Occupational Lead Poisoning in a Patient with Acute Abdomen and Normocytic Anemia

We herein report a 24-year-old male construction worker with occupational lead poisoning who presented with acute abdomen and normocytic anemia. The levels of urinary delta-aminolevulinic acid and free erythrocyte protoporphyrin were elevated without any increase in the level of urine porphobilinogen. Detection of an elevated blood lead level of 100 μg/dL confirmed a diagnosis of lead poisoning. Chelation therapy with calcium disodium ethylenediaminetetraacetate resulted in prompt improvement of the clinical symptoms and the blood lead level. Clinicians should be aware that lead poisoning caused by occupational exposure can still occur sporadically in construction workers in Japan.

[Utility of biomarkers in abdominal pain management]

Abdominal pain conditions that fall into the category of acute abdomen (AA) are the most important ones to identify quickly. Diagnostic delay can lead to death or significant complications. Biological markers have the potential to improve the diagnostic and prognostic capacity of clinical assessment and the conventional complement of tests. This review aims to explore the relevance of several markers to the management of AA in the emergency department. Creactive protein (CRP), procalcitonin, and lactate are the biomarkers most often used in the emergency department. CRP is often analyzed in the context of AA, but it is very difficult to establish a cutoff that gives good sensitivity and specificity. The kinetics of CRP make it the most sensitive biomarker and one that is appropriate for assessing severity before the onset of clinical signs of severe sepsis or altered hemodynamics. Lactate is a marker of poor tissue perfusion, a key element in the management of severe sepsis and septic shock in AA. Since lactate testing is easy and inexpensive, this important biomarker is useful in the emergency department.

Can C-reactive protein and white blood cell count alone rule out an urgent condition in acute abdominal pain?

Up to 10% of all patients at the Emergency Department present for acute abdominal pain. The C-reactive protein (CRP) and white blood cell (WBC) are routinely determined as part of the workup of patients with abdominal pain. Three large prospective cohort studies comprising a total of 2961 adult patients with acute abdominal pain were selected. CRP levels and WBC counts were compared between patients with urgent and nonurgent final diagnoses. These studies conclude that the laboratory values individually are weak discriminators and cannot be used as a triage instrument in the selection of patients with acute abdominal pain requiring additional diagnostic tests.

Routine Measurement of Serum Amylase in Acute Abdomen

BACKGROUND

Acute abdominal pain is a common condition presenting to both the emergency department (ED) and surgical admission unit. Increase in serum amylase levels are found in much gastrointestinal pathology. Serum amylase level is consistently high in acute pancreatitis though high values are not pathognomonic of pancreatitis .The aim of this study to assess the level of serum amylase in various diseases presenting with acute abdominal pain and to evaluate the role of routine measurement of serum amylase in the screening of patient with acute abdominal pain for the diagnosis of acute pancreatitis in a prospective series.

METHODS

A prospective observational study was performed from 15th May 2014 - 15th Nov 2014 (6 months) at Department of Surgery of Kathmandu medical College Teaching Hospital; Kathmandu. All consecutive patients presented at emergency department and required admissions in surgical ward were included. A multivariate analysis was performed to assess the level of serum amylase in various diseases presenting with acute abdominal pain including acute pancreatitis.

RESULTS

Overall, 318 patients were included during a period of 6 months among them 48 patients were excluded. 34 cases (12.6 %) were diagnosed of acute pancreatitis. three cases (1.1%) of non pancreatic pathology with raised serum amylase level (> 1000 U\L).

CONCLUSIONS

Routine assessment of serum amylase is helpful in excluding differential diagnosis of patient presenting with acute abdomen and this study identified serum amylase as a good screening tool if done in cases with clinical suspicion.

[The value of serum intestinal fatty acid binding protein measurement in discriminating intestinal ischemia in patients with acute abdomen]

OBJECTIVE

To assess the differential diagnostic value of serum intestinal fatty acid binding protein (I-FABP) in distinguishing intestinal ischemia patients from acute abdomen patients.

METHODS

A total of 151 patients with acute abdomen and 17 healthy controls from the PLA General Hospital were enrolled from November, 2009 to August, 2011. Serum I-FABP levels were measured by ELISA. According to the ROC curve, the cut-off value, sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), positive predictive value (PPV) and negative predictive value (NPV) were calculated.

RESULTS

Of the 151 acute abdomen patients, there were 24 intestinal ischemia patients and 127 without intestinal ischemia. Serum I-FABP level in intestinal ischemia group [(109.67 ± 48.82) µg/L] was significantly higher than those in patients without intestinal ischemia [(36.78 ± 11.25) µg/L] and healthy controls[(8.33 ± 6.25) µg/L](all P values < 0.01). The serum I-FABP cut-off value for the diagnosis of intestinal ischemia was 87.52 µg/L. Serum I-FABP was efficient in terms of sensitivity (0.762), NPV(0.963), PLR(3.05) and NLR (0.24) in the diagnosis of intestinal ischemia.

CONCLUSION

I-FABP is potentially useful for discriminating intestinal ischemia from acute abdomen.

[Renal infarction in two patients with acute abdominal pain]

BACKGROUND

Renal infarction is a condition not known to every physician, with often non-specific symptoms. The diagnosis is therefore often not considered initially in patients with acute abdominal pain.

CASE DESCRIPTIONS

In a 77-year-old man a renal infarction was found by chance on a CT-scan performed performed for the evaluation of dyspnoea. Previously he had visited the emergency unit with abdominal pain, in retrospect attributable to renal infarction. A 61-year-old man initially labelled as suffering from gastro-enteritis was diagnosed correctly with renal infarction after his renal function deteriorated and the lactate dehydrogenase (LDH) activity increased.

