10.3121/cmr.2018.1427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 10/14/2018] [Accepted: 10/24/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND This paper describes medical eponyms associated with abdominal palpation from the period 1926-1976. Despite opposition by some, eponyms are a long standing tradition and widely used in medicine. The techniques may still be useful in some cases, assisting in the selection of an appropriate and cost-effective approach to patient care. In this piece, we cover signs named in honor of physicians who contributed to medicine by developing new palpatory techniques in an attempt to better diagnose disease of the abdominal wall, umbilicus, gallbladder, pancreas, and appendix. DATA SOURCES PubMed, Medline, online Internet word searches, textbooks, and references from other source texts. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign. CONCLUSION We describe brief historical background information about the physician who reported the sign, original description of the sign, and its clinical application and implication into today's medical practice.
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Affiliation(s)
- Vaibhav Rastogi
- University of Central Florida College of Medicine, Department of Graduate Medical Education, 6850 Lake Nona Blvd, Orlando, FL 32827 USA
| | - Devina Singh
- University of Florida, Department of Medicine, 2000 SW Archer Rd, Gainesville, FL 32610 USA
| | - Halil Tekiner
- Erciyes University School of Pharmacy, Department of the History of Pharmacy and Ethics, Talas, Kayseri 38280 Turkey
| | - Fan Ye
- University of Central Florida College of Medicine, Department of Graduate Medical Education, 6850 Lake Nona Blvd, Orlando, FL 32827 USA
| | - Joseph J Mazza
- Marshfield Clinic Research Institute, 1000 North Oak Avenue, Marshfield, WI 54449 USA
| | - Steven H Yale
- University of Central Florida College of Medicine, Department of Internal Medicine, 6850 Lake Nona Blvd, Orlando, FL 32827
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Sweetser S. Abdominal Wall Pain: A Common Clinical Problem. Mayo Clin Proc 2019; 94:347-355. [PMID: 30711130 DOI: 10.1016/j.mayocp.2018.04.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 04/19/2018] [Accepted: 04/24/2018] [Indexed: 11/30/2022]
Abstract
Abdominal wall pain (AWP) is a common and underrecognized cause of chronic abdominal pain. The etiology of AWP varies. History and physical examination are critical to an accurate diagnosis of AWP. Trigger point injection using either a corticosteroid, a local anesthetic, or a combination of both often gives relief of pain and is of diagnostic and therapeutic value. Increased awareness of AWP as a cause of chronic, nonvisceral abdominal pain can prevent fruitless searches for intra-abdominal pathology and reduce medical costs.
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Affiliation(s)
- Seth Sweetser
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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Anterior Cutaneous Nerve Entrapment Syndrome in Children: A Prospective Observational Study. Clin J Pain 2018; 34:670-673. [DOI: 10.1097/ajp.0000000000000573] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Siawash M, Roumen R, Ten WTA, van Heurn E, Scheltinga M. Diagnostic characteristics of anterior cutaneous nerve entrapment syndrome in childhood. Eur J Pediatr 2018. [PMID: 29516161 DOI: 10.1007/s00431-018-3125-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
UNLABELLED Some children suffering from chronic abdominal pain may have an abdominal wall entity such as anterior cutaneous nerve entrapment syndrome. This syndrome is largely suspected on a combination of findings at history and physical examination. The aim is to obtain clues in history and physical examinations in a selected population of children with anterior cutaneous nerve entrapment syndrome. We analyzed all children with abdominal pain visiting our hospital between January 2013 and January 2015. A total of 71 cases were identified (median age 15 years, range 8-17, 77% female). Pain was severe (median 8, range 6-9), stabbing/burning (84%), superficial (88%), aggravated by physical activity (91%), and always in one abdominal area (97%). Hypo-/hyperesthesia (87%) or a positive pinch test (89%) was often found at the skin overlying the painful spot. Increased pain was reported by 97% when the abdominal muscles were tensed (Carnett test). A single anterior rectus sheath block is successful in almost all patients (97%). CONCLUSION A combination of typical findings in history and physical examination allows for diagnosing childhood ACNES. What is Known: • Anterior cutaneous nerve entrapment syndrome (ACNES) is often overlooked in chronic abdominal pain. • Pediatric literature on diagnostic work up for ACNES is poor. What is New: • Two third reported treatment delay due to misdiagnosis as functional abdominal pain. • Medical history and physical examination revealed neuropathic pain characteristic in up to 90% of the cases.
