Diagnosing and managing acute abdominal pain in children

ABSTRACT

Acute abdominal pain is a common complaint in children. The care of these patients is challenging for clinicians because presentation, diagnosis, and treatment are different in children than adults. This article describes the presentation, physical examination, diagnosis, and treatment of common causes of acute abdominal pain in children and discusses emerging trends in diagnosis and treatment.

Bhutan's First Emergency Air Medical Retrieval Service: The First Year of Operations

OBJECTIVE

The Bhutan Emergency Aeromedical Retrieval (BEAR) Team is the only helicopter emergency medical service in Bhutan. This study was performed to review the clinical cases cared for by the BEAR Team, ascertain the types of interventions that were performed, and determine the outcomes of patients evacuated in its first year of operations.

METHODS

This is a retrospective observational study in which medical evacuations performed in the first year of operations were analyzed. The number of airlifts activated during the study period determined the sample size (171). Data were obtained from case logs and trip sheets.

RESULTS

The BEAR Team provided services to all regions of the country in its first year. The overall survival rate was 73.1%. The most common intervention required was securing a definitive airway (n = 24). The top 3 conditions requiring air medical retrieval were sepsis, acute mountain sickness, and trauma.

CONCLUSION

Helicopter emergency medical services are known to decrease the time to definitive treatment. This is particularly pertinent in Bhutan, given the scattered population distribution, long transport times, and distribution of medical resources and specialty care. This study is the first of its kind in Bhutan, and this can pave way to conduct more studies involving patients transported by air ambulance.

Reduction of intra-abdominal pain through transcranial direct current stimulation: A systematic review

BACKGROUND

Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique to modulate cortical excitability and to induce neuronal plasticity. With a wide range of applications in neurological and psychiatric disorders, the efficiency of tDCS is also studied in the treatment of various pain conditions. Treatment with tDCS might accordingly provide pain relief for patients with acute or chronic pain and thus lead to an increase in quality of life. Moreover, applied as an adjunct therapy, tDCS can reduce help to reduce pain medication intake and accompanying adverse events. To this end, this review examines studies evaluating the efficacy of tDCS in pain relief in patients with intra-abdominal pain.

METHODS

A structured search of the PubMed medical database was carried out to identify possibly relevant studies. Studies were compared in terms of treatment characteristics, general conditions, and results. Jadad scale was applied for quality analyses.

RESULTS

Out of 289 articles that were found initially, 6 studies were identified that met eligibility criteria. Five out of 6 studies reported significant effects for pain reduction in different types of intra-abdominal pain.

CONCLUSIONS

Results indicate that tDCS might be able to reduce intra-abdominal pain. However, more randomized-controlled trials with larger sample size are necessary to define clinically relevant effects as well as treatment characteristics such as duration of stimulation.

Lymphomas and acute abdomen - a set of case reports

Surgical treatment of gastrointestinal solid tumors is the basic method with a curative potential. However, the first-line treatment modalities in lymphomas are systemic oncology therapy (chemotherapy, immunotherapy and hematopoietic stem cell transplantation), radiotherapy or their combination. Surgery in lymphomas is predominantly associated with acute disease and dominantly, surgery is still used mainly in diagnosing lymphomas. Acute abdomen associated with lymphoma can be divided into 3 groups: bleeding, obstruction and perforation of GIT due to lymphoma. All these conditions might be caused by both gastrointestinal (extranodal) lymphomas or advanced nodal lymphomas that directly infiltrate or compress gastrointestinal tract (GIT) as well. Perforation is also often associated with the effect of systemic chemotherapy administration. When treating acute abdomen conditions caused by lymphomas, multidisciplinary cooperation with all participating experts is necessary. From the surgical point of view, minimizing the risk of postoperative complications is crucial to ensure the possibility of early systemic oncological treatment administration.

Primary epiploic appendagitis as an unusual cause of acute abdominal pain in a middle-aged male: A case report

RATIONALE

Primary epiploic appendagitis (PEA) is a rare cause of acute abdomen caused by spontaneous torsion or venous thrombosis of epiploic appendices, it commonly manifests with acute lower quadrant pain, thus may mimic acute diverticulitis, appendicitis, or mesenteric infarction.

