Ovarian vein thrombus in a pediatric patient: A case study

Acute abdominal pain is a very common chief complaint in the pediatric population, accounting for 5-10% of emergency department (ED) visits. Etiology differentiation is determined by complete history and physical examination, basic laboratory studies, and a variety of imaging study options. In this case report, we present an 8-year-old female with an unusual etiology of acute lower abdominal pain. She presented with tachycardia, hypertension, and bilateral lower quadrant abdominal tenderness without peritonitis. Laboratory studies were unremarkable and appendix ultrasound was indeterminate. CT with contrast revealed right ovarian vein thrombosis. Hematology evaluation did not reveal hypercoagulability. She was discharged on rivaroxaban, which was discontinued after a 3 month course and negative follow-up MRI. Ovarian vein thrombosis (OVT) most commonly develops in the peripartum time frame, with an estimated 20%-40% of cases not related to pregnancies. However, patients with nonpregnancy related OVT were determined to be significantly older than patients with pregnancy related OVT. This case report demonstrates the youngest documented case of OVT. This patient was not in the peripartum period and did not have any identifiable risk factors. Given this unprovoked OVT in a pediatric patient, in patients presenting with abdominal pain with unspecified etiology, advanced imaging studies may be helpful in establishing a diagnosis.

Clinical features of patients with previous spontaneous rupture of ovarian endometrioma operated electively: a case-control study

BACKGROUND

The aim of the study is to investigate the proportion and clinical features of previous spontaneously ruptured ovarian endometrioma among women who underwent elective surgery for endometrioma.

METHODS

This retrospective study was based on a cohort of elective surgeries for endometrioma performed by the same gynecologic team at Peking Union Medical College Hospital from January 2017 to October 2022. Patients diagnosed with previous spontaneously ruptured endometrioma during elective surgery were enrolled in the ruptured group. In the same cohort, patients with unruptured endometrioma treated during the same period were selected as the unruptured group by 1:2 matching according to age. Demographic and clinical information were collected and compared between two groups.

RESULTS

A total of 422 patients in the cohort were diagnosed with endometrioma. There were 38 patients (9.0%) in ruptured group and 76 patients in unruptured group. All enrolled participants were treated by laparoscopic surgery. In ruptured group, 86.8% patients had a history of acute abdominal pain, which was only 13.2% in unruptured group (P < 0.001). Compared to unruptured group, patients diagnosed with ruptured endometrioma had a lower BMI (P = 0.021), larger maximum diameter of endometrioma (P = 0.040), higher proportion of cul-de-sac partial obliteration rather than complete obliteration (P = 0.003).

CONCLUSIONS

Spontaneous rupture of endometrioma is not rare. The proportion of spontaneous rupture of endometrioma in our study was higher than that reported in the literatures. In women with endometrioma, the onset of acute abdominal pain should be considered a rupture of cyst, especially in patients with big cysts.

Usefulness of magnetic resonance imaging for acute abdominal pain in a pregnant woman: A case of idiopathic renal hemorrhage

Acute abdominal pain in pregnant women may complicate the diagnostic process of acute abdominal pain because of anatomical and physiological changes and limitations of computed tomography examinations related to radiation exposure. Here, we present the case of a 35-year-old female in her 10th week of pregnancy who was seen in the emergency department with unilateral abdominal pain and gross hematuria. Ultrasound detected only hydronephrosis and failed to identify ureteral stones, but magnetic resonance imaging revealed a diagnosis of idiopathic renal hemorrhage and intraductal ureteral hematoma, not ureteral stones. Although magnetic resonance imaging for pregnant women has the disadvantages of prolonged scan time and difficulty in image interpretation, no harm or complications to the mother or fetus have been reported. Magnetic resonance imaging may be considered in assessing acute abdominal pain in pregnant women, especially when the diagnosis is uncertain, based on shared decision-making with the patient and assessing the clinical situation and availability.

Acute abdominal pain in women of reproductive age: keys to suggest a complication of endometriosis

Although endometriosis is a common gynecological condition in women of reproductive age, a complication of endometriosis is rarely considered as the differential diagnosis of acute abdominal pain in that context. However, acute events in women with endometriosis can represent life-threatening conditions, which require emergent treatment and often surgical management. Mass effect of endometriotic implants can give rise to obstructive complications, specifically occurring in the bowel or in the urinary tract, while inflammatory mediators released by ectopic endometrial tissue can lead to inflammation of the surrounding tissues or to superinfection of the endometriotic implants. Magnetic resonance imaging is the best imaging modality to reach the diagnosis of endometriosis, but an accurate diagnosis is possible on computed tomography, especially in the presence of stellar, mildly enhanced, infiltrative lesions in suggestive areas. The aim of this pictorial review is to provide an image-based overview of key findings for the diagnosis of acute abdominal complications of endometriosis.

Complicated urachal cyst in two pediatric patients: a case report

BACKGROUND

A urachal cyst has a rare incidence that has been reported as 1/5,000 live birth.

CASE PRESENTATION

We report two patients with a complicated urachal cyst, a 5-year-old female who presented to the emergency department with severe abdominal pain and a 3-year-old female presenting with abdominal pain and constipation. Upon laparoscopic exploration both patients had complicated urachal cysts which were adherent to the urinary bladder.

CONCLUSION

Complicated urachal cysts can present with acute abdominal pain.

Acute abdominal pain at referral emergency departments: an analysis of performance of three time-dependent quality indicators

BACKGROUND

Abdominal pain is one of the most frequent causes for emergency department (ED) visits. The quality of care and outcomes are determined by time-dependent interventions with barriers to implementation at crowded EDs.

OBJECTIVES

The study aimed to analyze three prominent quality indicators (QI) including pain assessment (QI1), analgesia in patients reporting severe pain (QI2), and ED length of stay (LOS) (QI3) in adult patients requiring immediate or urgent care due to acute abdominal pain. We aimed to characterize current practice regarding pain management, and we hypothesized that extended ED LOS (≥ 360 min) is associated with poor outcomes in this cohort of ED referrals.

METHODS

This is a retrospective cohort study enrolling all patients with acute abdominal pain as the main cause of ED presentation, triage category red, orange, or yellow, and age ≥ 30 years during two months period. Univariate and multivariable analyses were deployed to determine independent risk factors for QIs performance. For QI1 and QI2, compliance with the QIs were analyzed, while 30-day mortality was set as primary outcome for QI3.

RESULTS

Overall, 965 patients were analyzed including 501 (52%) males with a mean age of 61.8 years. Seventeen percent (167/965) of the patients had immediate or very urgent triage category. Age ≥ 65 years, and red and orange triage categories were risk factors for non-compliance with pain assessment. Seventy four per cent of patients with severe pain (numeric rating scale ≥ 7) received analgesia during the ED visit, in median within 64 min (IQR 35-105 min). Age ≥ 65 years and need for surgical consultation were risk factors for prolonged ED stay. After adjustment to age, gender and triage category, ED LOS ≥ 360 min proved to be independent risk factor for 30-day mortality (HR 1.89, 95% CI 1.71-3.40, p = 0.034).

CONCLUSION

Our investigation identified that non-compliance with pain assessment, analgesia and ED length of stay among patients presenting with abdominal pain to ED results in poor quality of care and detrimental outcomes. Our data support enhanced quality-assessment initiatives for this subset of ED patients.

Air ambulance retrievals of patients with suspected appendicitis and acute abdominal pain: The patients' journeys, referral pathways and appendectomy outcomes using linked data in Central Queensland, Australia

INTRODUCTION

Acute appendicitis is the most common cause of acute abdominal pain presentations to the ED and common air ambulance transfer.