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Affiliation(s)
- Murid Siawash
- Department of Surgery and SolviMáx, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, 7777, 5500 MB, Veldhoven, The Netherlands.
| | - Rudi Roumen
- Department of Surgery and SolviMáx, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, 7777, 5500 MB, Veldhoven, The Netherlands
| | - Walther Tjon A Ten
- Department of Pediatrics, Máxima Medical Center, Veldhoven, The Netherlands
| | - Ernst van Heurn
- Emma Children's Hospital AMC & VU University medical center, Department of Pediatric Surgery, Amsterdam, The Netherlands
| | - Marc Scheltinga
- Department of Surgery and SolviMáx, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, 7777, 5500 MB, Veldhoven, The Netherlands
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Pelvic musculoskeletal dysfunctions in women with and without chronic pelvic pain. J Bodyw Mov Ther 2018; 22:92-96. [DOI: 10.1016/j.jbmt.2017.05.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 04/04/2017] [Accepted: 04/29/2017] [Indexed: 01/13/2023]
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Siawash M, Mol F, Tjon-A-Ten W, Perquin C, van Eerten P, van Heurn E, Roumen R, Scheltinga M. Anterior rectus sheath blocks in children with abdominal wall pain due to anterior cutaneous nerve entrapment syndrome: a prospective case series of 85 children. Paediatr Anaesth 2017; 27:545-550. [PMID: 28295822 DOI: 10.1111/pan.13084] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chronic abdominal pain in children may be caused by the anterior cutaneous nerve entrapment syndrome. Local nerve blocks are recommended as an initial treatment in adults. Evidence on effectiveness and safety of such a treatment in children is lacking. AIM Our aim was to study outcome and adverse events of anterior rectus sheath blocks in childhood anterior cutaneous nerve entrapment syndrome. METHODS Patients <18 years of age receiving anterior rectus sheath blocks were prospectively followed. Injections were administered using a free-hand technique in the outpatient department. RESULTS A total of 85 children were included (median age 15 years, range 8-17, 76% female). Eighty-three children reported immediate pain relief following a single lidocaine block and 13 achieved long-term success. Another 19 children was successfully treated with additional blocks combined with steroids. A total 38% success ratio was attained after a median 17-month follow-up (range, 4-39). Pain intensity and diagnostic delay were not associated with a beneficial outcome. However, young age predicted success. An infrequently occurring adverse event was temporarily increased pain some 6 h post injection. CONCLUSION Anterior rectus sheath blocks using local anesthetics and steroids are safe and long-term successful in more than one-third of children suffering from abdominal pain due to anterior cutaneous nerve entrapment syndrome.
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Affiliation(s)
- Murid Siawash
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
| | - Frederique Mol
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
| | - Walther Tjon-A-Ten
- Department of Pediatrics, Máxima Medical Center, Veldhoven, The Netherlands
| | - Christel Perquin
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
| | - Percy van Eerten
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
| | - Ernst van Heurn
- Department of Pediatric Surgery, Emma Children's Hospital AMC & VU University Medical Center, Amsterdam, The Netherlands
| | - Rudi Roumen
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
| | - Marc Scheltinga
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
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Alnahhas MF, Oxentenko SC, Locke GR, Hansel S, Schleck CD, Zinsmeister AR, Farrugia G, Grover M. Outcomes of Ultrasound-Guided Trigger Point Injection for Abdominal Wall Pain. Dig Dis Sci 2016; 61:572-7. [PMID: 26320087 DOI: 10.1007/s10620-015-3857-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 08/19/2015] [Indexed: 12/09/2022]
Abstract
BACKGROUND Abdominal wall pain (AWP) is an important cause of chronic abdominal pain. History and physical examination are critical to the diagnosis of AWP. Trigger point injection (TPI) using either a steroid or a local anesthetic or a combination of both is often used to treat AWP. AIM To determine the efficacy of ultrasound-guided TPI and to determine the predictors of a successful response. METHODS Patients who received ultrasound-guided TPI between July 2010 and June 2011 were surveyed. The primary outcome was determined using the Treatment Efficacy Questionnaire (TEQ). Electronic medical records were reviewed to determine patient, pain and TPI characteristics. Linear regression was used to determine the predictors of a successful response on the TEQ. RESULTS Right upper quadrant was the most common site of AWP, and the median pain duration was 12 months. Pain was rated as >8 (1-10 scale) by 57 % and 30 % described it as an ache. Narcotic use was reported in 38 %, and 73 % had a history of at least one abdominal surgery. Forty-four of the 120 (37 %) patients met the criteria for responder on the TEQ. Compared to before treatment, 36 % reported being "significantly better" and 22 % "slightly better." Multiple linear regression analysis showed that higher somatization negatively predicted response. None of the other historical, examination or TPI characteristics were associated with response to the TPI. CONCLUSION TPI can provide significant, long-term symptom relief in a third of patients with chronic abdominal pain attributed to AWP. Somatization was inversely related to the treatment success.