PATIENT CONCERNS

In this case report, we report a 44 years old man who presented with persistent sharp pain in the left lower quadrant abdomen, Laboratory tests were mostly normal, contrast enhanced computed tomography (CECT) revealed a slightly high density shadow with fat foci in the middle was presented around the local descending colon, accompanied by the adjacent peritoneal thickening.

DIAGNOSES

He was diagnosed with PEA as confirmed by an abdominal contrast enhanced computed tomography (CECT) scan.

INTERVENTIONS

He was followed up in the clinic without any dietary restrictions, antibiotic or analgesic drugs use.

OUTCOMES

The abdominal pain gradually subsided a week later, and there were no recurrence of the symptoms during follow-up.

LESSONS

In our case, the diagnosis of PEA using CECT allows the patient to avoid surgery and other invasive treatment.

Pathology is common in subsequent visits after admission for non-specific abdominal pain

INTRODUCTION

Although not supported by evidence, there may be a risk of overlooking pathological findings at patients' return visit after emergency admission for non-specific abdominal pain (NSAP). The primary aim of this study was to evaluate the risk of missed acute pathology in patients primarily discharged with NSAP and re-admitted within three months.

METHODS

This was a retrospective review of hospital records within a three-month period (1 September-30 November, 2014) in a university hospital with unrestricted referral of abdominal emergency patients. Patients fulfilling the criteria for NSAP were included in the study.

RESULTS

Among the 1,474 patients admitted with acute abdominal pain, 390 (26%) were discharged with NSAP; 16% of the patients who were discharged with NSAP were re-admitted for abdominal pain. At their return visit, 39% received a verified specific diagnosis, corresponding to 6% of all patients with the NSAP diagnosis. A total of 40% of the early re-admissions of patients with NSAP were related to the biliary tract (cholelithiatis, cholangitis and cholecystitis). Co-morbidity, nausea, vomiting and increased white blood cell count at the primary admission were significantly associated with a risk of missing a specific diagnosis (p < 0.05).

CONCLUSIONS

This study found that only 6% of the patients who were admitted for acute abdominal pain and were discharged with no diagnosis had a somatic condition. However, risk of pathological findings at the return visit was relatively high among patients discharged with NSAP.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

Unsuspected Colchicine Overdose in a Female Patient Presenting as an Acute Abdomen

We report a case of multi-system organ failure as a result of unsuspected colchicine overdose in a patient with known gout and bulimia nervosa. The patient had initially presented with mild gastrointestinal symptoms with rapid progression to fulminant hepatic failure and multiple organ dysfunction before the causative agent was identified. The patient survived with aggressive intensive care support and ongoing medical treatment. Physicians should be aware of the risk assessment based on the ingested dose, that the clinical presentation of colchicine in toxic doses may be nonspecific with high potential for severe morbidity or death and that survival may occur despite multiple organ failure requiring aggressive support.

[Role of surgical oncologists in multidisciplinary team treatment of malignant acute abdomen]

Malignant acute abdomen is an acute abdominal disease caused by abdominal and extra-abdominal malignant tumors or secondary to various treatments for tumors, and belongs to the category of oncologic emergencies. Malignant acute abdomen includes perforation, bowel obstruction, infection and bleeding, etc. Most of the malignant acute abdomen is urgent and critical. The postoperative morbidity and mortality of these patients are high. The treatment strategy should ideally be discussed by a multidisciplinary team, which is often infeasible in the emergent setting. Surgery should be the main measures to improve survival and quality of life, but the risk of death should be fully evaluated before surgery to determine whether the surgery can benefit patients. In addition, the timing of surgery depends mostly on the surgeon. This article explores the treatment of malignant acute abdomen from the perspective of surgical oncology.

[Role of medical oncologists in multidisciplinary team treatment of malignant acute abdomen]