CONCLUSION

A raised serum creatinine level and LDH activity are classic indicators of renal infarction. In addition, most patients have haematuria. Typical wedge-shaped perfusion defects are visible on a CT-scan with intravenous contrast. Timely diagnosis of renal infarction is important both for the prevention of recurrence of thromboembolic complications and for potential revascularisation. The diagnosis of renal infarction should be included in the differential diagnosis in patients with acute abdominal pain.

S100A8/A9: a potential new diagnostic aid for acute appendicitis

OBJECTIVES

Diagnosing acute appendicitis is a daunting clinical challenge, as there is no single test that reliably distinguishes acute appendicitis from other etiologies of acute abdominal pain. In this study, the authors examined whether circulating levels of S100A8/A9 could be useful as a marker to aid in the diagnosis of acute appendicitis.

METHODS

Plasma samples from emergency department (ED) patients with acute abdominal pain (n=181) were tested using an immunoassay for S100A8/A9.

RESULTS

The sensitivity and specificity for S100A8/A9 in diagnosing acute appendicitis were estimated to be 93% (95% confidence interval [CI]=81% to 97%) and 54% (95% CI=45% to 62%), respectively. Negative predictive value (NPV) was 96% (95% CI=89% to 99%), and positive predictive value (PPV) was 37% (95% CI=28% to 47%). Performance characteristics of elevated white blood cell (WBC) count were also estimated: sensitivity 63% (95% CI=47% to 76%), specificity 67% (95% CI=59% to 75%), NPV 86% (95% CI=78% to 91%), and PPV 36% (95% CI=26% to 47%).

CONCLUSIONS

This is the first report exploring the relationship between circulating S100A8/A9 and acute appendicitis and establishes proof of concept for this biomarker as a diagnostic test for acute appendicitis. Further studies are indicated to optimize the use of this biomarker, in conjunction with other established approaches.

The value of D-dimer test in the diagnosis of patients with nontraumatic acute abdomen

BACKGROUND

A patient with acute abdominal pain requires rapid evaluation. In these patients, it is very important to distinguish between surgical and nonsurgical pathology. Our aim was to compare the accuracy of the leukocyte count and D-dimer test in the diagnosis of acute abdomen.

METHODS

In this prospective study, 225 patients admitted to the emergency unit due to nontraumatic acute abdomen between June 2006 and November 2007 were evaluated. The patients were divided into two groups: Group 1 patients who needed immediate laparotomy and Group 2 patients who did not. Age, gender, leukocyte count, D-dimer level, causes of acute abdominal pain, and operative findings were investigated. P values of <0.05 were considered statistically significant.

RESULTS

There was a positive correlation between the plasma D-dimer level and leukocyte count. D-dimer acted similarly to the leukocyte count in emergency abdominal conditions. The area under the receiver operating characteristic curve was statistically higher with the D-dimer test (p<0.0001). Additionally, in patients needing immediate laparotomy, the sensitivity of the D-dimer test was 95.7% versus 74.8% for leukocyte counts.

CONCLUSION

In a patient with acute abdomen, D-dimer test may be a strong alternative or an adjuvant to the leukocyte count.

Accurate diagnosis of acute abdomen in FMF and acute appendicitis patients: how can we use procalcitonin?

This study was conducted to define the value of procalcitonin (PCT) levels in the differential diagnosis of abdominal familial Mediterranean fever (FMF) attacks from acute appendicitis. From October 2006 to January 2007, 28 FMF (12 males, 16 females) patients with acute abdominal attacks and 34 patients (18 males) with acute abdomen who underwent operation with the clinical diagnosis of acute appendicitis were consecutively enrolled in this study. FMF patients with concurrent infectious diseases were excluded. PCT values were measured by an immunofluorescent method using the B.R.A.H.M.S. PCT kit (B.R.A.H.M.S. Diagnostica, Berlin, Germany). Erythrocyte sedimentation rate (ESR), C-reactive proteins (CRP) and leucocyte levels were also noted. Mean disease duration in FMF patients was 9.6 +/- 8.1 years (range 2-33 years) and all were on colchicine therapy with a mean colchicine dosage of 1.2 +/- 0.4 mg/day. Among the operated patients, 5 were excluded: 3 patients had normal findings and 2 had intestinal perforation (PCT levels were 2.69 and 4.93 ng/ml, respectively) at operative and pathologic evaluation. There were no significant differences between the two groups with respect to gender and age (p was not significant (NS) for all). Acute phase reactants and PCT levels were increased in patients with FMF compared to patients with acute appendicitis (0.529[0.12 +/- 0.96] vs 0.095 [0.01-0.80] p < 0.001, respectively). PCT levels higher than 0.5 ng/ml were found in 11% (3/28) of FMF patients compared to 62% (18/29) of acute appendicitis patients (p < 0.001). Our results suggest that PCT could be a useful test in the differentiation of abdominal FMF attacks from acute appendicitis, though it should not supplant more conventional investigations.

[Assessment of severity assessment and prognosis of pyodestructive abdominal diseases (with editor's comment)]

Leukocytic index of intoxication (LII), number of leukocytes and lymphocytes in blood were compared with clinical symptoms and histological examination of removed organs in patients with acute pyodestructive diseases of abdominal organs. Correlation between LII and inflammation severity was revealed. It is also demonstrated that high LII with low level of lymphocytes is a negative prognostic sign.