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Affiliation(s)
- Mhd Firas Alnahhas
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Shawn C Oxentenko
- Division of Physical Medicine and Rehabilitation, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - G Richard Locke
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Stephanie Hansel
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Cathy D Schleck
- Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Alan R Zinsmeister
- Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Gianrico Farrugia
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Madhusudan Grover
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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van Assen T, Boelens OB, van Eerten PV, Scheltinga MR, Roumen RM. Surgical options after a failed neurectomy in anterior cutaneous nerve entrapment syndrome. World J Surg 2015; 38:3105-11. [PMID: 25189442 DOI: 10.1007/s00268-014-2737-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Injection treatment followed by an anterior neurectomy in patients insufficiently responding to an injection regimen is successful long term in three-quarters of patients with anterior cutaneous nerve entrapment syndrome (ACNES). The efficacy of secondary surgery, including re-exploration or a posterior neurectomy in patients reporting recurrent pain after initially successful surgery or following an immediately failed anterior neurectomy is unknown. METHODS A database of ACNES patients receiving surgery between 2004 and 2012 in the SolviMáx institution was analysed. Adult patients with residual pain after an anterior neurectomy (failures) or with recurrent pain after initially successful surgery (recurrences) were selected. Following a re-exploration or a posterior neurectomy, pain was scored using a pain intensity numeric rating scale (PI-NRS 0-10) and a six-point verbal category rating scale (VRS). Success was defined as a ≥50 % PI-NRS reduction and/or ≥2 point VRS reduction. RESULTS ACNES patients undergoing an anterior neurectomy (n = 181) were analysed during the 8-year study period. At follow-up, 51 patients reported unacceptable pain levels following an anterior neurectomy, whereas 20 developed recurrent abdominal wall pain. Of these 71 unsuccessful patients, 41 underwent secondary surgery, including a re-exploration (n = 10), or a posterior neurectomy (n = 31). After a 25-month median follow-up, secondary surgical treatment regimens proved successful in 66 % (27/41). Patients with recurrent pain did better (14/15) than patients who were immediate failures after the anterior neurectomy (13/26, p = 0.01). CONCLUSIONS Secondary surgery including re-explorations and posterior neurectomies are successful in two-thirds of ACNES patients with persistent pain or recurrence of pain after an anterior neurectomy.
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Affiliation(s)
- T van Assen
- Department of Surgery, Máxima Medical Center, de Run 4600, P.O. Box 7777, 5500 MB, Eindhoven, Veldhoven, The Netherlands,
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van Assen T, Brouns JAGM, Scheltinga MR, Roumen RM. Incidence of abdominal pain due to the anterior cutaneous nerve entrapment syndrome in an emergency department. Scand J Trauma Resusc Emerg Med 2015; 23:19. [PMID: 25887961 PMCID: PMC4327965 DOI: 10.1186/s13049-015-0096-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 01/19/2015] [Indexed: 12/29/2022] Open
Abstract
Background Patients with chronic abdominal pain occasionally suffer from the anterior cutaneous nerve entrapment syndrome (ACNES). A substantial number of patients report previous visits to an emergency department (ED) with acute pain. Aim of this study was to obtain the incidence of ACNES in patients presenting with abdominal pain in the ED of a Dutch teaching hospital. Methods In this observational study, data sets of all patients visiting Máxima Medical Center’s (MMC) ED in 2011–2012 were searched for key terms ‘ACNES’, ‘intercostal neuralgia’ or ‘abdominal wall pain’. Files of potential patients living within hospital’s adherence area were checked using accepted criteria indicating the presence of ACNES. Disease incidence was calculated as a ratio to the hospital’s adherence data. The ACNES MMC 2013’s incidence in patients evaluated in the surgical outpatient department was also calculated. Results During the study period, 473 ED patient files met inclusion criteria. A total of 88 patients belonging to MMC’s adherence area were diagnosed with ACNES leading to a mean 22/100.000 ACNES yearly incidence rate. About one of 50 patients with abdominal pain visiting the ED suffered from ACNES. A 35/100.000 outpatient department ACNES incidence rate was calculated in the year of 2013. Combining these two ratios, a 1:1800 ACNES incidence in the general population was obtained. Conclusions In an ED setting of a Dutch teaching hospital, approximately 2% of patients presenting with acute abdominal pain suffered from ACNES. ED physicians should consider ACNES in abdominal pain patients with normal laboratory or imaging tests.
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Affiliation(s)
- Tijmen van Assen
- Department of Surgery, Máxima Medical Center, Eindhoven/Veldhoven, The Netherlands. .,SolviMáx, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven/Veldhoven, The Netherlands.
| | - Jill A G M Brouns
- Department of Surgery, Máxima Medical Center, Eindhoven/Veldhoven, The Netherlands.
| | - Marc R Scheltinga
- Department of Surgery, Máxima Medical Center, Eindhoven/Veldhoven, The Netherlands. .,SolviMáx, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven/Veldhoven, The Netherlands.
| | - Rudi M Roumen
- Department of Surgery, Máxima Medical Center, Eindhoven/Veldhoven, The Netherlands. .,SolviMáx, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven/Veldhoven, The Netherlands.