Acute abdomen in patients with malignant tumors is called malignant acute abdomen, often seen in the digestive system tumor or abdominal pelvic metastasis of the other primary tumors. Bleeding, perforation, gastrointestinal obstruction, biliary obstruction with infection, acute peritonitis are acute and severe, however, prevention is more important than treatment. For high-risk patients, even if acute abdomen does not occur when the disease is diagnosed, we should make precautions, including actively local treatment of local lymph nodes or primary lesions and careful choice of drugs. Malignant acute abdomen is mainly treated by surgical intervention. However, to seize the opportunity of anti-tumor treatment while actively treating acute abdomen requires multidisciplinary team (MDT), including co-management of diagnostic team, treatment team and support team. Most patients with malignant acute abdomen are in late stage, so the role of medical oncologists can not be ignored in the prevention, intervention and management of malignant acute abdomen. For patients with potentially resectable malignant acute abdomen who are suitable for neoadjuvant therapy and technically unresectable malignant acute abdomen, the opportunity for drug treatment should be sought first. For those presenting with obstruction, bleeding or perforation during radiotherapy or chemotherapy, we should carefully evaluate the response of previous antitumor treatment, the reason of acute abdomen and discuss the option of surgery. Some concomitant medications may also increase the risk of malignant acute abdomen. Here, we discuss the role of medical oncologists in the management of malignant acute abdomen in the MDT setting.

Providing high-quality fundamental care for patients with acute abdominal pain

PURPOSE

Globally, acute abdominal pain (AAP) is one of the most common reasons for emergency admissions, yet little is known about how this patient group experiences the delivery of fundamental care across the acute care delivery chain. The purpose of this paper is to describe how patients with AAP experienced fundamental care across their acute care presentation, and to explicate the health professional behaviours, reported by patients, that contributed to their positive experiences.

DESIGN/METHODOLOGY/APPROACH

A qualitative descriptive study, using repeated reflective interviews, was analysed thematically ( n=10 patients).

FINDINGS

Two themes were identified: developing genuine, caring relationships with health professionals and being informed about one's care. Patients reported that health professionals established genuine professional-patient relationships despite the busy care environment but perceived this environment as impeding information-provision. Patients were typically accepting of a lack of information, whereas poor professional-patient relationships were seen as inexcusable.

PRACTICAL IMPLICATIONS

To provide positive fundamental care experiences for patients with AAP, health professionals should establish caring relationships with patients, such as by using humour, being attentive, and acknowledging patients' physical pain and emotional distress; and should inform patients about their care, including allowing patients to ask questions and taking time to answer those questions.

ORIGINALITY/VALUE

This is the first Australian study to explore the experiences of patients with AAP across the acute care delivery chain, using a novel method of repeated interviews, and to demonstrate how fundamental care can be delivered, in clinical practice, to ensure positive patient experiences.

Acute abdominal pain-changes in the way we assess it over a decade

AIMS

Acute abdominal pain accounts for 5-10% of all emergency department visits. Rapid and accurate diagnosis is critical to ensure optimal outcomes. In the last decade, increased use of CT scans and the introduction of surgical short stay units has changed the way this group of patients is managed. The aim of this study was to evaluate the effects of these changes on patient management.

METHODS

A retrospective clinical study was undertaken including all patients admitted with abdominal pain under general surgery in the years 2004, 2009 and 2014. Two hundred from each of the three years were randomly selected and their care was reviewed.

RESULTS

During the study period, more patients were admitted under general surgery, from 1,462 in 2004 to 2,737 in 2014 (P=0.001). There was an increase in the proportion of patients admitted with non-surgical abdominal pain (25% in 2004 vs 34% in 2014, P=0.035). More computed tomography (CT) scans were performed (26.0% in 2004 vs 45.0% in 2014, P=0.001).

CONCLUSIONS

More patients were admitted under general surgery with abdominal pain and a greater proportion of these patients were admitted with non-surgical problems. Use of CT scans increased during the study period.

A study of events between the onset of symptoms and hospital admission in patients with acute abdomen

BACKGROUND

Acute abdomen is a common surgical emergency. Prompt investigation and treatment, including surgical intervention, is critical in reducing morbidity and mortality.

METHODS

We carried out a prospective observational study at a large urban secondary healthcare centre in India. Patients with surgical acute abdomen were consecutively enrolled in the study over a period of 2 years. Data were collected regarding the onset of symptoms, time of presentation to the hospital and events in the intervening period.

RESULTS

Analysis showed that misdiagnosis by medical personnel was significantly associated with delay in admission to the hospital. Unfamiliarity with the medical facilities, ignorance, low education and illiteracy and public holiday were the contributing factors for delayed presentation. Even though we detected some trends, the delay was not significantly associated with age, sex, educational level or socioeconomic status of the patient. The delay resulted in an increased mortality and morbidity especially in patients who needed emergency operative management.