Expression and significance of toll-like receptor 2, 4 of peripheral blood mononuclear cells in acute abdomen patients associated with systemic inflammatory response syndrome

The changes of Toll-like receptor (TLR) 2, 4 of peripheral blood mononuclear cells (PBMCs) in the acute abdomen patients associated with systemic inflammatory response syndrome (SIRS) and their potential significance were explored. A clinical study was performed on 103 acute abdomen patients in whom 65 were associated with SIRS. Forty healthy individuals served as normal controls. The mRNA expression of TLR2, 4 was detected by RT-PCR, and the expression of TNF-alpha and IL-6 by ELISA. The level of plasma endotoxin, hospital stay and mortality were measured. It was found that the endotoxin level was increased to varying degrees in all the acute abdomen patients, and the endotoxin level was and hospital stay longer in SIRS group than in non-SIRS group (P<0.01). TLR2 mRNA, TLR4 mRNA, IL-6 and TNF-alpha could be detected with low value in normal controls, but they were up-regulated markedly on the 1st day after admission. Then TLR4 mRNA, IL-6 and TNF-alpha were decreased gradually, but TLR2 mRNA maintained at a high level till the 5th day. These indexes above in SIRS group were higher than those in non-SIRS group (P<0.01). The results of correlation analysis revealed the expression of TLR2, 4 mRNA was positively correlated with the levels of TNF-alpha and IL-6, and the hospital stay. The results of Logistic regression demonstrated that overexpression of TLR2, 4 mRNA might result in higher risk of multiple organ dysfunction syndrome (MODS). It was concluded that in the acute abdomen patients associated with SIRS, the expression of TLR2, 4 in PBMCs was increased markedly, suggesting that TLR might play an important role in the pathogenesis of acute abdomen associated with SIRS.

Abdominal manifestations in childhood-onset systemic lupus erythematosus

BACKGROUND

Childhood-onset lupus erythematosus is a rare disorder of unknown origin.

OBJECTIVES

To describe the frequency of gastrointestinal manifestations at presentation of systemic lupus erythematosus SLE and at follow-up, and discuss the specific causes of these manifestations.

METHODS

Medical records of 201 patients with childhood-onset SLE followed up in French paediatric nephrological, haematological and rheumatological centres were reviewed and abstracted for gastrointestinal manifestations.

RESULTS

Gastrointestinal involvement was recorded in 39 (19%) children. The median (range) age at the time of initial gastrointestinal manifestations was 11.3 (4.5-16) years. Gastrointestinal symptoms were present at or occurred within 1 month after diagnosis in 32% patients. Abdominal pain was the most frequent symptom, present in 34 (87%) patients. It was mostly related to lupus involvement, especially ascites (n = 14) and pancreatitis (n = 12), more rarely to treatment-induced events (n = 1) or infection (n = 1) and never to events unrelated to SLE. Three children with surgical abdomen underwent a laparotomy before SLE was diagnosed, with a final diagnosis of lupus peritonitis and lupus acalculous cholecystitis. C reactive protein values were <40 mg/l in all but two patients who had surgical abdomen. Abdominal ultrasonography and computed tomography scans were abnormal in 58% and 83% of the evaluated patients, respectively. Corticosteroids, associated with intravenous cyclophospamide in eight patients, led to complete remission of gastrointestinal involvement in 30 of 31 treated patients.

CONCLUSION

Gastrointestinal involvement is common in children with SLE, and is mainly due to primary lupus involvement. Corticoidsteroid treatment should be promptly considered in children with lupus presenting with abdominal pain after infectious disease; side effects of treatment and intestinal perforation have been excluded.

[Endotoxin aggression in the development of hemostatic disorders in children with surgical diseases]

The role of endotoxin aggression in the development of hemostatic disorders was analyzed in 62 children who had undergone urgent and elective surgeries. It is demonstrated that indices of endotoxin-antiendotoxin system and hemostasis before surgery may be regarded as prognostic criteria for development of complications during and after surgery.

Use of plasma ionized calcium levels and Ca2+ substitution response patterns as prognostic parameters for ileus and survival in colic horses

OBJECTIVE

Hypocalcaemia is a common finding in horses with enterocolitis and severe gastrointestinal disorders. The aims of this study were to investigate in colic horses 1)the parameters related to hypocalcaemia, 2)the influence of hypocalcaemia on outcome and 3)the possible beneficial effect of Ca2+ substitution.

DESIGN

Randomized controlled trial.

SETTING

Intensive care unit.

PATIENTS

One hundred forty-four horses that were admitted with an acute abdomen during a 1.5 year period were enrolled and daily evaluated for clinical criteria and whole blood ionized Ca2+ levels. Colic horses with hypocalcaemia were randomly assigned to receive Ca2+.

INTERVENTIONS

Analysis of heparinised whole blood samples. Horses that were assigned to be treated received 400 mEq Ca2+ diluted in 10L of Ringer's lactate solution every 24 h until low reference range limits were obtained or until death.

MEASUREMENTS AND MAIN RESULTS

88% of all colic patients showed blood ionized Ca2+ levels below the reference range at the time of admission. Multivariable analysis revealed that the presence of reflux, signs of endotoxaemia, increased Packed Cell Volume (PCV), alkalinization of pH and the interaction PCV/pH all predispose colic horses to low ionized Ca2+ levels at the time of admission. The Odds for developing ileus during hospitalization are +/- 11.94 times larger for horses in the "very low" calcaemia interval, in comparison with normocalcaemic horses. The Odds for fatal outcome are respectively +/- 9.82 and 8.33 times larger for horses in the "very low" and "low" calcaemia interval. Ca2+ substitution increased the probability of survival, provided that Ca2+ levels could be normalized. The lack of an upward calcaemia response, despite repetitive Ca2+ substitutions, can be guarded as a poor ominous sign.