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van Assen T, Boelens OB, Kamphuis JT, Scheltinga MR, Roumen RM. Construction and validation of a questionnaire distinguishing a chronic abdominal wall pain syndrome from irritable bowel syndrome. Frontline Gastroenterol 2012; 3:288-294. [PMID: 23914291 PMCID: PMC3730810 DOI: 10.1136/flgastro-2012-100207] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 06/27/2012] [Accepted: 06/30/2012] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE The irritable bowel syndrome (IBS) population is heterogeneous, harbouring a variety of abdominal symptoms. Therefore, IBS is often termed a 'diagnosis of exclusion'. Chronic abdominal wall pain (CAWP) is a poorly recognized entity, frequently caused by the anterior cutaneous nerve entrapment syndrome (ACNES). Some patients may be misdiagnosed because IBS and CAWP share symptoms. Aim of this study was to construct and validate a questionnaire to distinguish patients with CAWP (including ACNES) patients with IBS. DESIGN A questionnaire was designed of 17 ACNES characteristic items obtained from ACNES patients (n=33) and expert opinion of two specialized surgeons. Eleven IBS-related items ('Rome III' criteria) were added leading to a questionnaire containing 28 items. This was validated in a 'gold standard' ACNES group (successfully operated ACNES patients, n=68) and a 'prospective' IBS group (n=64) as well as in a 'prospective' ACNES group (n=47). Distinctive power of individual items was analyzed by χ2. Reliability was tested with Crohnbach's α. ROC curve was used to determine cut-off values. RESULTS Eighteen of 28 items were significantly distinctive (p<0.01) between ACNES and IBS patients leading to an 18-point ACNES score with good internal consistency (α=0.85). Cut-off value of 10 points resulted in 94% sensitivity, 92% specificity and areas under the curve (AUC) of 0.98. Evaluation of the prospective ACNES group led to 85% sensitivity, 92% specificity and AUC 0.95 indicating high discriminative properties of the questionnaire. CONCLUSIONS This novel questionnaire may be useful and valid as a simple tool distinguishing patients harbouring a CAWP syndrome from those having IBS.
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Affiliation(s)
- Tijmen van Assen
- Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Oliver B Boelens
- Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Jan T Kamphuis
- Department of Gastroenterology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Marc R Scheltinga
- Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Rudi M Roumen
- Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands
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Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med 2012; 5:789-97. [PMID: 23055768 PMCID: PMC3468117 DOI: 10.2147/ijgm.s25936] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Indexed: 11/25/2022] Open
Abstract
Evaluation of the emergency department patient with acute abdominal pain is sometimes difficult. Various factors can obscure the presentation, delaying or preventing the correct diagnosis, with subsequent adverse patient outcomes. Clinicians must consider multiple diagnoses, especially those life-threatening conditions that require timely intervention to limit morbidity and mortality. This article will review general information on abdominal pain and discuss the clinical approach by review of the history and the physical examination. Additionally, this article will discuss the approach to unstable patients with abdominal pain.
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Affiliation(s)
- Christopher R Macaluso
- Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, PA, USA
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14
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Abstract
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.
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Affiliation(s)
- Robert McNamara
- Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, PA 19140, USA.
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Takada T, Ikusaka M, Ohira Y, Noda K, Tsukamoto T. Diagnostic usefulness of Carnett's test in psychogenic abdominal pain. Intern Med 2011; 50:213-7. [PMID: 21297322 DOI: 10.2169/internalmedicine.50.4179] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Carnett's test is a simple clinical test in which abdominal tenderness is evaluated while the patient tenses the abdominal muscles. It is useful for differentiating abdominal wall pain from intra-abdominal pain. However, no study has reported its association with psychogenic abdominal pain. We evaluated its diagnostic usefulness in psychogenic abdominal pain. METHODS Two physicians performed Carnett's test on each patient, but only one received the medical history. The other physician only conducted the test. Based on the final diagnosis, patients were categorized into 3 groups: psychogenic pain, abdominal wall pain, or intra-abdominal pain. Each group was analyzed in association with the results of Carnett's test conducted by the blinded physician. PATIENTS A total of 130 outpatients with the chief complaint of abdominal pain who had abdominal tenderness. RESULTS There were 22 patients with psychogenic abdominal pain, 19 with abdominal wall pain and 62 with intra-abdominal pain. In patients with psychogenic pain or abdominal wall pain, Carnett's test was usually positive, whereas the test was usually negative in patients with intra-abdominal pain (p<0.001, respectively). The positive likelihood ratio of Carnett's test for psychogenic abdominal pain was 2.91 (95% confidence interval [CI], 2.71-3.13), while the negative likelihood ratio was 0.19 (95% CI, 0.11-0.34). The corresponding values for abdominal wall pain were 2.62 (95% CI, 2.45-2.81) and 0.23 (95% CI, 0.13-0.41), respectively. CONCLUSION Carnett's test may be useful for ruling in and ruling out psychogenic abdominal pain in addition to distinguishing between abdominal wall pain and intra-abdominal pain.