AIMS

describe how linked data can be used to explore patients' journeys, referral pathways and request-to-activation responsiveness of patients' appendectomy outcomes (minor vs major complexity).

METHODS

Data sources were linked: aeromedical, hospital and death. Request-to-activation intervals showed strong right-tailed skewness. Quantile regression examined whether the longest request-to-activation intervals were associated with appendicitis complexity in patients who underwent an appendectomy.

RESULTS

There were 684 patients in three referral pathways based on hospital capability levels. In total, 5.6 % patients were discharged from ED. 83.3 % of all rural origins entered via the ED. 3.8 % of appendicitis patients were triaged to tertiary hospitals. Appendectomy patients with major complexity outcomes were less likely to have longer request-to-activation wait times & had longer lengths of stay than patients with minor complexity outcomes.

CONCLUSIONS

Linked data highlighted four aspects of a functioning referral system: appendectomy outcomes of major complexity were less likely to have longer request-to-activation intervals compared to minor (sicker patients were identified); few were discharged from EDs (validated transfer); few were triaged to tertiary hospitals (appropriate level for need), and no deaths relating to appendectomy.

Associations between elevated high-sensitive cardiac troponin t and outcomes in patients with acute abdominal pain

PURPOSE

The purpose of this study was to determine outcomes in patients presenting to emergency department (ED) with acute abdominal pain and suspected occult myocardial injury [OMI (high-sensitive cardiac troponin T, hs-cTnT level > 14 ng/L)] without clinical signs of myocardial ischaemia. We hypothesized that OMI is a common entity associated with poor outcomes.

METHODS

After institutional research ethics committee approval, a retrospective review was performed on patients subjected to extended use of hs-cTnT measurements during two months period in patients admitted to ED with a chief complaint of abdominal pain, aged 30 years or older and triaged to red, orange, or yellow categories. Primary outcomes were 30-day, six-month, and one-year mortality, respectively. Adjusted mortality rates were compared using the Cox proportional hazard regression model.

RESULTS

Overall, 1000 consecutive patients were screened. A total of 375 patients were subjected to hs-cTnT measurement and 156 of them (41.6%) experienced OMI. None of the patients had acute myocardial infarction diagnosed in the ED. Patients with OMI had a significantly higher 30-day, six-month and one-year mortality compared to the normal hs-cTnT level group [12.8% (20/156) vs. 3.7% (8/219), p = 0.001, 34.0% (53/156) vs. 6.9% (15/219), p < 0.001 and 39.1% (61/156) vs. 9.1 (20/219), p < 0.001, respectively]. OMI was an independent risk factor for mortality at every time point analyzed.

CONCLUSION

Our investigation noted OMI in older patients with co-morbidities and in higher triage category presenting with abdominal pain to ED, respectively. OMI is an independent risk factor for poor outcomes that warrants appropriate screening and management strategy. Our results support the use of hs-cTnT as a prognostication tool in this subgroup of ED patients.

Mesanteric ischemia in a COVID-19 patient with no risk factors: A case report

BACKGROUND

Acute mesenteric ischemia (AMI) may present in COVID-19 patients without the classic risk factors of AMI, and the symptoms might confuse physicians, leading to delayed diagnosis and increased mortality. In this manuscript, we report a patient with COVID-19 who presented with AMI as its initial presenting symptom.

CASE PRESENTATION

A 68-year-old man presented to the emergency room with periumbilical non-radiating pain that had started three days before the admission. He had no defecation or gas passing in the past three days. In the physical exam, the patient had guarding of the abdomen, generalized tenderness, and rebound tenderness. C-reactive protein, Creatine phosphokinase and WBC count were elevate. Abdominal X-ray in the supine position was suggestive of obstruction of the small intestine. Diagnostic laparotomy was performed because of peritonitis and acute abdominal pain. The diagnosis was mesenteric ischemia due to vein thrombosis based on laparotomy and paraclinic findings. In the post-surgery evaluations COVID-19 infection was confirmed based on PCR and chest CT scan.

DISCUSSION

Based on paraclinical, clinical, and diagnostic laparotomy findings, the patient was diagnosed with small bowel obstruction and gangrene due to acute mesenteric ischemia (AMI). But as described, this patient didn't have any history of medical diseases that cause a hypercoagulable state, in the past. While AF was ruled out because his ECG was normal. We concluded that in this patient AMI was due to his infection with COVID-19.

CONCLUSION

Patients with COVID-19 may not have the typical risk factors for AMI, and AMI diagnosis should be considered in patients presenting with acute abdominal pain, even without the routine risk factors.

Application of SPARK teaching in acute abdomen radiography teaching for undergraduate medical students

BACKGROUND

Acute abdomen is a series of acute and severe abdominal diseases commonly encountered in clinic. It is important to strengthen the image teaching of acute abdomen for undergraduates.

AIM

This study aimed to explore the application effect of SPARK[sub-speciality (S), problem-based learning (P), assessment (A), report (R) and reading skill (K)] teaching mode in the experimental teaching of acute abdomen for undergraduate medical students.

METHODS

We selected a total of 58 third year medical students for observation. The students were divided into experimental group and control group. Among them, 29 students in the experimental group studied in SPARK teaching mode, 29 students in the control group studied in traditional teaching mode. The two groups of students were tested after the theory class, before and after the experimental class, and one week after the experimental class, to compare the application effects of the two teaching modes. After the test one week after the experimental class, the two groups of students jointly adopted SPARK mode to learn, and were tested again one month after the experimental class to compare whether the two groups of students achieved the same results. The total score of all tests was 150.

RESULTS

The average scores of the experimental group and the control group after theory class were (69.0 ± 26.4) and (72.1 ± 24.1) respectively, with no statistical difference (t = 0.468, P = 0.642). The average scores of the experimental group before, after and one week after the experimental class were higher than those of the control group. The experimental group was (84.5 ± 23.1), (109.7 ± 23.8), (105.5 ± 31.0) respectively, and the control group was (52.8 ± 15.1), (93.8 ± 17.0), (80.0 ± 22.8) respectively. The differences were statistically significant (t = -6.195, P = 0.00; t = -2.919, P = 0.05; t = -3.569, P = 0.01). The average scores of the experimental group and the control group after one month were (99.0 ± 31.0) and (95.5 ± 25.6) respectively, and there was no significant difference between the two groups (t = -0.462, P = 0.646).

CONCLUSIONS

The SPARK teaching mode was helpful for undergraduate medical students to consolidate image foundation, improve image reading skills.

Factors associated with unfavorable outcomes in patients with acute abdominal pain visiting the emergency department

BACKGROUND

Unfavorable outcomes occur in patients with acute abdominal pain who visit the emergency department (ED). We aimed to determine the factors associated with unfavorable outcomes in patients with acute abdominal pain visiting the ED.

METHODS

This retrospective cohort study was conducted from July 1, 2015 to June 30, 2016. The inclusion criterion was patients aged older than 18 years who presented to the ED with acute abdominal pain. Significant factors associated with unfavorable outcomes were examined using univariate and multivariate logistic regression analyses.