CONCLUSIONS

Hypocalcaemia in colic horses is of prognostic relevance both with regard to survival as to the probability of development of ileus during hospitalization. This study shows the importance of routine measurement of ionized calcium levels in colic horses. Moreover, correction of hypocalcaemia seems to improve clinical outcome.

Predictive performance of 'Diprifusor' TCI system in patients during upper abdominal surgery under propofol/fentanyl anesthesia

OBJECTIVE

To evaluate the predictive performance of 'Diprifusor' TCI (target-controlled infusion) system for its better application in clinical anesthesia.

METHODS

The predictive performance of a 'Diprifusor' TCI system was investigated in 27 Chinese patients (16 males and 11 females) during upper abdominal surgery under total intravenous anesthesia (TIVA) with propofol/fentanyl. Measured arterial propofol concentrations were compared with the values predicted by the TCI infusion system. Performance was determined by the median performance error (MDPE), the median absolute performance error (MDAPE), the divergence (the percentage change of the absolute PE with time), and the wobble (the median absolute deviation of each PE from the MDPE).

RESULTS

The median (range) values of 14.9% (-21.6%-42.9%) for MDPE, 23.3% (6.9%-62.5%) for MDAPE, -1.9% h(-1) (-32.7%-23.0% h(-1)) for divergence, and 18.9% (4.2%-59.6%) for wobble were obtained from 227 samples from all patients. For the studied population, the PE did not increase with time but with increasing target propofol concentration, particularly following induction. conclusions: The control of depth of anaesthesia was good in all patients undergoing upper abdominal surgical operation and the predictive performance of the 'Diprifusor' target controlled infusion system was considered acceptable for clinical purposes. But the relatively bigger wobble showed that the pharmacokinetic model is not so suitable and requires improvement.

[Determination of beta-endorphin plasma concentrations in surgical patients with acute abdominal pain]

Abdominal pain and surgery, frequently associated with this kind of pain, modify plasma levels of stress-hormones and iniciates the response of endogenous analgetic system. The aim of this study was to determine serum concentration of beta-endorphine in patients with acute abdominal pain (n=12), which were surgically treated. Serum concentration of beta-endorphin was measured on five data points: before, during and after surgery. During abdominal surgery serum concentration of beta-endorphin was increased by 7% compared to preoperative period; in postoperative period the concentration continued to rise and remained increased within next hours. The maximal levels of beta-endorphine were not observed during, and immediately after surgery. Postoperatively, between 6 and 8 p.m. on the day of surgery, maximal level of beta-endorphin was noted, which was even ten times higher than to preoperative value. Plasma level of beta-endorphin fell to the baseline values 24 hours after surgery. In conclusion, abdominal surgery induces a postponed (delayed) increase in serum beta-endorphine levels, which are associated with modulation of preoperative, intraoperative and postoperative pain perception.

Evaluation of Pankrin, a new serum test for diagnosis of acute pancreatitis

AIM

Evaluation of a new serum test for diagnosis of acute pancreatitis.

PATIENTS AND METHODS

One hundred and sixty-three patients presenting with acute abdominal pain were included into the study. Acute pancreatitis was diagnosed by CT or ultrasound. Serum samples were taken 0-1 days, 2-3 days, and 4-5 days after onset of symptoms and C-reactive protein, lipase, elastase, and amylase were determined. As a further parameter, Pankrin, a newly available kit for the measurement of a mixture of elastase and other pancreatic secretory proteins was used. As control, serum from 558 apparently healthy blood donors was analysed. The receiver operator characteristics (ROC) and the areas under the curves (AUC) were calculated for each individual test.

RESULTS

In Western blot analysis the antibodies of the Pankrin assay detected the majority of protein bands in human pancreatic juice. In blood donors, the median value of Pankrin was 88 U/ml (range 14-316 U/ml). In 16 from 163 patients with acute abdominal pain, acute pancreatitis was diagnosed and the median Pankrin level in samples collected on days 0-1 was 345 U/ml (range 220-518 U/ml, p<0.0001). In those patients with abdominal pain but without pancreatitis, the median was 116 U/ml (range 17-396 U/ml). The ROC-curves for amylase, lipase, elastase, and Pankrin from samples collected after 0-1 days were similar (area under the curves (AUC) >0.98). After 2-3 days, the AUC of all markers decreased (AUC 0.80-0.89) and after 4-5 days the AUC of Pankrin (0.85) was higher than all other parameters.

CONCLUSION

In those patients with abdominal pain, who present several days after onset of pain, the new serum test for pancreatitis, Pankrin, could be of help to improve the diagnosis of pancreatitis.

Total antioxidant capacity and malondialdehyde in acute abdominal pain

Recent investigations suggest that oxidative stress markers are useful in the evaluation of some types of abdominal pathology. We hypothesized that the severity of abdominal pain is correlated with oxidative stress as quantified by total antioxidant capacity (TAC) and malondialdehyde (MDA). The objective of this study was to determine the plasma TAC and MDA levels in patients with acute abdominal pain and to examine their relation to abdominal emergency. We recruited 128 patients presenting with acute abdominal pain at the emergency department. Medical history, vital signs and laboratory data were collected on arrival. TAC and MDA levels were determined using serums obtained from the initial blood sampling. Patients with acute abdominal pain had lower levels of TAC and higher levels of MDA than normal control. When patients were grouped according to whether they were discharged early (less than 24 hours) or hospitalized longer than 24 hours, Patients with hospital stay > 24 hours had significantly elevated pulse rate, temperature, leukocyte count, and C reactive protein (CRP) and lower TAC. No significant difference was found in age, sex, temperature, respiratory rate, blood pressure, and MDA level. Multivariate logistic regression analysis revealed that CRP and TAC were significant indicators of quantitative variables for disposition. This study found a correlation exists between oxidative stress and disease severity in patients with abdominal pain. This suggests that TAC might be useful as a guide for patient disposition in the emergency department.