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Affiliation(s)
- Toshihiko Takada
- Department of General Medicine, Chiba University Hospital, Japan.
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Matsunaga S, Eguchi Y. Importance of a physical examination for efficient differential diagnosis of abdominal pain: diagnostic usefulness of Carnett's test in psychogenic abdominal pain. Intern Med 2011; 50:177-8. [PMID: 21297317 DOI: 10.2169/internalmedicine.50.4934] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Abdominal myofascial pain syndrome must be considered in the differential diagnosis of chronic pelvic pain. Eur J Obstet Gynecol Reprod Biol 2009; 147:21-4. [DOI: 10.1016/j.ejogrb.2009.06.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Revised: 05/06/2009] [Accepted: 06/22/2009] [Indexed: 11/19/2022]
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Lindsetmo RO, Stulberg J. Chronic abdominal wall pain--a diagnostic challenge for the surgeon. Am J Surg 2009; 198:129-34. [PMID: 19555786 DOI: 10.1016/j.amjsurg.2008.10.027] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2008] [Revised: 10/20/2008] [Accepted: 10/20/2008] [Indexed: 11/15/2022]
Abstract
BACKGROUND Chronic abdominal wall pain (CAWP) occurs in about 30% of all patients presenting with chronic abdominal pain. METHODS The authors review the literature identified in a PubMed search regarding the abdominal wall as the origin of chronic abdominal pain. RESULTS CAWP is frequently misinterpreted as visceral or functional abdominal pain. Misdiagnosis often leads to a variety of investigational procedures and even abdominal operations with negative results. With a simple clinical test (Carnett's test), >90% of patients with CAWP can be recognized, without risk for missing intra-abdominal pathology. CONCLUSION The condition can be confirmed when the injection of local anesthetics in the trigger point(s) relieves the pain. A fasciotomy in the anterior abdominal rectus muscle sheath through the nerve foramina of the affected branch of one of the anterior intercostal nerves heals the pain.
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Affiliation(s)
- Rolv-Ole Lindsetmo
- Department of Gastrointestinal Surgery, University Hospital of North Norway, Tromsø, Norway.
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Montenegro MLLS, Vasconcelos ECLM, Candido Dos Reis FJ, Nogueira AA, Poli-Neto OB. Physical therapy in the management of women with chronic pelvic pain. Int J Clin Pract 2008; 62:263-9. [PMID: 18067562 DOI: 10.1111/j.1742-1241.2007.01530.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Chronic pelvic pain (CPP) is defined as lower abdominal pain lasting for at least 6 months, which occurs continuously or intermittently and is not associated exclusively with menstruation or intercourse. CPP is a highly prevalent debilitating disease with negative impact on the quality of life and productivity of women. The dilemma regarding the management of CPP continues to frustrate the health professionals, partly because its physiopathology is poorly understood. Consequently, the treatment of this condition is often unsatisfactory and limited to temporary symptom relief. In the present review, we discuss characteristics of the clinical history and physical examination associated with musculoskeletal involvement in women with CPP and possible treatments, especially in the area of physiotherapy. METHODS We evaluated data available in PubMed (1984-2006) and surveyed the reference list. Three reviewers analysed the data independently, considering a study to be of high quality if it had at least three of the following characteristics: prospective design, valid measurement instruments, and adequate sample estimate and response rate. Other studies such as retrospective investigations, reviews and expert opinions were also considered, but with decreasing emphasis. RESULTS There are evidences of musculoskeletal system disorders in most women with CPP. These musculoskeletal disorders can be the primary cause of CPP or postural changes and pelvic muscle contractures secondary to CPP. CONCLUSIONS Synchronised intervention by physicians and physiotherapists is becoming increasingly more necessary both in terms of a more refined diagnosis of the clinical situation and of the institution of effective and lasting treatment.