RESULTS

A total of 951 patients were included in the study. Multivariate logistic regression analysis showed that the ED length of stay (EDLOS) > 4 h (adjusted odds ratio (AOR) 2.62, 95% confidence interval [CI]: 1.33-5.14; p = 0.005), diastolic blood pressure (DBP) < 80 mmHg (AOR 3.31, 95% CI: 1.71-6.4; p ≤ 0.001), respiratory rate ≥ 24 breaths/min (AOR 2.03, 95% CI: 1.07-3.86; p ≤ 0.031), right lower quadrant (RLQ) tenderness (AOR 3.72, 95% CI: 1.89-7.32; p ≤ 0.001), abdominal distension (AOR 2.91, 95% CI: 1.29-6.57; p = 0.010), hypoactive bowel sounds (AOR 2.89, 95% CI: 1.09-7.67; p = 0.033), presence of specific abdominal signs (AOR 2.07, 95% CI: 1.1-3.88; p = 0.024), white blood cell count ≥ 12,000 cells/mm³ (AOR 2.37, 95% CI: 1.22-4.6; p = 0.011), and absolute neutrophil count (ANC) > 75% (AOR 2.83, 95% CI: 1.39-5.75; p = 0.004) were revealed as significant factors associated with unfavorable outcomes.

CONCLUSIONS

The present study revealed that the significant clinical signs associated with the occurrence of unfavorable outcomes were DBP < 80 mmHg, tachypnea (≥ 24 breaths/min), RLQ tenderness, abdominal distension, hypoactive bowel sounds, and presence of specific abdominal signs. Moreover, the associated laboratory results identified in this study were leukocytosis and ANC > 75%. Additionally, patients with abdominal pain visiting the ED who had an EDLOS longer than 4 h were associated with unfavorable outcomes.

A Patient with Acute Abdominal Pain Caused by an Unnoticed Swallowed Toothpick Misdiagnosed as Acute Appendicitis

The differential diagnosis of acute abdominal pain is a challenging task for medical doctors working in the department of gastroenterology. It is clear that acute abdominal pain may be associated with a number of pathologic conditions. We report an unusual case of an unnoticed swallowed wooden toothpick stuck in the ileocecal area of a young man with right lower abdominal pain who was misdiagnosed as acute appendicitis. However, an abdominal computed tomography scan showed an elongated foreign body stuck in the ileocecal area. The elongated foreign body was identified as a wooden toothpick, which was then grasped with a foreign body forceps and successfully removed through colonoscopy. The patient's abdominal pain was significantly relieved within 2 days following treatment. On the basis of the case report, we suggest the importance of abdominal computed tomography scans for the differential diagnosis of acute abdominal pain and highlight the need for extra vigilance in excluding the diagnosis of foreign bodies in the gastrointestinal tract of patients with acute abdominal pain.

Managing acute abdominal pain in the emergency centre: Lessons from a patient's experience

Pain is one of the most common reasons people present to the emergency centre with 7-10% of presentations being due to acute abdominal pain. However, pain is also often neglected by clinicians in emergency centres. The well validated South African Triage Score (SATS) incorporates pain assessment in the prioritising of patients with the aim of guiding clinicians. Based on the SATS, severe pain (a score of ≥8 out of 10) should prompt the clinician to initiate treatment within 10 min of presentation, as unmanaged pain has multiple negative consequences, including poor outcomes of the acute incident with delayed healing and increased risk of developing chronic pain. In this commentary, we present a patient's experience when attending an emergency centre for acute abdominal pain, describe relevant pain mechanisms and highlight the stages where clinical management could have been optimised.

[Imaging in the acute abdomen-part 2 : Case examples of frequent organ-specific causes: gastrointestinal tract and urogenital system]

The acute abdomen is a potentially life-threatening condition and requires a rapid diagnosis. After clinical inspection and in cases with unclear ultrasound findings or unclear serious symptoms computed tomography (CT) and in pregnant women and children magnetic resonance imaging (MRI) is usually necessary. This second part of "Imaging in the acute abdomen" focuses on frequent organ specific causes of the gastrointestinal tract and the urogenital system.

Angioedema with severe acute abdominal pain: Think of hereditary angioedema

Angioedema can be either mast cell-(histamine-)mediated or bradykinin-mediated. Treatment approaches for the two types are very different, making differential diagnosis critical. Severe acute abdominal pain caused by intestinal angioedema is commonly misdiagnosed, especially when associated with bradykinin-mediated angioedema. After describing a typical clinical scenario and diagnostic journey of a patient with recurrent, undiagnosed abdominal pain due to hereditary angioedema (HAE), a rare variant of bradykinin-mediated angioedema, we delve into the classification and differential diagnosis of the various types of angioedema and provide an overview of appropriate management with an emphasis on the bradykinin-mediated types. Bradykinin-induced angioedema may be inherited or acquired and is infrequent compared to mast cell-mediated angioedema. HAE is a rare disease characterized by recurrent attacks of non-urticarial, nonpruritic edema usually affecting the face, respiratory tract, extremities, gastrointestinal tract, and genitalia. Unlike mast cell-mediated angioedema, painful abdominal symptoms are prevalent in bradykinin-mediated angioedema and are sometimes the only manifestation of an attack, increasing the likelihood of initial misdiagnosis as appendicitis or other forms of acute abdomen. It is important for gastroenterologists to be vigilant for the possibility of angioedema pathology in patients presenting with undiagnosed, recurrent, abdominal symptoms to facilitate accurate diagnosis and effective treatment.

Strangulated internal hernia following severe ovarian hyperstimulation syndrome: a case report

Ovarian hyperstimulation syndrome (OHSS) is a serious complication of ovarian stimulation. Herein, we report a rare case of strangulated internal hernia in a woman with severe OHSS following ovulation induction. A delay in the diagnosis and management of acute abdominal pain can lead to serious problems. The aim of this case report was to highlight the diagnostic difficulties of abdominal pain in women with OHSS, and emphasize the positive effects of imaging and a timely differential diagnosis in clinical practice.

Laparoscopic Salpingectomy for an Isolated Case of Left Fallopian Tube Torsion in a Premenarcheal 13 years old

Isolated torsion of the fallopian tube without an ovarian abnormality is an uncommon clinical finding even rarer before menarche and postmenopause, with an incidence of approximately 1 in 1.5 million women. Left fallopian tube torsion is infrequent as compared to right. Here, we report a rare case of a prepubertal girl who presented with acute left abdominal pain. Ultrasound suggested normal ovaries, and a significant left hydrosalpinx and color-Doppler was done, which confirmed signs of left-sided fallopian tube torsion. On laparoscopy, her left fallopian tube was twisted around its axis five times with the signs of necrosis, a laparoscopic salpingectomy was performed. Laparoscopy is the gold standard for the diagnosis and management of this condition. A high index of suspicion is necessary to make an early diagnosis allowing conservative surgical management and hence fertility preservation.

Left sided omental torsion with inguinal hernia: Case report

•

Omental torsion should be a differential diagnosis of acute abdominal pain in untreated inguinal hernia.

•

Clinical presentation of left-sided omental torsion mimics colonic diverticulitis.

•

Computed tomography scan is helpful for diagnosis.

Introduction

Omental torsion is an unusual cause of acute abdominal pain. This condition may mimic other common pathologies, for instance, appendicitis or colonic diverticulitis. As a result, the diagnosis of omental torsion could be challenging to achieve preoperatively.

Presentation of case

A 63-year-old male patient of secondary omental torsion accompanied by the left inguinal hernia was described. The patient presented to the hospital with a painful mass occupying in the left lower quadrant of his abdomen. A computed tomography scan with intravenous contrast administration demonstrated a whirling sign of intraabdominal fatty mass extending to the left inguinal canal. Therefore, emergency laparotomy was performed. Hemorrhagic infarction of the greater omentum was observed, and double-twisting points were identified at both ends of the greater omentum. Then, the strangulated omental portion was resected. The patient recovered uneventfully and was able to be discharged home on postoperative day 4.