Herbal remedy poisoning presenting with acute abdomen and raised urine porphyrins

We describe a case of lead poisoning due to herbal remedies, presenting with an acute abdomen, raised porphyrins and increased liver enzyme activities. We suggest that lead poisoning should be considered in the differential diagnosis of the 'acute abdomen', and that the presence of liver dysfunction points to the possibility of Asian herbal remedies as the source of the lead poisoning.

Cholecystokinin in acute alcoholic and biliary pancreatitis

BACKGROUND

Recent studies have shown that cholecystokinin (CCK) agonist, cerulein can induce acute pancreatitis in animals. The role of CCK in the induction of acute pancreatitis in humans is unclear. We investigated plasma CCK levels in alcoholic and biliary pancreatitis on admission and during the episode of acute pancreatitis.

METHODS

Plasma CCK concentrations were determined by a specific and sensitive radioimmunoassay using CCK antiserum (Euro-Diagnostica, Malmö, Sweden) in 35 patients with acute alcoholic pancreatitis, in 27 patients with acute biliary pancreatitis, in 34 patients with nonpancreatic acute abdominal pain, and in 43 healthy subjects. The mean time from the first symptoms to the plasma sample was 31 (+/- 3.7) h in alcoholic pancreatitis patients and 25 (+/- 5.1) h in biliary pancreatitis patients. We also determined CCK levels in 20 patients during the episode of acute pancreatitis. Normal fasting level of CCK is < or = 1.12 pmol/L according to manufacturer.

RESULTS

Basal plasma CCK concentrations were significantly lower both in alcoholic pancreatitis (mean +/- SEM, 0.04 +/- 0.03 pmol/L, p < 0.0001) and biliary pancreatitis patients (0.17 +/- 0.13 pmol/L, p < 0.0001) than in nonpancreatic acute abdominal pain patients (1.23 +/- 0.32 pmol/L) or healthy subjects (1.18 +/- 0.20 pmol/L). Plasma CCK levels also remained low until the patient was well-recovering and had started oral diet.

CONCLUSION

Basal plasma CCK concentrations are significantly decreased in acute alcoholic and biliary pancreatitis after the first day from the beginning of the symptoms until the patient was well-recovering.

No microheterogenous changes of plasma C-reactive protein found in man during various diseases

Increased levels of the acute phase protein C-reactive protein (CRP) in plasma may indicate severe acute abdominal disease, risk of serious postoperative complications or malignancy; serial measurements may indicate postoperative complications, relapse of intra-abdominal sepsis and complications during acute pancreatitis. The increase in CRP is an unspecific acute phase reaction, however, and low levels do not exclude these conditions. These facts are important obstacles to the clinical routine use of CRP measurements. The aim of this study was to look for possible biochemical microheterogeneity of CRP in single plasma samples from various large groups of patients to overcome these problems. Two-hundred-and-twelve patients with acute abdominal diseases, 274 patients with various forms and stages of cancer and 134 patients operated on due to benign diseases, were studied. The biochemical studies included SDS-PAGE, native PAGE and gel filtration for molecular weight determinations, isoelectric focusing and crossed immuno-electrophoresis for electrophoretic mobility studies and Concavalin A and ACA 34 as intermediary gels for possible lectin binding or complexation. Western blot analysis was also used to identify CRP. In summary, however, these more elaborate biochemical methods could not disclose any microheterogneity of CRP in plasma and thus did not add any diagnostic information to the crude levels.

[The treatment of acute endotoxicosis in diabetic patients with surgical diseases requiring emergency intervention]

The aim of the study is the development of integral methods for early diagnosis and treatment of systemic pathobiochemical disturbances in patients with diabetes mellitus under conditions of acute surgical endotoxicosis as well as optimisation of surgical policy and drug pathogenetic correction. Blood lipids peroxidation (malonic dyaldehyde content in NADF and ascorbate-dependent systems, intermolecular sewings in erythrocytes membranes) and central hemodynamic parameters. The study was carried out in 199 patients with acute surgical diseases accompanied with diabetes mellitus. Peculiarities of the course of the disease were revealed in dependence of the form of blood lipoperoxidation. The scheme of intensive care in conditions of decompensation of diabetes mellitus aimed at correction of pathobiochemical disturbances in patients with acute surgical endotoxicosis has been developed.

[Nothing gained from the determinations of plasma lactate levels in the evaluation of a patient with acute abdomen]

OBJECTIVE

To establish the diagnostic value of laboratory tests, especially the plasma lactate concentration, for determination of the indication for acute surgery in patients with an acute abdomen.

DESIGN

Cross-sectional study.

SETTING

Kennemer Gasthuis, location Elisabeth Gasthuis, Haarlem, the Netherlands.

METHOD

The study group consisted of all 200 successive patients presenting at the emergency room with acute abdomen from June 1993 to December 1994 (19 months). Patients with suspected acute appendicitis were excluded. The diagnosis and indication for surgery if any were based on case history, physical examination, radiological examination if performed and standard laboratory tests: ESR, leukocyte count, haemoglobin, creatinine and amylase. The first matter considered was to what extent the indication for acute operation based on these clinical criteria was in agreement with the diagnosis at discharge. The next question studied was what would be the extra value of the plasma lactate concentration which, although determined, had not been reported to the clinician. Statistical analysis was performed using the two-sample Student t test and the chi 2 test. A p-value of < 0.05 was regarded as statistically significant.