CONCLUSION

Delayed presentation of acute abdomen is often not due to a single reason. The causes are distributed over various levels starting from the patient, family, medical personnel, administrative deficiencies, socioeconomic and sociocultural status of the country.

[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.

MODERN VIEWS ON THE MECHANISMS OF FORMATION AND PROSPECTS OF THERAPY OF THE PAIN ABDOMINAL SYNDROME IN PATIENTS WITH CHRONIC PANCREATITIS

Pain in chronic pancreatitis is one of the most mysterious and complex problems of modern gastroenterology. In a review article presents current information about intrapancreatic and central mechanisms of formation of pain in patients with chronic pancreatitis. Based on the pathogenetic mechanisms outlined prospects for the treatment of patients with chronic pancreatitis with pain syndrome.

Acute abdomen in patients with systemic lupus erythematosus and antiphospholipid syndrome. Importance of early diagnosis and treatment

Systemic lupus erithematosus (SLE) is an autoimmune disease with multiorgan involvement caused principally by vasculitis of small vessels. The gastrointestinal tract is one of the most frequently affected by SLE, with abdominal pain as the most common symptom. An early diagnosis and treatment of lupus enteritis is essential to avoid complications like hemorrhage or perforation, with up to 50 % of mortality rate. However, differential diagnosis sometimes is difficult, especially with other types of gastrointestinal diseases as digestive involvement of antiphospholipid syndrome (APS), moreover when both entities may coexist. We describe the case of a patient with both diseases that was diagnosed with lupus enteritis and treated with steroid therapy; the patient had an excellent response.

[Acute abdomen in patients with HIV/AIDS seen in a national hospital of Lima, Peru]

The aim of this study was to describe the features in the presentation and management of acute abdomen (AA) in patients with human immunodeficiency virus (HIV). We reviewed the medical records of 97 HIV patients who presented with AA and were seen in 2006-2011 at Cayetano Heredia National Hospital in Lima, Peru. 1.6% of immunosuppressed patients underwent surgery. Appendectomy was the most common surgical procedure (33.3%). Morbidity was 28.1% and postoperative mortality was 9.4%. Infection by mycobacterium tuberculosis was the most common cause of acute abdominal pain, at 26.8%. Data suggest that an early surgical decision for cases of AA in HIV patients may prevent significant morbidity and mortality.

Front-end specialists reduce time to a treatment plan for patients with acute abdomen

INTRODUCTION

Emergency departments (EDs) are replacing acute specialised wards in Denmark. The aim was to compare time to a treatment plan for patients with acute abdomen at a surgical assessment unit (SAU) and at an ED, respectively.

MATERIAL AND METHODS

A comparative prospective observational study was performed. The data collected included time to a doctor, a surgeon, a plan for treatment, analgesics, blood tests and time spent with health professionals.

RESULTS

The study included 109 patients. In the SAU, the median waiting time to be seen by a doctor was 72 min. and in the ED it was 86 min. (p = 0.25). The median time to be seen by a surgeon was 72 min. in the SAU and 148 min. in the ED (p ≤ 0.0001). In the SAU, the median time to a treatment plan was 131 min. and in the ED 166 min. (p = 0.02). In the SAU, patients spent 15 min. with nurses, in the ED 32 min. (p ≤ 0.0001). In the SAU, patients spent 11 min. with doctors in the ED 24 min. (p ≤ 0.0001).

CONCLUSION

Waiting time until a plan was presented to the patient was significantly shorter in the SAU than in the ED and this owed to the presence of a specialist surgeon at the hospital front-end in the SAU. The staff spent significantly more time with patients in the ED than in the SAU and significantly more blood tests were taken.

FUNDING

University of Southern Denmark, Odense University Hospital and Novo Nordisk Foundation.

Common presentation uncommon diagnosis primary omental torsion

Primary omental torsion is a rare cause of acute abdomen and mimics common acute abdominal condition like appendicitis. Torsion of the greater omentum may be primary or secondary. Here we present 2 cases admitted through emergency with the pain in right iliac fossa with this unusual diagnosis.

Surgical emergencies in obstetrics and gynaecology in a tertiary care hospital

INTRODUCTION

The management of Obstetrics and Gynaecological Emergency is directed at the preservation of life, health, sexual function and the perpetuation of fertility. Main aim of the study was to access the burden of Surgical Emergency in Obstetrics and Gynaecology and their course of management at BPKIHS.