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Affiliation(s)
- M L L S Montenegro
- Department of Gynecology and Obstetrics, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
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Rivero Fernández M, Moreira Vicente V, Riesco López JM, Rodríguez Gandía MA, Garrido Gómez E, Milicua Salamero JM. Dolor originado en la pared abdominal: una alternativa diagnóstica olvidada. GASTROENTEROLOGIA Y HEPATOLOGIA 2007; 30:244-50. [PMID: 17408555 DOI: 10.1157/13100598] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Chronic abdominal pain is a common clinical problem in primary care, and is usually referred to gastroenterologists or general surgeons. Although up to 20% of cases of idiopathic abdominal pain arise in structures of the abdominal wall, this is frequently overlooked as a possible cause. It includes pain arising from structures of the abdominal wall including skin, parietal peritoneum, cellular subcutaneous tissue, aponeuroses, abdominal muscles and somatosensorial innervation from lower dorsal roots. The diagnosis is based on anamnesis and physical examination. Carnett's sign is a simple maneuver that discriminates between parietal and visceral pain. Management with topical anesthesia is effective in a majority of patients and can help to confirm the diagnosis.
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Gokhale S. Sonography in identification of abdominal wall lesions presenting as palpable masses. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2006; 25:1199-209. [PMID: 16929022 DOI: 10.7863/jum.2006.25.9.1199] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
OBJECTIVE Abdominal wall lesions often present as palpable masses. The purpose of this presentation is to provide an overview of the sonographic appearances of different abdominal wall lesions. METHODS Patients were scanned with high-frequency (5- to 12-MHz) linear transducers. Extended or panoramic views were recorded often to show the lesion in perspective to adjacent structures in the abdominal wall. RESULTS The different layers of the abdominal wall could be clearly shown on high-frequency sonography, and the abdominal wall abnormalities were recognized in all the patients. CONCLUSIONS Hernias are the most common abdominal wall lesions. Herniated bowel loops have variable appearances depending on their air-fluid content and degree of obstruction. Localized fluid collections in the abdominal wall (seromas, liquefying hematomas, and abscesses) can be well visualized. More infrequently, tumors or vascular lesions can be identified in the abdominal wall.
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Rhee HD, Park EY, Lee B, Kim WO, Yoon DM, Yoon KB. Treatment Experiences of Abdominal Cutaneous Nerve Entrapment Syndrome -A report of 3 cases-. Korean J Pain 2006. [DOI: 10.3344/kjp.2006.19.2.292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Ho Dong Rhee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Young Park
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Bahn Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Won Oak Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Duck Mi Yoon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Bong Yoon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Abdel-Fattah M, Barrington J, Yousef M, Mostafa A. Effect of Total Abdominal Hysterectomy on Pelvic Floor Function. Obstet Gynecol Surv 2004; 59:299-304. [PMID: 15024230 DOI: 10.1097/01.ogx.0000120166.84206.dd] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Historically, hysterectomy is one of the oldest gynecologic operations, dating back to the 1840s. Currently, it is the most common gynecologic operation performed and is associated with marked improvement in the patients' quality of life. It is widely considered a safe procedure with an extremely low mortality rate (<0.1%). The majority of hysterectomies are done abdominally, with the vast majority being total abdominal hysterectomies. The effect of hysterectomy on pelvic floor function has been a subject of long debate. Various studies have reached different and rather contradictory results. Most of these studies lack stringent methodologic standards, being retrospective, observational, or uncontrolled. A recent excellent study assessed the effect of abdominal hysterectomy on pelvic floor function as 1 functional unit and concluded that both total and subtotal abdominal hysterectomies have no detrimental effect on the pelvic floor function up to 1 year postoperatively.
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Affiliation(s)
- M Abdel-Fattah
- Obstetrics & Gynaecology Department, Torbay Hospital, Torquay, UK.
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Affiliation(s)
- Cynthia M Holland-Hall
- Section of Adolescent Medicine, Department of Pediatrics, Children's Hospital, The Ohio State University College of Medicine and Public Health, 700 Children's Drive, Columbus, OH 43205, USA.
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Sparkes V, Prevost AT, Hunter JO. Derivation and identification of questions that act as predictors of abdominal pain of musculoskeletal origin. Eur J Gastroenterol Hepatol 2003; 15:1021-7. [PMID: 12923376 DOI: 10.1097/00042737-200309000-00013] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Although most causes of abdominal pain have a visceral origin, the musculoskeletal system must be considered when the cause is not obvious. This prospective study aimed to identify questions that would aid the diagnosis of patients with abdominal pain of musculoskeletal origin. DESIGN Assessment of consecutive patients with abdominal pain recruited from gastroenterological outpatient clinics to develop diagnostic pointers to identify abdominal pain arising from musculoskeletal disorders. PARTICIPANTS Subjects with benign abdominal pain, with or without a change in bowel habit, were recruited from gastroenterological clinics. Patients with inflammatory or neoplastic disease were excluded. SETTING The study was conducted in the Physiotherapy Department, Addenbrooke's NHS Trust Hospital, Cambridge. MAIN OUTCOME MEASURES A set of questions developed to indicate a musculoskeletal cause of a patient's abdominal symptoms. RESULTS The questions 'Does taking a deep breath aggravate your symptoms?' and 'Does twisting your back aggravate your symptoms?' had a significant positive indication of abdominal symptoms of musculoskeletal origin. The questions 'Has there been any change in bowel habit since onset of your symptoms?', 'Does eating foods aggravate your symptoms?' and 'Has there been any weight change since onset of symptoms?' had a significant negative indication for abdominal symptoms not of musculoskeletal origin. A combination of these questions gave 96% specificity and 67% sensitivity. CONCLUSION These questions may help with the early identification of patients with abdominal pain of musculoskeletal origin and will be tested in further studies.