RESULTS

Fifty-four patients were operated within 24 hours for good reasons, six were incorrectly not operated within 24 hours, 128 correctly received conservative treatment and 12 were correctly treated conservatively and subsequently underwent operation after longer than 24 hours. Diagnostics based on the clinical criteria had a sensitivity of 90%. The mean plasma lactate concentration, temperature and ESR were statistically significant more often increased in the operated patients than in those treated conservatively. The sensitivities of these determinations were 75%, 67% and 40% (all: p < 0.05). The lactate concentration was increased in 50% of the patients who in retrospect had incorrectly not been subjected to acute surgery.

CONCLUSION

Neither determination of the plasma lactate concentration nor the results of the separate standard laboratory tests in acute abdomen patients resulted in a better sensitivity for the determination of an indication for acute surgery than clinical examination combined with standard laboratory tests and, if desired, supplementary radiology.

Endogenous intoxication syndrome when acute process in abdominal cavity

In the time of simultaneous study of the components of blood of sick patient and animals with acute processes in abdominal cavity it was revealed that in short periods there is increase in value indeces of endogenous intoxication syndrome. The independent index is offered for studying the endotoxicosis of whole blood. It is recommended to use for general and particular characteristics of dynamics during the pathological process.

Polyclonal pancreatic elastase assay is superior to monoclonal assay for diagnosis of acute pancreatitis

We compared the clinical values for diagnosis of acute pancreatitis of two commercial assays for pancreatic elastase: an ELISA procedure with monoclonal antibodies and a RIA technique with polyclonal antibodies. In 14 patients with acute pancreatitis, serum concentrations of elastase determined by ELISA (ELISA-elastase) decreased much faster (half-life 0.4 days) than those of elastase determined by RIA (RIA-elastase) (2.2 days), amylase (0.8 days), or lipase (0.9 days). Serum samples from 253 additional patients with abdominal pain (32 of these with acute pancreatitis) were analyzed. In sera collected up to 48 h after the onset of disease, the ROC curves showed a slightly higher diagnostic value of RIA-elastase. In samples taken later, at a sensitivity of 90% the specificity of RIA-elastase was 95% (ELISA-elastase 40%). We conclude that serum ELISA-elastase is of much lower clinical value than RIA-elastase for diagnosis of acute pancreatitis.

Clinical value of pancreatitis-associated protein in acute pancreatitis

OBJECTIVES

Pancreatitis-associated protein (PAP) is a secretory protein that is overexpressed by the pancreas during acute pancreatitis. This study was carried out to assess the clinical value of PAP in acute pancreatitis, particularly its ability to indicate the severity of the disease.

METHODS

Twenty-one healthy subjects, 58 patients with acute pancreatitis, and 20 patients with nonpancreatic acute abdomen were studied. In addition to serum PAP concentration, serum concentrations of amylase, lipase, and C-reactive protein (CRP) were measured at admission and, in patients with acute pancreatitis, during the following 5 days.

RESULTS

On admission, serum PAP concentrations were abnormally high in 46 of the 58 patients with acute pancreatitis (79%); serum amylase, in 57 patients (98%); serum lipase, in all patients (100%); and serum CRP, in 40 patients (69%). During the subsequent days of the study, PAP and CRP tended to increase, whereas amylase and lipase decreased. No significant differences in PAP or amylase and lipase concentrations were found between patients with mild pancreatitis and those with severe pancreatitis during the entire study period, whereas from the third day to the sixth day, CRP concentrations were significantly higher in patients with severe pancreatitis than in those with mild pancreatitis. Among the 20 patients with nonpancreatic acute abdomen, PAP concentrations were abnormally high in 10 (50%), whereas amylase concentrations were abnormally high in five (25%), and lipase concentrations were high in two (10%).

CONCLUSIONS

Our results indicate that the clinical value of PAP in acute pancreatitis is quite limited and, in particular, that PAP is not a useful marker for determining the severity of the disease.

[Mesenteric infarct in primary antiphospholipid antibody syndrome]

The mesenteric infarction is a rare but life threatening cause of acute abdomen. A 55-year-old woman was referred to the hospital because of acute mesenteric infarction and in the history claudication. In the absence of risk factors (atrial fibrillation, atherosclerosis, nicotin abusus) a postoperative work up was started to identify the cause of the arterial occlusions. A primary antiphospholipid-antibody syndrome was found. The patient is now receiving low-dose aspirin and anticoagulation therapy. The follow-up over now 14 months shows no further events.

[Warning signals in acute abdominal disorders. Lactate is the best marker of mesenteric ischemia]

An increased plasma lactate concentration (PLC) is a recognized danger signal often found in cases of shock, septicaemia, hepatic and renal failure, and diabetic ketoacidosis. In 120 patients with abdominal complaints, we found the PLC to be above normal limits in 96 per cent (24/25) of the mesenteric ischaemia subgroup, in all 20 of the general bacterial peritonitis subgroup, in 30 per cent (6/20) of the acute pancreatitis subgroup, and in about half of the 25 cases of intestinal obstruction. In all other abdominal conditions represented (n = 30), comprising various inflammatory or infectious abdominal diseases, the PLC was within the normal range. In patients with abdominal complaints, an increased PLC usually indicates the needs of emergency surgery. In the present series, the PLC manifested a sensitivity of 96 per cent and a specificity of 38 per cent as a marker of mesenteric ischaemia, and was also found to be a useful aid in the diagnosis of bowel obstruction and general bacterial peritonitis.