METHODS

A total of 314 women presenting at the emergency admission room of Obstetrics and Gynaecology Department of BPKIHS over two years, who required surgical intervention were included in this hospital based descriptive study. Clinical assessment and routine laboratory investigations were performed in all cases. All patients who presented with shock were resuscitated and surgery was done at earliest possible time.

RESULTS

The age of patients ranged from 15- 55 years with approximately 43% in the 25-34 years category. Ninety two percent of them were married. Among the unmarried, 64% came with problems related to unsafe abortion. About 61% of females presenting as acute surgical abdomen had ruptured ectopic pregnancy, 7.64% had twisted ovarian cyst, and 6.26% had haemoperitoneum and pyoperitoneum following vaginal hysterectomies, total abdominal hysterectomies and caesarean section. Almost half (47.8%) of the cases underwent salphingectomy.

CONCLUSIONS

Women present with wide range of complaints and conditions in the admission room of Obstetrics and Gynecology department of BPKIHS. Skilled clinicians, immediate investigation facilities and experienced specialty Obstetrical and Gynaecological surgeons are the main backbone of the emergency case management and saving lives. Study indicates there is need of some prospective study to establish the causes of rising trend in Ectopic Pregnancies.

[A case of primary epiploic appendagitis of the sigmoid colon diagnosed by abdominal CT and managed conservatively]

A 40-year-old man presented to our department with left lower abdominal pain. Laboratory test showed slight leukocytosis and moderately elevated C-reactive protein (CRP). Computed tomography (CT) of the abdomen showed a typical fat density lesion adjacent to the sigmoid colon. The diagnosis of primary epiploic appendagitis of the sigmoid colon was established, and the patient was managed conservatively. Primary epiploic appendagitis is a self-limiting illness, and diagnosed by characteristic radiographic findings. Inaccurate diagnosis can lead to unnecessary treatments including surgical intervention. When we encounter a case of acute abdomen, we should consider the possibility of this disease to make accurate diagnosis and give proper treatment.

Acute abdominal pain during an Antarctic cruise--a case report

A 21-year-old female crew member experienced a number of medical conditions during a summer cruise to the Antarctic Peninsula. At one point symptoms and signs strongly suggested acute appendicitis. She was monitored and treated conservatively on board and recovered uneventfully without surgery. Later she had a biliary colic attack and then an allergic reaction to the pain medication given. The pre-employment medical fitness certificate cannot always be trusted regarding previous history of allergies and medical conditions.

The acute abdomen in the newborn

INTRODUCTION

clinicians must be aware of the wide range of disorders causing acute abdomen in the newborn, a frequent condition that causes challenging problems from many aspects.

AIMS

to evaluate our incidence of acute abdomen in the newborn, main aetiologies, antenatal diagnosis, clinical presentation and evolution.

METHODS

a retrospective chart review at a tertiary centre neonatal intensive care unit, from 1997 to 2006.

RESULTS

233 (4.9%) out of 4743 newborns had acute abdomen. Conditions causing abdominal distension were the most frequent (39.5%), followed by conditions causing peritonitis (33.9%), abdominal wall anomalies (23.6%), functional obstructions (1.7%), and bleeding disorders (1.3%); 158 (67.8%) patients underwent surgical intervention, and 39 (16.7) were deceased. Antenatal diagnosis rate was 50%.

CONCLUSIONS

some conditions associated to acute abdomen in the newborn are obvious, but others are rare and provide challenging problems in respect to diagnosis and treatment. Antenatal diagnosis, early recognition and timely transfer for surgery may avoid deterioration and loss of functioning bowel.

[Acute abdomen due to jejunal perforation secondary to metastatic lung carcinoma]

INTRODUCTION

Lung cancer metastases of small bowel are rare (1,1%), often with few or not symptoms. This aspecific onset and the difficult physical-instrumental approach to small bowel, led often to diagnosis at autopsy. This is not true for intestinal metastases that cause complications (haemorrhage, obstruction, perforation); in this cases emergency surgery leds to the diagnosis.