Discussion

Secondary omental torsion has been reported more frequently than primary omental torsion. However, most of the patients were right-sided torsion. Precise diagnosis might not be possible by only clinical examination and plain abdominal radiography. The computed tomography scan, demonstrating classic whirling pattern, is useful in suspected cases. The treatment was straightforward by resection of the affected omentum.

Conclusion

The omental torsion is a rare cause of acute abdominal pain and could mimic other intra-abdominal pathologies.

Engagement under difficult conditions: Caring for patients with acute abdominal pain across the acute-care chain: A qualitative study

BACKGROUND

Studies report that patients with acute abdominal pain do not always receive optimal care and can experience poor pain management, safety failures, and emotional harm. Deeper understanding of how health professionals experience care delivery is needed to improve care to patients with acute abdominal pain.

AIM

To explore, from the perspective of registered nurses and physicians, how care is provided for patients with acute abdominal pain in the acute care chain, and to identify barriers that they describe in the delivery of care.

METHOD

Registered nurses and physicians (n = 19) working in ambulance services, emergency departments, and surgical departments at five hospitals in Sweden were interviewed. A content analysis was performed.

RESULTS

Five categories were identified; interaction: a decisive moment, competence and resources: not always available, guidelines: limited use, medical care: a main focus, and feedback and collaboration: limited across acute care chain.

CONCLUSION

This study adds new insights relating to how health professionals reflect on patient needs and obstacles to satisfying them. To deliver high quality care and meet patients' fundamental needs, there is a need of general guidelines and close collaboration in the acute care chain.

OMENTAL INFARCTION: SURGICAL or CONSERVATIVE TREATMENT? A CASE REPORTS and CASE SERIES SYSTEMATIC REVIEW

BACKGROUND

Omental infarction (OI) is an infrequent cause of acute abdominal pain and there is no consensus on whether conservative or surgical treatment is the best strategy when performing positive CT diagnosis.

OBJECTIVES

To assess which of the two treatments is the most commonly adopted and compare outcomes in terms of success rate in resolution of symptoms and hospital length of stay.

ELIGIBILITY CRITERIA

Case report and case series of patients with abdominal pain and positive diagnosis by CT of omental infarction.

DATA SOURCES

PubMed, Science Direct and Google Scholar in combination with cross-referencing searches and manual searches of eligible articles from January 2000 to June 2018.

PARTICIPANTS

Patients older than 18 years of age.

METHODS

Patient characteristics and results were summarized descriptively. Categorical variables were assessed by chisquare test or Fischer's exact test, and continuous variables by the Wilcoxon-Mann-Whitney or Kruskal-Wallis test. Risk factors for failure of the conservative management were identified using multivariate logistic regression.

RESULTS

90 articles were included in the final analysis (146 patients). 107 patients (73.3%) received conservative treatment with a failure rate of 15.9% (patients needing surgery) and 39 patients (26.7%) received surgery as first treatment. The mean hospital length of stay was 5.1 days for the conservative treatment group and 2.5 days for the surgery group with statistically significant differences (p = 0.00). Younger age and white blood cells count ≥12000/μl were predictive factors of conservative treatment failure.

CONCLUSIONS

Although conservative treatment is effective in most patients, surgery has advantages in terms of hospital length of stay.

Clinical evaluation of testicular torsion presenting with acute abdominal pain in young males

Objective

To evaluate the features of testicular torsion presenting with acute abdominal pain and to raise awareness of testicular torsion with specific symptoms.

Methods

From October 2005 to June 2016, nine patients with testicular torsion who presented with isolated acute abdominal pain rather than scrotal pain as their primary symptom were retrospectively reviewed. Data, including the age of patients, season at admission, initial medical history, external genital examination, emergency ultrasound findings, operative findings, duration of abdominal pain, complications, and follow-up results, were collected.

Results

The average age of patients was 14 years (range 10–17 years). Seven patients whose genitals were not initially examined externally were misdiagnosed as having ordinary abdominal diseases. Surgical exploration revealed that all the involved testes necrotized, and orchidectomy was performed. In the other two patients, scrotal and testicular abnormalities were detected immediately on admission, and emergency surgical exploration determined that the involved testis remained vital, so orchiopexy was performed. The mean duration from symptom onset to diagnosis was 4 h (3–5 h) in the orchiopexy group and 37 h (18–72 h) in the orchidectomy group. Six patients were psychologically affected during postoperative follow-up. Neither recurrence of testicular torsion nor testicular atrophy was recorded.

Conclusion

Acute abdominal pain can be the initial and sole symptom of testicular torsion in young males. Physicians should pay close attention to the specific clinical presentation of testicular torsion.

[Radiological evaluation of acute abdomen in children]

CLINICAL/METHODICAL ISSUE

Acute, non-traumatic abdominal pain is one of the main reasons for medical consultation in pediatric patients. Knowledge of different diseases and their age dependence is essential for correct diagnosis and treatment.

STANDARD RADIOLOGICAL METHODS

Ultrasonography is the imaging method of choice. X‑ray is only used in case of emergency, e. g., suspected perforation.

METHODICAL INNOVATIONS

Contrast-enhanced ultrasonography (CEUS) and elastography complement ultrasonography.

PERFORMANCE

Magnetic resonance imaging is of increasing relevance for differential diagnosis of unclear sonographic results.

PRACTICAL RECOMMENDATIONS

The primary imaging modality in pediatric patients is ultrasonography. Cross-sectional imaging should only be used in cases of unclear sonographic findings.

Neutrophil-to-lymphocyte ratio and mesenteric ischemia: can it predict the etiology of mesenteric ischemic at computed tomography?

OBJECTIVES

To assess the usefulness of the neutrophil-to-lymphocyte ratio (NLR) as a predictive factor of acute mesenteric ischemia (AMI) in patients presenting at the emergency department (ED) with acute abdominal pain.

METHODS

This is a retrospective case-control study of patients older than 16 years admitted to the ED with acute abdominal pain with CT and histologic confirmation. The study group corresponded to patients with abdominal CT with radiological signs of AMI. The control group corresponded to patients with non-AMI findings in abdominal CT. Association measurements of NLR with radiological signs were compared with a paired-sample t test, and multivariate regression performed to analyze potential correlations. To assess the diagnosis capacity of NLR, ROC curves were calculated.

RESULTS

A total of 61 patients were included (32 cases and 29 controls). The cases of AMI showed higher mortality (43.8% vs 6.9%, p < 0.01) and higher NLR on the limit of statistical significance (13.8 vs 8.7, p = 0.053). Patients with AMI due to occlusion of the superior mesenteric artery (SMA) showed a higher NLR (8.3 vs 22.3, p < 0.001). The area under the curve (AUC) of the NLR for AMI due to occlusion of the SMA was 0.88 (95% CI 0.7-1.0, p = 0.001). No patient with NLR < 5 presented AMI due to occlusion of the SMA. An NLR of 12.8 showed a sensitivity of 92% and a specificity of 74% for AMI due to occlusion of SMA.

CONCLUSIONS

The NLR is a useful parameter of AMI of arterial origin due to occlusion of the SMA; it can help the clinician to raise suspicion of this diagnosis and the interpreting radiologist in the acquisition protocol for the CT study and would alert for an early surgical treatment.

Utility of MR Imaging in Abdominopelvic Emergencies

Acute abdominopelvic pain, a common symptom in emergency department patients, is challenging given the spectrum of differential diagnoses encompassing multiple organ systems, ranging from benign self-limiting to life-threatening and emergent. Diagnostic imaging is critical given its high accuracy and management guidance. A contrast-enhanced computed tomography (CT) scan is preferred given its widespread availability and speed of acquisition. MR imaging may be appropriate, usually performed for specific indications with tailored protocols. It is accurate for diagnosis and may be an alternative to CT. This article discusses the advantages and disadvantages, protocols, and appearances of MR imaging of common diagnoses.