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Affiliation(s)
- Valerie Sparkes
- Department of Physiotherapy, Addenbrooke's NHS Trust Hospital, Institute of Public Health, Cambridge, UK.
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Srinivasan R, Greenbaum DS. Chronic abdominal wall pain: a frequently overlooked problem. Practical approach to diagnosis and management. Am J Gastroenterol 2002; 97:824-30. [PMID: 12003414 DOI: 10.1111/j.1572-0241.2002.05662.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Chronic abdominal wall pain is frequently misdiagnosed as arising from a visceral source, often resulting in inappropriate diagnostic testing, unsatisfactory treatment, and considerable cost. Its prevalence in general medical practice is unknown, although it may account for about 10% of patients with chronic idiopathic abdominal pain seen in gastroenterological practices. The most common cause appears to be entrapment of an anterior cutaneous branch of one or more thoracic intercostal nerves; myofascial pain and radiculopathy are less frequent. Sharply localized pain and superficial tenderness are suggestive of abdominal wall origin. Carnett's test (accentuated localized tenderness with abdominal wall tensing) is a helpful diagnostic sign, especially when incorporated with other findings. Early exclusion of a parietal source should increase diagnostic accuracy when evaluating patients with chronic abdominal pain. Reassurance of patients by the correct diagnosis and avoidance of precipitating causes is often sufficient treatment. However, accurately placed anesthetic/corticosteroid injections give substantial pain relief to more than 75% of patients, often for prolonged periods, and may be confirmatory for the source of the complaint. The probability of missing visceral disease is small (probably less than 7%) with strict adherence to diagnostic criteria and diligent observation of patients.
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Affiliation(s)
- Radhika Srinivasan
- Gastroenterology Division, University of Pennsylvania School of Medicine, Philadelphia, USA
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Dellenbach P, Rempp C, Haeringer MT, Simon T, Magnier F, Meyer C. [Chronic pelvic pain. Another diagnostic and therapeutic approach]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2001; 29:234-43. [PMID: 11300048 DOI: 10.1016/s1297-9589(00)00078-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Chronic pelvic pain (CPP) is a frequent and difficult problem because despite the quality and diversity of diagnostic procedures no relevant etiology will be found in 30 to 40% of all cases. Psychologic and psychotherapeutic counselling is than usually proposed and usually not well accepted. A different approach can now be proposed according to a new semeiologic overall. In many cases the pain dominant is not visceral but parietal. The pelvic envelope is actually more painfull than the pelvic content. In these cases one can evoke the diagnosis of pelvic fibromyalgia and this is quite similar to classic fibromyalgia. This pelvifibromyalgia can be quantified with an algometric index. This form of pain actually is the somatisation of a past and difficult issue which will be very slowly and progressively revealed in the realm of a multidisciplinary and simultaneous physical and psychological approach. In the majority of cases these women have occurred physical, moral or sexual trauma inflicted by family members or a third party. Taking in account the physical dimension of body pain at the same time as psychotherapy will considerably enhance the efficiency of treatment. In our experience 70% of all women will be cured using this new approach.
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Affiliation(s)
- P Dellenbach
- Centre de la douleur pelvienne chronique, service de gynécologie, syndicat inter-hospitalier de la Communauté urbaine de Strasbourg (SIHCUS), centre médico-chirurgical et obstétrical (CMCO), 19, rue Louis-Pasteur BP 120, 67303 Schiltigheim, France
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Abstract
Chronic recurrent abdominal pain remains a common medical and surgical problem, frequently dismissed as functional. Instead, these patients should be approached systematically, based on the pattern of recurrent abdominal pain. It is vital to seek out the potential cause of this type of chronic pain because specific and often curative treatment is available.
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Affiliation(s)
- S W Zackowski
- Department of Emergency Medicine, Naval Medical Center, Portsmouth, Virginia, USA.