CASE REPORT

We describe a case of a male 56 years old patient with acute abdomen due to perforation (X-ray and CT). He refers, about 6 months before, an upper right lobectomy for lung cancer, followed by adjuvant chemo-radiotherapy, because the presence of brain and bone metastases. During the emergency surgery we found out a perforation of the Treitz tract, treated with intestinal resection and immediate end-to-end anastomosis with manual suture. Histological examination shows the perforation of the intestinal wall tract with lung cancer metastases.

CONCLUSIONS

Our case shows that any acute abdomen in patient with lung cancer can be considered as expression of intestinal metastases. Negative prognosis of this complication imposes to surgeons only a local treatment.

The role of ultrasonography in the diagnosis and management of non-traumatic acute abdominal pain

Our aim was to assess the effects of initial ultrasonography (US) evaluation on the diagnosis and management of non-traumatic acute abdominal pain in the emergency department. Three hundred patients with the complaint of non-traumatic acute abdominal pain who were sent for US examination with an initial clinical impression were included in the study. Pre-US and post-US surveys were designed for the clinicians who requested US. The percentage concordance of US findings with the discharge diagnosis made by clinical follow-up, imaging modalities and surgery was determined by calculating the confidence interval. The concordance of the initial clinical impression and the US diagnosis with the discharge diagnosis were compared using the McNemar test. US could not detect any pathology in 102 (34%; 95%CI, 28.6-39.3%) of the patients. The US revealed a different diagnosis than the clinical impression in 69 (23%; 95%CI, 18.2-27.7%), and confirmed the diagnosis in 121 (40%; 95%CI, 34.4-45.5%) patients. The US changed the treatment plans in 47% (95%CI, 41.3-52.6%) of the patients. The clinicians stated US helped them "very much" or "moderately" in making a diagnosis in 83% (95%CI, 78.7-87.2%). When US results were compared with the discharge diagnosis, there was concordance in 238 (79.3%; 95%CI, 74.3-83.6%) patients but not in 62 (20.6%; 95%CI, 16-25.1%). Among 121 patients the initial clinical impression agreed with the US diagnosis and there was concordance with the discharge diagnosis in 105 (86.7%; 95%CI, 80-92.7%). The concordance of US findings with the discharge diagnosis was significantly higher than that of the initial clinical impression statistically. In the initial evaluation of the patients with acute abdominal pain, US is considerably helpful in making the correct diagnosis, and that the concordance with the discharge diagnosis is high. When whole abdominal scanning is not performed, targeted US study according to the initial clinical impression decreases the clinical benefit of US.

Acute abdominal vascular emergencies

Abdominal vascular emergencies are relatively uncommon, frequently catastrophic, and highly lethal. Despite improved understanding of the pathophysiology and natural history of these disorders, delays in diagnosis and treatment remain the most important factors contributing to the observed high mortality. A high index of clinical suspicion together with a sound understanding of the clinical presentation, natural history, and management of these disorders are critical to improving outcomes. This article focuses on abdominal vascular emergencies presenting with acute visceral ischemia or catastrophic intra-abdominal hemorrhage.

Gastrointestinal perforation and the acute abdomen

The acute abdomen accounts for up to 40% of all emergency-surgical hospital admissions and is considered in the differential in the more than 7 million visits to the emergency department annually for abdominal pain in the United States. A large percentage of these cases are secondary to perforation or impending gastrointestinal perforation. Gastrointestinal perforation causes considerable mortality and usually requires emergency surgery.Rapid diagnosis and treatment of these conditions is essential to reduce the high morbidity and mortality of late-stage presentation. Successful treatment requires a thorough understanding of the anatomy, microbiology, and pathophysiology of this disease process and in-depth knowledge of the therapy, including resuscitation,antibiotics, source control, and physiologic support.

Factors influencing management and comparison of outcomes in paediatric intussusceptions

AIM

This study aims to compare management strategy and outcomes of paediatric ileocolic intussusceptions (ICI) versus small-bowel intussusceptions (SBI).

METHODS

Hospital charts of patients with intussusceptions between January 1999 and June 2006 were reviewed retrospectively.