Diagnosis of pain in the right iliac fossa. A new diagnostic score based on Decision-Tree and Artificial Neural Network Methods

INTRODUCTION

Pain in the right iliac fossa (RIF) continues to pose diagnostic challenges. The objective of this study is the development of a RIF pain diagnosis model based on classification trees of type CHAID (Chi-Square Automatic Interaction Detection) and on an artificial neural network (ANN).

METHODS

Prospective study of 252 patients who visited the hospital due to RIF pain. Demographic, clinical, physical examination and analytical data were registered. Patients were classified into 4 groups: NsP (nonspecific RIFP group), AA (acute appendicitis), NIRIF (RIF pain with no inflammation) and IRIF (RIF pain with inflammation). A CHAID-type classification tree model and an ANN were constructed. The classic models (Alvarado [ALS], Appendicitis Inflammatory Response [AIR] and Fenyö-Linberg [FLS]) were also evaluated. Discrimination was assessed using ROC curves (AUC [95% CI]) and the correct classification rate (CCR).

RESULTS

53% were men. Mean age 33.3±16 years. The largest group was the NsP (45%), AA (37%), NRIF (12%) and IRIF (6%). The analytical model results were: ALS (0.82 [0.76-0.87]), AIR (0.83 [0.77-0.88]) and FLS (0.88 [0.84-0.92]). CHAID determined 10 decision groups: 3 with high probability for NsP, 3 high for AA and 4 special groups with no predominant diagnosis. CCR of ANN and CHAID were 75% and 74.2%, respectively.

CONCLUSIONS

The methodology based on CHAID-type classification trees establishes a diagnostic model based on four pain groups in RIF and generates decision rules that can help us in the diagnosis of processes with RIF pain.

Concomitant leukocytosis and lymphopenia predict significant pathology at CT of acute abdomen: a case-control study

BACKGROUND

Acute abdominal pain accounts for about 10% of emergency department visits and has progressively become the primary indication for CT scanning in most centers. The goal of our study is to identify biological or clinical variables able to predict or rule out significant pathology (conditions requiring urgent medical or surgical treatment) on abdominal CT in patients presenting to an emergency department with acute abdominal pain.

METHODS

This was a retrospective cohort study performed in the emergency department of an academic center with an annual census of 60'000 patients. One hundred and-nine consecutive patients presenting with an acute non-traumatic abdominal pain, not suspected of appendicitis or renal colic, during the first semester of 2013, who underwent an abdominal CT were included. Two medical students, completing their last year of medical school, extracted the data from patients' electronic health record. Ambiguities in the formulations of clinical symptoms and signs in the patients' records were solved by consulting a board certified emergency physician. Nine clinical and biological variables were extracted: shock index, peritonism, abnormal bowel sounds, fever (> 38 °C), intensity and duration of the pain, leukocytosis (white blood cell count >11G/L), relative lymphopenia (< 15% of total leukocytes), and C-reactive Protein (CRP). These variables were compared to the CT results (reference standard) to determine their ability to predict a significant pathology.

RESULTS

Significant pathology was detected on CT in 71 (65%) patients. Only leukocytosis (odds ratio 3.3, p = 0.008) and relative lymphopenia (odds ratio 3.8, p = 0.002) were associated with significant pathology on CT. The joint presence of these two anomalies was strongly associated with significant pathology on CT (odds ratio 8.2, p = 0.033). Leukocytosis with relative lymphopenia had a specificity of 89% (33/37) and sensitivity of 48% (33/69) for the detection of significant pathology on CT.

CONCLUSION

The high specificity of the association between leukocytosis and relative lymphopenia amongst the study population suggests that these parameters would be sufficient to justify an emergency CT. However, none of the parameters could be used to rule out a significant pathology.

Administering analgesia sublingually is a suitable option for children with acute abdominal pain in the emergency department

AIM

Acute abdominal pain is a frequent complaint in children attending emergency departments. The aim of this study was to investigate the pain score reductions when children with acute abdominal pain received medication sublingually.

METHODS

We carried out a multicentre randomised controlled trial in three children's hospitals in Italy between March 2015 and June 2017. Children from four to 18 years of age with acute abdominal pain were recruited if their self-reported pain was at least six on a scale from 0-10. The children were randomised to receive ketorolac 0.5 mg/kg (n = 70) or tramadol 2 mg/kg (n = 70) sublingually or a melt in the mouth powder of 20 mg/kg paracetamol (n = 70). The main study outcome was the pain scores for the three drugs after two hours.

RESULTS

The 210 children (58.6% girls) had a median age of 12 years with an interquartile range of 9-14.3. The median pain scores at two hours were not significantly different between ketorolac 2.0 (interquartile ranges, IQR 0.0-4.3) and tramadol 3.0 (IQR 1.0-5.0) vs paracetamol 3.0 (IQR 0.8-5.0). The median pain reductions were all 5.0 points.

CONCLUSION

Delivering analgesia sublingually was a suitable option for pain relief in children with acute abdominal pain in the emergency department.

Experience in the diagnosis and treatment of mesenteric lymphangioma in adults: A case report and review of literature

BACKGROUND

Mesenteric lymphangioma (ML) in adults is a very rare disease. We report six hospitalized adult patients with ML in our hospital between January 2013 and July 2018 to investigate the characteristics and prognosis of ML in adults.

CASE SUMMARY

The male-to-female ratio was 3:3, and the median age at diagnosis was 55.2 years. Clinical manifestations varied; however, most were acute cases (5/6). No history of trauma was reported. None (0/6) of the patients were accurately diagnosed with ML in the emergency and outpatient departments. Mesenteric cysts were identified in four patients (66.7%) by abdominal ultrasound and in five patients (83.3%) by computed tomography. ML was postoperatively confirmed by pathology. Most MLs (4/6) were associated with infection of other systems. ML was located in the mesentery of the small intestine (n = 4), ileum (n = 1) and rectum (n = 1). Cyst fluid was clear (n = 4), chylous (n = 1) and bloody (n = 1). Surgical procedures included complete tumor removal and partial intestinal excision (n = 6). Recurrence and adhesive intestinal obstruction were not observed during the 3-12 mo follow-up period.

CONCLUSION

ML in adults is a rare benign acquired disease that can be cured by surgical treatment. Infection may be a cause of ML.

Etiologies and outcomes of emergency surgery for acute abdominal pain: an audit of 1456 cases in a single center

PURPOSE

There are few studies that have reported the details of emergency surgery for acute abdominal pain. This study aimed to clarify the etiologies and outcomes of emergency abdominal surgery among patients in different age categories.

METHODS

Between January 2014 and December 2016, 1456 patients aged 7 years or older who underwent emergency surgery for acute abdominal pain at our institution were enrolled in this study. The patients were divided into three age groups: 7-17 years (n = 146), 18-64 years (n = 628), and 65 years or older (n = 682). The clinical characteristics, etiology of abdominal emergency surgery, and surgical outcomes were compared among the three groups.

RESULTS

The proportion of patients with comorbid conditions significantly increased with increasing ages. In patients in between 7 and 17 and in those between 18 and 64 years, acute appendicitis was the most frequent etiology, followed by bowel obstruction. Conversely, the most frequent etiology was bowel obstruction, followed by biliary disease in patients 65 years or older. The morbidity and mortality rate were 12% and 0.2% in patients 18-64 years, and 25% and 1.8% in patients 65 years or older (P < 0.001 and P = 0.004, respectively). In the group of patients 65 years or older, more patients were transferred to different hospitals for rehabilitation or recovery.