White blood cell counts in patients undergoing abdominal surgery

BACKGROUND

The role of pre-operative white blood cell counts (WBCC) in patients with an acute abdomen is contentious.

METHODS

This study documents the association between pre-operative WBCC and the extent of intraperitoneal inflammation at the time of surgery in a heterogeneous group of 1166 patients undergoing abdominal surgery.

RESULTS

WBCC failed to adequately discriminate between groups of patients with varying degrees of intraperitoneal inflammation. For example, only 31% (37/118) of the patients with either free pus or an abscess within the peritoneal cavity had a WBCC > 15.0 x 10(9)/L.

CONCLUSIONS

There is a need to replace the WBCC with more powerful predictors of inflammation within the peritoneal cavity.

C-reactive protein for the evaluation of acute abdominal pain

The diagnostic value of C-reactive protein (CRP) was established in 143 patients with acute abdominal pain, 67 men and 76 women with mean age of 48 +/- 20 years old. Clinical and laboratory variables were collected after the patients' arrival at the emergency department. The attending clinicians did not consider the CRP value during the study period and did not use it for their management. When patients were grouped by final disposition, which was according to severity, only CRP and leukocyte count were identified as significant quantitative variables by multivariate analysis. CRP can detect the serious conditions, ie, in 79% of the hospitalized group, although specificity was 64%, the total accuracy was 73%. When elevated CRP was combined with leukocytosis, the diagnostic value was much improved, with specificity of 89% and positive predictive value of 88%. The sensitivity was improved to 90% when elevated CRP or leukocytosis was used. It is thus concluded that CRP is a helpful quantitative variable for disposition decision-making in patients with acute abdominal pain.

Human pancreatic secretory trypsin inhibitor in the assessment of the severity of acute pancreatitis. A comparison with C-reactive protein

We assessed the ability of serum human pancreatic secretory trypsin inhibitor (hPSTI) to establish the severity of acute pancreatitis and compared it in this respect to that of serum C-reactive protein (CRP). Of 26 patients studied with acute pancreatitis, 16 had mild pancreatitis, and 10, severe disease. Initial studies were performed at onset of the disease in 20 patients, on the second day of illness in two, and on the third day of illness in the remaining four. In all, serum hPSTI and CRP concentrations were determined on admission and daily for the following 5 days using commercial kits; Ranson's score was evaluated within the first 48 h of admission. Sixty-three healthy subjects and 31 patients with nonpancreatic acute abdomen were also studied. Values of 70 ng/ml for serum hPSTI and 10 mg/dl for serum CRP were taken as limits to distinguish severe from mild-to-moderate acute pancreatitis. When assessed within the first 24 h of pain, serum hPSTI correctly classified 71% of the patients with severe acute pancreatitis, whereas serum CRP did so for 29%. In subsequent days, the two markers showed a similar sensitivity in predicting severe acute pancreatitis. Serum hPSTI and CRP were alike in excluding a diagnosis of severe acute pancreatitis. Ranson's score correctly identified 50% of patients with severe illness and 63% of patients with mild pancreatitis. This study indicates that, when assessed within 24 h of pain onset, serum hPSTI is a better predictor of the severity of acute pancreatitis than serum CRP or Ranson's criteria.

Usefulness of plasma lactate concentration in the diagnosis of acute abdominal disease

OBJECTIVE

To verify the diagnostic importance of the plasma lactate concentration in acute abdominal disease and to examine its role as a marker of mesenteric ischaemia.

DESIGN

Prospective study.

SETTING

Two departments of surgery, one in Sweden and one in Germany.

SUBJECTS

85 patients with acute abdominal symptoms.

MAIN OUTCOME MEASURES

Correlation between the plasma lactate concentration before operation or (in the case of those not operated on) before the diagnosis was established, and the final diagnosis.

RESULTS

Plasma lactate concentrations exceeded the reference range in all cases of mesenteric ischaemia (n = 20) and general bacterial peritonitis (n = 15) and in half of the 20 cases of intestinal obstruction. They were also raised in 3 of 10 cases of acute pancreatitis.

CONCLUSIONS

A raised plasma lactate concentration is always a sign of an acute life-threatening condition, and usually indicates the need for an emergency operation. As a marker of mesenteric ischaemia its sensitivity was 100% and its specificity 42%. We conclude that a raised serum lactate concentration is the best marker of mesenteric ischaemia to date.

Peritoneal fluid lactic acid and diagnostic dilemmas in acute abdominal disease

Our previous canine research suggested that the determination of peritoneal fluid lactic acid levels may be helpful in the evaluation of potential acute abdomen cases. To investigate the clinical significance of those findings, we obtained simultaneous peritoneal and plasma lactic acid values from patients undergoing emergency celiotomy or in whom surgical consultation was sought to rule out an acute abdomen. The lactic acid value was significantly higher in peritoneal fluid than in plasma in patients who were found to have hollow viscus perforation, gangrenous intestine, peritonitis, or intra-abdominal abscess. In contrast, the values were similar in patients who did not have those conditions. Our findings suggest that the calculated difference between simultaneous peritoneal and plasma lactic acid values is a helpful diagnostic index for patients in whom the diagnosis of acute abdomen is not otherwise obvious.