RESULTS

A total of 135 patients with the diagnosis of intussusceptions were found in the database. In 111 patients the diagnosis was confirmed using ultrasound. The median age of the patients was 2.25 years (range 9 weeks-10 years). ICI were documented in 83 patients (74.8%) and SBI in 28 (25.2%). Spontaneous reductions were observed in 11 of 83 (13.3%) ICI and 18 of 28 (64.3%) SBI. Pneumatic reductions were attempted and were successful in 61 of 67 (91%) ICI and 6 of 7 (85.7%) SBI. Surgery was performed in 11 of 83 (13.3%) ICI and 4 of 28 (14.3%) SBI; with 2 of 83 (2.4%) ICI and 3 of 28 (10.7%) SBI patients requiring bowel resections. The median age of patients requiring surgery was 9 months in ICI and 6 years in SBI.

CONCLUSION

There are differences in ICI and SBI with regard to spontaneous reductions, and bowel resection, and age with regard to surgery and bowel resection. The treatment efficacy depends on time of presentation, intussusception type, pathologic lead points, ultrasound/colour Doppler interpretation and expertise in reduction techniques.

"Acute abdomen": early laparoscopy or active laparotomic-laparoscopic observation?

BACKGROUND/AIMS

Acute abdomen accounts for 13-40% of all emergency surgical admissions. The aim of this prospective randomized controlled study was to examine the role of early laparoscopy in the management of acute abdomen compared with the more traditional active observation.

METHODOLOGY

From July 1993 to August 2004, 522 patients consecutively, admitted with "acute abdomen", were randomized to either early laparoscopy (260 patients) (group 1) or active observation and non-invasive investigation (262 patients) (group 2). Baseline investigations included a full blood count, a pregnancy test in women of reproductive age, chest and/or abdominal radiograph if indicated clinically.

RESULTS

Sixty-two patients in the laparoscopy group underwent a total of 116 radiological investigations compared with a total of 558 investigations in all patients in the observation group (P < 0.05). In the observation group 34.7% of patients remained without a clear diagnosis compared with 4.2% of patients in the early laparoscopic group (P < 0.0001). The morbidity rate was 1.1% in group 1 and 27% in group 2 (P < 0.0001). The duration of hospital stay was significantly shorter in group 1 (3.1 vs. 7.3 days) (P < 0.01). Eight patients in group 1 required readmission (total readmission 46 days) compared with 58 patients in group 2 who stayed a total of 201 days (P < 0.05).

CONCLUSIONS

Early laparoscopy is valuable in the management of acute abdomen. It provides a significantly higher diagnostic accuracy and a better improvement in quality of life than the more traditional approach observation.

Non-obstetrical acute abdomen during pregnancy

Acute abdomen in pregnancy remains one of the most challenging diagnostic and therapeutic dilemmas today. The incidence of acute abdomen during pregnancy is 1 in 500-635 pregnancies. Despite advancements in medical technology, preoperative diagnosis of acute abdominal conditions is still inaccurate. Laboratory parameters are not specific and often altered as a physiologic consequence of pregnancy. Use of laparoscopic procedures as diagnostic tools makes diagnosis of such conditions earlier, more accurate, and safer. Appendicitis is the most common cause of the acute abdomen during pregnancy, occurring with a usual frequency of 1 in 500-2000 pregnancies, which amounts to 25% of operative indications for non-obstetric surgery during pregnancy. Surgical treatment is indicated in most cases, as in nonpregnant women. Laparoscopic procedures in the treatment of acute abdomen in pregnancy proved safe and accurate, and in selected groups of patients are becoming the procedures of choice with a perspective for the widening of such indications with more frequent use and subsequent optimal results. Despite these advances, laparotomy still remains the procedure of choice in complicated and uncertain cases.

[Acute abdomen in antiphospholipid antibodies syndrome (PAPS)]

Intestinal ischemia in antiphospholipid antibody syndrome (PAPS) could be due to arterial thrombosis from hypercoagulability. A male patient, 45 years old, was admitted to the hospital with symptoms of acute abdomen and after laparotomy he developed sepsis, right kidney infarction, jejunal ischemia, aortic thrombosis, wide necrosis of both gluteus muscles, left subclavian vein thrombosis. Our therapeutic and diagnostic strategy was delineated after demonstration of antiphospholipid antibodies. The patient was treated with total parenteral nutrition in the presence of 5 enteric fistulas with very high outflow, arterial stent insertion and daily changes of medicated dressings. Outcome was excellent with small residual deficit in walking. Continuous nutritional status monitoring and very high nitrogen supply allowed excellent healing of huge wounds and closure of enteral fistulas.