CONCLUSIONS

This study demonstrated significant differences among patients in different age categories in terms of the etiologies and outcomes of emergency abdominal surgery.

Solitary cecal diverticulitis, a rare cause of right lower quadrant pain: Four cases

Solitary cecal diverticulitis is a rare clinical condition. Like diverticulitis in other segments of the colon, it requires immediate surgical intervention if it is causing complications. Solitary cecal diverticulitis may be misdiagnosed as acute appendicitis, since it causes right lower quadrant pain, or as a cecal tumor or inflammatory bowel disease, due to an intraoperative appearance resembling an inflammatory mass. Four patients with solitary cecum diverticulitis presenting with acute right lower quadrant pain are discussed in this report. Three patients underwent surgery with a preliminary diagnosis of acute appendicitis or cecal tumor, and 1 patient was diagnosed with cecal diverticulitis and treated medically. The treatment approach may change depending on a preoperative or intraoperative diagnosis of cecal diverticulitis. Therefore, in areas where this disease is uncommon, cecum diverticulitis should not be forgotten in the differential diagnosis of acute right lower quadrant pain or inflammatory bowel mass.

Post coital hemoperitoneum: The pain of love

Acute abdominal pain in women of reproductive age is common and frequent cause for visit to emergency department which warrants emergent evaluation. We present the case of a 23-year-old nulliparous women presenting with post-coital haemoperitoneum secondary to a ruptured corpus luteum cyst. This is a rare case demonstrating the need to elicit sexual history in patients presenting with an acute abdomen in emergency department.

Acute Abdominal Pain Assessment in the Emergency Department: The Experience of a Greek University Hospital

Background

Acute abdominal pain (AAP) is a common symptom in the emergency department (ED). Because abdominal pain can be caused by a wide spectrum of underlying pathology, evaluation of abdominal pain in the ED requires a comprehensive approach, based on patient history, physical examination, laboratory tests and imaging studies. The aim of this study was to investigate predictive factors for admission to the hospital in patients who presented to the ED with AAP as the main symptom.

Methods

This prospective observational study enrolled 125 patients who presented with AAP in the ED of the Patras University Hospital in western Greece. The sample of patients who enrolled in the study was representative of patients who receive care in this academic institution. All patients underwent clinical examination, laboratory testing and radiological assessment. Clinical and laboratory data were analyzed in an attempt to identify clinical or laboratory factors predicting hospital admission.

Results

Based on clinical, laboratory and radiologic evaluation, 37.6% of patients enrolled in the study were admitted to the hospital, whereas 62.4% were not admitted. Compared to patients who were not admitted, patients admitted to the hospital had higher age and significantly higher inflammatory markers, white blood count and C-reactive protein (CRP). Binary logistic regression analysis showed that abnormal imaging findings (odds ratio (OR) = 6.47, 95% confidence interval (CI): 2.11 - 19.77, P < 0.001) and elevated serum CRP levels (OR = 6.24, 95% CI: 2.16 - 18.03, P < 0.001) were significant predictive factors for hospital admission.

Conclusions

Assessment of AAP remains a challenging problem in the ED. Comprehensive history combined with detailed clinical examination, appropriate laboratory testing and radiologic imaging facilitates effective assessment of patients who present in the ED with AAP and guides the decision to admit patients to the hospital for further care.

Core curriculum illustration: epiploic appendagitis

This is the 45th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at: http://www.erad.org/page/CCIP_TOC.

Clinical Predictors of Isolated Tubal Torsion: A Case Series

STUDY OBJECTIVE

A rare cause of adolescent abdominal pain includes isolated tubal torsion (ITT). Presentation is nonspecific and few studies have investigated ITT in adolescents. Our study objective was to describe the presentation and management of ITT in a large case series.

DESIGN

Retrospective observational case series.

SETTING

Tertiary care children's hospital.

PARTICIPANTS

Participants were female and aged 3-21 years, presenting to Children's Hospital Colorado and diagnosed with ITT between January 2004 and August 2015.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Clinical presentation, physical exam, laboratory findings, surgical diagnosis, and treatment provided.

RESULTS

A total of 19 cases were included. Average age was 13.3 (range, 11-18) years. In patients with unilateral abdominal pain (n = 16), there was 100% correlation with side of adnexal pathology. Ultrasound examination in 14 of 18 cases (78%) noted abnormal findings ipsilateral to the ITT. Most cases were managed with laparoscopy (84%; n = 16 of 19) and detorsion with or without cystectomy (74%; n = 14 of 19). Salpingectomy was more common with prolonged pain greater than 24 hours (relative risk 5.6, 95% confidence interval, 0.7-39.0). The most common intraoperative finding was a paratubal cyst (74%; n = 14 of 19). When Doppler flow was performed, it was present in 88% (n = 16 of 18) of the affected adnexa. ITT was more common on the left side (68%; n = 13 of 19).

CONCLUSION

The high occurrence of paratubal cysts might suggest pathologic predisposition for ITT. Providers should maintain a high index of suspicion for ITT, particularly if associated with a paratubal cyst. Classic examination findings of surgical abdomen, leukocytosis, fever, and absence of Doppler flow are infrequently present. Laparoscopy and detorsion are appropriate treatments for managing ITT.

Non-specific abdominal pain remains as the most common reason for acute abdomen: 26-year retrospective audit in one emergency unit

OBJECTIVE

Distribution of diagnoses causing acute abdominal pain (AAP) may change because of population aging, increased obesity, advanced diagnostic imaging and changes in nutritional habits. Our aim was to evaluate the diagnoses causing AAP during a 26-year period.

MATERIALS AND METHODS

This was a retrospective cross-sectional cohort study in one emergency department (ED) covering population about 250,000. All patients admitted to the ED in 1986, 2003 and 2012 were evaluated from hospital electronic database. Demographic data, utilization of diagnostic tests, surgical treatment and discharge diagnosis were analyzed. Statistical data of population aging, obesity and alcohol consumption during 1980-2012 were obtained from national registers.

RESULTS

The AAP patients represented 10-20% of our total ED census. The most common causes of AAP were nonspecific abdominal pain (NSAP, 31-37%), acute appendicitis (11-23%), biliary disease (9-11%), bowel obstruction (5-7%), acute pancreatitis (4-8%) and acute diverticulitis (1-7%). The percentage of NSAP remained highest throughout the study period. Decrease in the number of acute appendicitis (from 23 to 11%; p < .0001), increase in acute diverticulitis (from 1 to 5%; p ≤ .0001) and acute pancreatitis (from 4 to 7%; p = .0273) was observed over time. The utilization of diagnostic imaging increased significantly (CT from 2 to 37% and US from 4 to 38%, p < .0001). Hospital mortality was very low (1-2%).

CONCLUSIONS

NSAP is still the main differential diagnostic problem in the ED. Except acute appendicitis, distribution of specific diagnoses causing AAP remained rather stable through 26-year audit.

Mesenteric cysts and mesenteric venous thrombosis leading to intestinal necrosis in pregnancy managed with laparotomy: a case report and review of the literature

Background

Mesenteric cyst is a rare clinical entity especially in pregnancy; therefore, few cases have been reported in the literature. The standard method of their treatment is surgical excision either with laparotomy or laparoscopy. In addition, mesenteric vein thrombosis is a rare and life-threatening condition in pregnancy and needs immediate treatment because it can lead to intestinal necrotic ischemia. This is the first report of the coexistence of mesenteric cysts and mesenteric vein thrombosis during gestation.