Vitamin C status in patients with acute pancreatitis

Vitamin C is a key antioxidant in human blood plasma and hence could influence the outcome of conditions such as acute pancreatitis in which oxidative stress apparently plays a pivotal role. The concentrations of vitamin C and its immediately bioavailable form, ascorbic acid, in fasting plasma samples from 30 healthy volunteers were compared with those in admission samples from 29 consecutive patients with acute pancreatitis and 27 patients with other acute abdominal crises. Median (range) levels of vitamin C and ascorbic acid, respectively, were 15 (6.3-19) and 12 (4.5-18) micrograms/ml in the control group, 2.8 (0.3-10) and < 0.5 (< 0.5-6.0) micrograms/ml in patients with acute pancreatitis, and 3.7 (0.6-15) and 2.3 (< 0.5-15) micrograms/ml in those with other acute abdominal problems. Admission plasma samples showed equally low vitamin C levels in both groups of patients (P < 0.001 versus controls), but those from patients with acute pancreatitis were further characterized by a disproportionate reduction in ascorbic acid, such that the concentration of ascorbic acid and its ratio to vitamin C were both significantly lower than in samples from patients with an acute abdomen (P < 0.005 and P < 0.001 respectively). It is concluded that the stress of an acute intra-abdominal crisis is accompanied by a non-specific decrease in the plasma level of vitamin C. In acute pancreatitis early and profound oxidative stress compounds this problem by denaturing the available vitamin. There may be a case for the judicious parenteral administration of ascorbic acid to patients with acute pancreatitis to boost plasma antioxidant defence.

Ionized calcium concentration in horses with surgically managed gastrointestinal disease: 147 cases (1988-1990)

Packed cell volume, total plasma protein, serum sodium, potassium, and ionized Ca2+ concentrations, and blood pH were determined at the time of admission and following surgery in 147 horses with acute abdominal crisis. Horses were allotted to 3 categories on the basis of the surgical lesion: (1) nonstrangulating obstruction of the ascending or descending colon (category A, n = 76), (2) strangulating and nonstrangulating infarction of the cecum or ascending colon (category B, n = 37), and (3) strangulating and nonstrangulating infarction of the small intestine (category C, n = 25). Horses with low serum ionized Ca2+ concentration following surgery were given 23% calcium gluconate (100 to 300 ml) IV to effect, and ionized Ca2+ concentration was determined following treatment. The serum ionized Ca2+ concentrations of horses in categories A, B, and C before and after surgery were lower than our normal laboratory reference range. Prior to surgery, serum ionized Ca2+ concentration measured from horses in category B and C was lower than that in horses in category A. There was no difference in ionized Ca2+ concentration in serum samples obtained before surgery in horses from category B and C, and in serum samples obtained following surgery. There was a decrease in ionized Ca2+ concentration during surgery in horses in category A. There was no change between preoperative and postoperative ionized Ca2+ concentration in the samples obtained from horses in category B and C. After calcium gluconate administration, all horses with low serum ionized Ca2+ after surgery had concentrations within our normal range. Measurement of serum ionized Ca2+ in horses with an acute abdominal crisis is recommended.(ABSTRACT TRUNCATED AT 250 WORDS)

[Sulfhydryl groups and succinate dehydrogenase of blood lymphocytes in patients with inflammatory processes]

Patients with pyo-inflammatory processes were found to have a reduced SH-group content and SDH activity of peripheral blood lymphocytes. A clear dependence between the severity and extent of the pyo-inflammatory process and the SH-group and SDH values. Lymphocyte SDH is more sensitive than the SH-groups to the pyo-inflammatory process and responds by reduced activity. Study of SDH activity and SH-group content of lymphocytes in dynamics are sensitive tests for the severity of the pyo-inflammatory process, unspecific reactivity of the organism, and the efficacy of the applied treatment.

[Differential diagnostic significance of lactate in acute abdominal diseases]

Fourty-four patients with abdominal complaints were analysed for blood lactate levels prior to surgery. Exploratory surgical diagnoses were co-related with blood lactate levels and these co-relations are summarised here. Rise in blood lactate level was found to be significant in all cases of mesenteric infarction (n = 10). The lactate levels were also high in all cases of general peritonitis (n = 4) and 50% (5 out of 10) of cases of bowel strangulation. In all the other surgical explorations, besides the above mentioned, blood lactate was found to lie within a normal range. From the aforesaid study, although pertaining to a small group, it seems plausible that patients presenting with abdominal diseases associated with an elevated blood lactate level represent a surgical emergency. Measurement of blood lactate level can be of great help in the diagnosis of acute surgical emergencies needing early exploration, especially in cases of mesenteric infarction.

[Photomodification of autologous blood and hemosorption in suppurative and septic diseases]

An investigation of the concentration of middle-molecule peptides in the blood, blood viscosity and esterase activity in patients with pyo-septic diseases who were treated by using photomodification of autoblood and hemosorption has substantiated expedience of the successive use of the methods of extracorporal hemocorrection for prophylactics of possible complications and to increase the detoxicating effect of hemosorption.

[Hereditary angioneurotic edema. Treatment of a pseudosurgical digestive attack with C1 inhibitor concentrate]

Although anabolic androgens can be used to prevent acute attacks of hereditary angioneurotic oedema, these are still observed. When they are severe, and even more so when they involve the larynx or the abdominal viscera, an emergency treatment is necessary, ideally with the purified C1-inhibitor (C1-INH) administered by intravenous infusion. In a case with pseudo-surgical abdominal symptoms, this treatment was followed by an unusually dramatic regression of all symptoms. Serial laboratory examinations showed an increase in C1-INH and C2 plasma levels and in the number of basophils within less than 30 minutes; the increase in C4 levels occurred later. Thus, C1-INH is very effective in the treatment of acute hereditary angioneurotic oedema, but the product is not widely available; it should be reserved to severe forms affecting the larynx and the viscera.