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van Dam JH, Gosselink MJ, Drogendijk AC, Hop WC, Schouten WR. Changes in bowel function after hysterectomy. Dis Colon Rectum 1997; 40:1342-7. [PMID: 9369110 DOI: 10.1007/bf02050820] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE It has been suggested that hysterectomy has a disturbing influence on bowel function. To assess the incidence and nature of these changes, we performed a retrospective study. METHODS A retrospective study was performed in all 593 women who had undergone hysterectomy between 1989 and 1993. A control group consisted of 100 women who had undergone laparoscopic cholecystectomy. RESULTS The response rate was 90 percent (n = 531; median age, 45 (range, 18-84) years). Of the responding women, 315 patients (59 percent) indicated a normal defecation pattern before hysterectomy. Of these women, severe deterioration in bowel function was reported by 98 patients (31 percent), whereas 36 women (11 percent) mentioned a moderate change after hysterectomy. Most frequent symptoms were severe straining (90 patients), incomplete and/or digital evacuation (83 and 50 patients, respectively). According to most patients, the changes in bowel function were reported to have started within one month after hysterectomy. With advancing age, fewer complaints were recorded (P = 0.008). No significant difference was found in the incidence of disturbed bowel function between the different types of operation (abdominal, vaginal, supravaginal, or radical hysterectomy). In the control group, the response rate was 96 percent. Median age of these women was 46 (range, 25-78) years. Fifty-eight patients (60 percent) reported normal bowel function before laparoscopic cholecystectomy. In this group of patients, disturbed bowel function after surgery was reported by five women (9 percent), which figure is significantly (P < 0.001) lower compared with that in the corresponding hysterectomy group. CONCLUSION Hysterectomy seems to play an important role in the pathogenesis of disturbed defecation.
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Affiliation(s)
- J H van Dam
- Department of General Surgery, University Hospital Dijkzigt, Rotterdam, The Netherlands
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Abstract
Evaluation of the older patient presents a unique challenge to the emergency physician. The increased age of the population, a high incidence of comorbidity, general poverty of history and clinical signs in acute abdominal conditions, poor reliability of diagnostic procedures, and the variable presentations of diseases with significant morbidity and mortality summarize the problems to be encountered with the complaint of abdominal pain in the elderly. The correct diagnosis is often difficult to establish and coexisting complicating diseases influence the patient's condition and the ED management. The emergency physician must maintain a wide differential and have a low threshold for admission and more extensive evaluation in this patient population.
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Affiliation(s)
- T G Sanson
- Coperhaver, Bell and Associates, Mease Countryside Hospital, Safety Harbor, Florida, USA
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Greenbaum DS, Greenbaum RB, Joseph JG, Natale JE. Chronic abdominal wall pain. Diagnostic validity and costs. Dig Dis Sci 1994; 39:1935-41. [PMID: 8082500 DOI: 10.1007/bf02088128] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Chronic abdominal wall pain (CAWP) is common and frequently mistaken for visceral pain. We determined the stability of this diagnosis with Main Outcome Measures of: (a) change of pain intensity after local anesthetic-corticosteroid injection, (b) pain relief after three or more months follow-up, and (c) costs of diagnostic procedures for visceral causes of abdominal pain in patients with confirmed CAWP. Seventy-nine patients fulfilled tentative criteria for CAWP; 72 (91%) experienced > or = 50% pain relief with anesthetic injection and were followed for at least three months (mean = 13.8 months). Abdominal pain in four patients was later diagnosed as caused by visceral disease. CAWP was confirmed in 56 of remaining 68 patients; 12 of 19 patients with recurrent pain were unavailable for re-injection of anesthetic. Thirty patients with confirmed CAWP had had diagnostic procedures to exclude visceral disease costing almost $700 per patient. CAWP is usually easily identified and treated; greater awareness should minimize misdiagnosis.
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Affiliation(s)
- D S Greenbaum
- Michigan State University, Department of Medicine, East Lansing 48824-1315
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Affiliation(s)
- D Sharpstone
- Queen Alexandra Hospital, Cosham, Portsmouth, Hampshire
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34
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Heaton KW, Parker D, Cripps H. Bowel function and irritable bowel symptoms after hysterectomy and cholecystectomy--a population based study. Gut 1993; 34:1108-11. [PMID: 8174964 PMCID: PMC1374364 DOI: 10.1136/gut.34.8.1108] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Because unsubstantiated beliefs link hysterectomy and cholecystectomy with bowel function, this study examined all the women who had had these operations in a defined population (79 and 37 respectively, out of 1058) with respect to bowel habits, irritable bowel syndrome symptoms, and whole gut transit time calculated from records of three defecations. Compared with unoperated controls, women after hysterectomy were more likely to consider themselves constipated; they also strained more and admitted more often to bloating and feelings of incomplete evacuation. Their stools tended to be lumpier and, in women over 50 years, transit time was longer. When women treated by cholecystectomy were compared with women having newly discovered, asymptomatic gall stones, they more often described defecation as urgent but had no other detectable differences. In conclusion symptomatic constipation is frequent in women after hysterectomy; after cholecystectomy, bowel habit is not consistently changed but the rectum seems to be more irritable.
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Affiliation(s)
- K W Heaton
- Department of Medicine, University of Bristol
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