Case presentation

A 27-year-old Greek woman, gravida 2 para 1, presented at 10 weeks’ gestation to the Emergency Unit of our hospital complaining of diffuse abdominal pain which deteriorated the last 3 days, which was localized in her right iliac fossa, along with vomiting. She had undergone open laparotomy and right salpingo-oophorectomy at the age of 23 due to an ovarian cyst. Besides this, her personal and family medical history was unremarkable. She had never received oral contraceptives or any hormone therapy. On arrival, a clinical examination revealed tenderness on palpation of her right iliac fossa, without rebound tenderness or muscle guarding. Within 10 hours of hospitalization, her symptoms deteriorated further with rebound tenderness during the examination, tachycardia, and a drop of 12 units in her hematocrit value. An emergency laparotomy was performed. Two mesenteric cysts and a 60 cm necrotic part of her intestine were revealed intraoperatively. In the postoperative period, she complained of acute abdominal pain, tachycardia, and dyspnea. Computed tomography imaging revealed mesenteric vein thrombosis and pulmonary thromboembolism. She was treated with low molecular weight heparin and she was discharged on the 11th postoperative day.

Conclusions

To the best of our knowledge, this is the first report in the literature of a simultaneous mesenteric cyst and mesenteric vein thrombosis in pregnancy. It is known that pregnancy is a state of hypercoagulation and clinicians should bear in mind this rare clinical condition in their diagnostic algorithm for acute abdominal pain.

A rare case of acute primary omental infarction

Primary omental infarction (POI) is a rare cause of acute abdomen. Most patients have aggravating abdominal pain without gastrointestinal symptoms. Here, we report a case of omental infarction in a 50-year-old woman, who had left abdominal pain and intestinal obstruction. Preoperative computed tomography (CT) of the abdomen showed a left ovarian cyst measuring 6.0 cm × 4.5 cm but otherwise seemed normal initially. The white blood cell count was 9.71 × 10⁹/L, and D-dimer was 1.58 mg/L. Laparoscopic exploration was performed 1 day after admission because of peritonitis and intestinal obstruction. During the exploration, a segment of congested necrotic omentum was found adhering to the abdominal wall with a segment of small intestine. Bloody ascites was also observed in the abdominal cavity. We resected the nonviable segmental omentum, and the ovarian cyst was removed by the gynecologist using laparoscopic procedures. Final pathological findings confirmed POI. While reanalyzing the preoperative CT, a segmental fat mass with an increased density was noted in the left lower quadrant, which was consistent with the intraoperative view 6 days after surgery. The patient recovered uneventfully and was discharged.

Diagnostic accuracy and prognostic utility of D Dimer in acute appendicitis in children

The objective was to determine the uselfulness of D Dimer (DD) as a diagnostic or prognostic marker in acute appendicitis (AA) in children using a prospective observational study in the pediatric emergency department of a tertiary hospital. We enrolled 135 patients aged 1-16 years presenting with abdominal pain consistent with AA, who required laboratory studies. We analyzed clinical, analytical variables and histopathology findings (when they underwent surgery). Statistical analysis was conducted using SPSS. 38.5% of the children were clinically diagnosed with AA (n = 52), confirmed by pathology in 51 patients. 55.8% were gangrenous appendicitis. Leucocyte count, C-reactive protein (CRP), and DD were higher in the AA group and in the gangrenous appendicitis group (p < 0.05), with highest values of DD in the gangrenous group. The area under the receiving operating characteristics (ROC) curve for DD in the diagnosis of AA is 0.66 (95% CI 0.56-0.75). For DD cut-off point of 230 ng/mL, sensitivity (Se) was 0.40, specificity (Sp) 0.80, positive predictive value (PPV) 0.57, and negative predictive value (NPV) 0.66. The area under the ROC curve for DD in children with gangrenous appendicitis is 0.93 (95% CI 0.87-1). A DD cut-off point of 230 ng/mL exhibited: Se = 0.69, Sp = 1, PPV = 1 and NPV = 0.72.

CONCLUSION

DD levels increase in patients with AA. Although it does not constitute a useful diagnostic marker, it could be a good prognostic marker.

Detecting acute mesenteric ischemia in CT of the acute abdomen is dependent on clinical suspicion: Review of 95 consecutive patients

OBJECTIVES

(1) To evaluate the ability of emergency room radiologists to detect acute mesenteric ischemia (AMI) from computed tomography (CT) images in patients with acute abdominal pain. (2) To identify factors affecting radiologists' performance in the CT interpretation and patient outcome.

MATERIALS AND METHODS

A retrospective study of 95 consecutive patients treated for 97 AMI events between 2009 and 2013 was carried out. The etiology of AMI was embolism in 24 (25%), atherosclerotic vascular disease (ASVD) in 39 (40%), non-obstructive mesenteric ischemia (NOMI) in 25 (26%), and mesenteric venous thrombosis (MVT) in nine (9%) cases. The protocols, referrals and initial radiology reports of the abdominal CTs were analyzed. The CT studies were further scrutinized for vascular and intestinal findings.

RESULTS

The referring clinician had suspected AMI in 30 (31%) cases prior to imaging. The crucial findings of AMI had been stated in 97% of the radiology reports if the clinician had mentioned AMI suspicion in the referral; if not, the corresponding rate was 81% (p=0.04). Patients without suspicion of AMI prior to CT were more prone to undergo bowel resection. CT protocol was optimal for AMI (with contrast enhancement in arterial and venous phases) in only 34 (35%) cases. Intestinal findings were more difficult to detect than vascular findings. Vascular findings were retrospectively detectable in 92% of cases with embolism and 100% in ASVD and MVT. Some evidence of intestinal abnormality was retrospectively found in the CT findings in 92%, 100%, 100% and 67% of cases with embolism, ASVD, NOMI and MVT, respectively.

CONCLUSIONS

AMI is underdiagnosed in the CT of the acute abdomen if there is no clinical suspicion.

Clinical profile of non-traumatic acute abdominal pain presenting to an adult emergency department

Background:

Abdominal pain is one of the most common reasons for presenting to the emergency depatment (ED) and the etiology is varied.

Materials and Methods:

This prospective observational study was conducted in a large ED of a tertiary care center in India. All patients older than 15 years and presenting with non-traumatic abdominal pain to the ED from May 2012 to October 2012 were recruited and the demographic characteristics, diagnosis and outcome were analyzed.

Results:

The study cohort included 264 patients over a 6 month period. More than half (55.6%) were aged between 15 and 40 years. There was a male predominance (56.8%). Majority of the patients (76.9%) presented with abdominal pain of less than 72 hour duration. The pain was sudden in onset in 54.9% of patients. Dull type was the most common character of pain (36%) followed by colicky type (22.3%). The most common site of pain was the lower abdomen (45.8%). Upper abdominal pain was seen in 26.9% and the pain was generalized in 27.3% of patients. The common causes were uretericcolic (16.3%), urinary tract infection (12.5%), acute pancreatitis (11%), acute appendicitis (10.6%) and acute gastritis (8%). More than half (51.9%) discharged from ED and 37% of cases were managed by the emergency physicians. Surgical intervention was required in 25.8% of patients. The mortality rate was 2.3%.

Conclusions:

Abdominal pain is a common ED symptom and clinicians must consider multiple diagnoses, especially those that require immediate intervention to limit morbidity and mortality.