Perforated GIST of the small intestine as a rare cause of acute abdomen: Surgical treatment and adjuvant therapy. Case report

A case of perforated gastrointestinal stromal tumor (GIST) of small intestine causing acute abdomen is described, with a brief review of the literature. A male patient presented with symptoms of acute abdomen. After evaluation, a laparotomy was performed, where perforation of a tumor in the ileum was found. The perforated part along with the tumor was resected and the cytopathological examination showed that the tumor was GIST. Postoperatively, the patient received treatment, using imatinib. Gastrointestinal stromal tumors are relatively rare and often present with vague symptoms. Their first clinical manifestation as acute abdomen due to their perforation is extremely rare. In emergency laparotomy, a R0 resection is required and adjuvant therapy with imatinib must be considered.

The acute abdomen in the newborn

The acute abdomen in the newborn provides challenging problems from many aspects, not only with regard to diagnosis, resuscitation and treatment, but also now with prenatal management. Most conditions are uncommon and treatment in specialist centres enables concentration of appropriate resources and expertise. Co-morbidity is common, particularly in the preterm or low birth weight infant. A multi-disciplinary team of surgeons, anaesthetists, neonatologists, radiologists, cardiologists, obstetricians, nurses, physiotherapists and other health professionals experienced in dealing with extremely small infants will provide the best outcome. The infant should be resuscitated and, as soon as conditions permit, transferred to a specialist surgical centre with intravenous fluids, gastric tube drainage and circulatory, respiratory and general support as needed. This involves close liaison within healthcare networks and readily available patient transfer facilities. Surgery itself should be carried out in a theatre fully equipped for neonatal surgery. A gentle touch is essential because of the fragility of the tissues, and painstaking care should be taken with blood loss.

[Red, yellow, green: management of gastrointestinal complaints]

In a patient presenting with acute abdominal pain, initiation of symptomatic treatment must be preceded by the reliable exclusion of a potentially serious situation (acute abdomen = red light). Rapidly progressive or severe abdominal pain mandates an urgent diagnostic investigation on the part of the physician. No less important is the positive diagnosis of psychosomatic disorders (yellow light). If the family doctor fails to properly counsel the patient, too much diagnostic effort can lead to an iatrogenic somatic fixation. In the absence of all the above, the light shows green for causal therapy, an open mind on the diagnosis, symptomatic treatment and follow-up.

Abdominal compartment syndrome in a newly diagnosed patient with Burkitt lymphoma

We present the radiological and clinical aspects of a patient with advanced-stage Burkitt lymphoma who presented with an acute abdomen complicated by abdominal compartment syndrome.

[Acute abdomen in the elderly]

BACKGROUND

Nearly 10% of emergency consultations are due to acute abdominal pain. In people over 65 years old, it can have atypical presentations, that retard the correct diagnosis and worsens prognosis.

AIM

To study the causes, evolution and prognosis of acute abdomen in the elderly.

MATERIAL AND METHODS

Prospective study of 45 patients aged more than 65 years old (mean age+/-SD, 75.7+/-7.7, 51% men) and 221 patients of less than 65 years old (mean age+/-SD, 36.7+/-14.0, 48% men), consulting for acute abdomen in the emergency room.

RESULTS

Sixty six percent of elderly patients had concomitant diseases, that were multiple in 63%. In this age group, the causes accounting for 71% of acute abdominal pain were bilio-pancreatic diseases (31.1%), intestinal adhesive obstruction (17.7%), complicated abdominal wall hernia (13.7%), and complications of peptic ulcer disease (8.9%). Sixty four percent required surgical treatment and, in almost 50% the surgical risk was classified in ASA III or IV, according to the American Society of Anesthesiology. Thirty one percent had postoperative complications. Compared with their younger counterparts, elderly patients required significantly (p<0.05) more admissions to intensive care units (2.7 and 24.2% respectively), more connections to mechanical ventilation (1.4 and 8.9% respectively) and longer hospital stays (5.4+/-7.4 and 12.4+/-10.9 days, respectively). In this series overall mortality was 6.7%, being 0.6% for young patients and 11.1% for the surgical group over 65 years old.

CONCLUSIONS

Acute abdomen in the elderly has a high rate of complications and mortality. According to the causes of acute abdomen in this group, evaluation in the emergency setting with an ultrasonography may be very useful. In the elderly, elective correction of potential causes of acute abdomen should be done.