Uncommon Surgical Causes Of Right Lower Quadrant Pain In Children. Single Center Experience

Right lower quadrant pain is one of the major reasons of children reference at the emergency department. The most common surgical cause, which needs appropriate management, is acute appendicitis. The purpose of this study is to reveal uncommon surgical causes found during surgery in children who were misdiagnosed as acute appendicitis in our department during the last 10 y. Data of patients who have undergone appendicectomy during a ten year period (since Feb 2004 until Mar 2014) were collected retrospectively. Eight hundred twenty children have undergone appendicectomy in our department. In six children another uncommon cause of the symptoms was revealed during surgery. In one patient the cause was a duplication cyst of the terminal ileum, in two patients an omental torsion, in one patient a meckel diverticulum torsion, in one patient a splenic rupture and in one patient a retroperitoneal tumor. All of the patients were successfully managed during the first operation. The possibility of other uncommon causes of right quadrant abdominal pain should always be kept in mind, especially when there is a negative appendicitis. However, the transaction of further paraclinical examinations - ultrasonography or computed tomography- preoperatively is under discussion. Nevertheless a thoroughly taken case history is undoubtedly always necessary.

Experiences of Indonesian mother managing preschool children's acute abdominal pain in Taiwan

The aim of this study was to understand the Indonesian mothers' experiences of managing preschool children's acute abdominal pain. The descriptive qualitative research design comprises semi-structured interviews with 11 Indonesian mothers. The qualitative content analysis revealed three themes, including (1) insight of abdominal pain, (2) "inheritance of the strategies for assessment of management for abdominal pain from the family of origin", (3) "obstacles and insights related to cultural differences". The results presented that pain management was affected by family, environment, cultural background and religious beliefs. Healthcare providers should provide culturally competent pain management care for the patients of difference nationalities.

Small intestinal obstruction secondary to jejunal trichobezoar removed per anum without an enterotomy: a case report

Trichobezoars can rarely present with obstruction. This is usually due to collection of a hair ball in the stomach. We encountered an interesting case of small bowel obstruction due to a jejunal trichobezoar. The treatment generally is an enterotomy with removal of the hair ball. We report a case of a 29-year-old post partum female who presented to us with sub acute intestinal obstruction. Exploratory laparotomy revealed an impacted mass in the distal jejunum which was removed per anum without an enterotomy. Postoperative gastroscopy did not show trichobezoar in the stomach. This case highlights the importance of trichobezoar as a differential diagnosis in young women with small bowel obstruction that can be treated without an enterotomy and avoiding the risks and morbidities associated with it.

Systemic classification for a new diagnostic approach to acute abdominal pain in children

PURPOSE

With previous methods based on only age and location, there are many difficulties in identifying the etiology of acute abdominal pain in children. We sought to develop a new systematic classification of acute abdominal pain and to give some helps to physicians encountering difficulties in diagnoses.

METHODS

From March 2005 to May 2010, clinical data were collected retrospectively from 442 children hospitalized due to acute abdominal pain with no apparent underlying disease. According to the final diagnoses, diseases that caused acute abdominal pain were classified into nine groups.

RESULTS

The nine groups were group I "catastrophic surgical abdomen" (7 patients, 1.6%), group II "acute appendicitis and mesenteric lymphadenitis" (56 patients, 12.7%), group III "intestinal obstruction" (57 patients, 12.9%), group IV "viral and bacterial acute gastroenteritis" (90 patients, 20.4%), group V "peptic ulcer and gastroduodenitis" (66 patients, 14.9%), group VI "hepatobiliary and pancreatic disease" (14 patients, 3.2%), group VII "febrile viral illness and extraintestinal infection" (69 patients, 15.6%), group VIII "functional gastrointestinal disorder (acute manifestation)" (20 patients, 4.5%), and group IX "unclassified acute abdominal pain" (63 patients, 14.3%). Four patients were enrolled in two disease groups each.

CONCLUSION

Patients were distributed unevenly across the nine groups of acute abdominal pain. In particular, the "unclassified abdominal pain" only group was not uncommon. Considering a systemic classification for acute abdominal pain may be helpful in the diagnostic approach in children.

Acute abdominal pain in childhood and adolescence: assessing the impact of sonography on diagnosis and treatment

PURPOSE

To assess the impact of ultrasonography on defining the diagnostic and therapeutic pathways for pediatric patients admitted to the emergency department for acute abdominal pain.

METHODS

We performed a retrospective study of all patients aged <16 years with acute abdominal pain who underwent ultrasound examination at our Diagnostic Imaging Department from October 2010 to March 2012. We investigated for each patient the pathway following ultrasound examination and definitive diagnosis. The impact of ultrasonography was defined based on the frequency with which the information resulting from this examination confirmed or denied the diagnostic suspicion made by the emergency physician on the basis of clinical and laboratory findings.

RESULTS

In 497/729 patients (69 %), ultrasound examination did not determine variations in the diagnostic and therapeutic pathways, either because it confirmed the outcome of clinical examination and laboratory tests, or because, even addressing in the opposite direction to these, the emergency physician did not consider its result because of being particularly alarmed or sufficiently reassured by clinical examination and laboratory tests. In the remaining 232/729 cases (31 %), ultrasound examination determined an increase or a reduction of the provided care and attention (subsequently proved justified in the vast majority of cases) in spite of what was initially assessed based on clinical examination and laboratory tests.

CONCLUSIONS

The results of our retrospective study demonstrated that ultrasonography was a valuable tool in the management of pediatric patients with acute abdominal pain together with clinical examination and laboratory tests.

Effects of Meperidine on Pain Intensity and Accuracy of Clinical Diagnosis in Patients with Acute Abdominal Pain: A Randomized Clinical Trial

OBJECTIVES

To determine the effects of Meperidine (Pethedine®) on pain intensity, clinical findings, final diagnosis and management of patients with acute abdominal pain.

METHODS

This was a randomized clinical trial including 100 patients, with lower abdominal pain lasting for less than 48 hours who were referred to the emergency department of Imam Khomeini hospital affiliated with Ilam University of Medical Sciences, over a period of 11 months. Hemodynamically unstable patients were not included in the study. The baseline pain severity was measured using a visual analogue scale (VAS). Patients were randomly assigned to receive 25 mg of intramuscular Meperidine (Pethedine®) (n=50) or 5 mL of intravenous normal saline as placebo intravenously (n=50). After 1-hour the patients were then re-examined and the pain severity was re-assessed and the clinical diagnosis was recorded.

RESULTS

There was no significant difference between two study groups regarding the baseline characteristics. The mean pain score on arrival was comparable between groups (6.80 ± 1.6 vs. 6.81 ± 1.2; p=0.956). The abdominal tenderness was not affected in Meperidine group. Rebound tenderness disappeared in 4% of the Meperidine group and in 2% of the placebo group. Nausea was decreased in 14% of the Meperidine group and 32% of the placebo group. Changes in the clinical pattern and diagnostic peritoneal signs in patients were negligible and did not significantly interfere with the diagnosis (p=0.133). Diagnostic accuracy was 96% in the Meperidine group and 98% in placebo group, which was not significantly different (p=0.554).

CONCLUSION

Administration of Meperidine reduces pain intensity in patients with acute abdominal pain without interference with the clinical diagnosis. Thus analgesics could be safely administered to the patients with acute abdominal pain for increasing the patients comfort.

Acute abdomen and ascites as presenting features of autosomal dominant polycystic kidney disease

We describe a patient with sudden onset of abdominal pain and ascites, leading to the diagnosis of autosomal dominant polycystic kidney disease (ADPKD). Her presentation was consistent with acute liver cyst rupture as the cause of her acute illness. A review of literature on polycystic liver disease in patients with ADPKD and current management strategies are presented. This case alerts physicians that ADPKD could occasionally present as an acute abdomen; cyst rupture related to ADPKD may be considered in the differential diagnoses of acute abdomen.