Rectal Examination and Appendicitis

A 25 y/o man comes to the ED because of abdominal pain started 2 hours before, fever and vomit.

He has not history of disease, no history of surgery, no history of other ED admission for abdominal pain.

Clinical examination shows rigidity and diffused painfull abdomen.

You perform digital rectal examination were you evidence no pain in the Douglas space and normal stool, can you exclude appendicitis?.

Conclusion 

Digital rectal examination (DRE) is not necessary in patients with suspected acute appendicitis, it provides no additional information that is not available on the abdominal examination.

It is not useful in comparison with the discomfort and privacy problems that often accompany its use, it can be very unpleasant for the patient. 

There is also poor evidence regarding the clinical utility of the DRE in the diagnosis of undifferentiated abdominal pain.

Bibliography 

R. E. B. Andersson

Meta-analysis of the clinical and laboratory diagnosis of appendicitis

British Journal of Surgery 2004; 91: 28–37

J Quaas , M Lanigan, D Newman, J McOsker, R Babayev, C Mason

Utility of the digital rectal examination in the evaluation of undifferentiated abdominal pain

American Journal of Emergency Medicine (2009) 27, 1125–1129

S A Colucciello, T W Lukens, D L Morgan 

Assessing Abdominal Pain In Adults: A Rational, Cost-Effective, And Evidence-Based Strategy

Emergency Medicine Practice, Premier Issue Volume1,Number1, 1999

N Manimaran, RB Galland

Significance of routine digital rectal examination in adults presenting with abdominal pain

Ann R Coll Surg Engl 2004; 86: 292–295

Ilenia Spallino

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Bowel obstruction and physical examination

A 75 y/o man arrives in ED from a nursing. 

He complains abdominal pain. 

No fever, no jaundice, abdomen presents distended. 

Inspection shows a midline old scar,

there is diffuse rigidity, 

increased bowel sounds and vomit on the sheets. 

Can history and clinical examination contribute to diagnosis of bowel obstruction?

Conclusion 

Medical history and physical examination are a good method in evaluation of a patient with a suspected bowel obstruction. Age > 50 years, distended abdomen, increased bowel sounds, vomit, history of costipation,  previous abdominal surgery  alone can increase the probability of bowel obstruction. The combination of three of this has a very high LR+ from 19 to infinity! Although in some case clinical examination could be diagnostic of bowel obstruction without any other investigation, the practice of plain radiography is still very diffused….what about it?

Bibliography 

H Bohner, Q Yang et al:

Simple data from history and physical examination help to exclude bowel obstruction and to avoid radiographic studies in patients with acute abdominal pain. 

Eur J Surg 1998; 164:777-784

to be continued...

Ciro Paolillo and Ilenia Spallino

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Septic Arthritis and Arthrocentesis

A 33 y/o male comes to the ED for fever, knee swelling and pain.
He has a history of joint surgery because of trauma, and prothesis, dating 4 years before.
He is HIV positive
He presents feverish (38°C), the left knee is swollen and hot.
WBC 34.000/μL, CRP 109 mg/L, PCT 0,05 ng/mL.
As we have seen in previous post, history, clinical examination and serum test are not useful to rule out or in a septic arthritis. It’s time to perform arthrocentesis: sWBC: 60x109, sLactate: 10 mmol/L


Are this findings useful?

Conclusion 

Although arthrocentesis is not a risk-free procedure, synovial fluid analysis is essential for the diagnosis. 

sWBC count has been studied in several trials but a significant heterogeneity was noted so it should not be used in isolation to rule in or rule out the diagnosis of septic arthritis, anyway it should augment the entire clinical evaluation.

Synovial lactate, instead, has consistently demonstrated desirable diagnostic properties to rule in septic arthritis using a threshold of >10 mmol ⁄ L. 

Bibliography 

C. R. Carpenter et al;

Evidence-based Diagnostics: Adult Septic Arthritis

Acad Emerg Med Aug 2011, vol 18 n 8. 

see previous...


Ilenia Spallino

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Septic Arthritis

A 33 y/o male comes to the ED for fever, knee swelling and pain.

He has a history of joint surgery because of trauma, and prothesis, dating 4 years before.

He is HIV positive

He presents feverish (38°C), the left knee is swollen and hot.

WBC 34.000/μL CRP 109 mg/L PCT 0,05 ng/mL

Are history, clinical examination, serum test enough to rule out or in a septic arthritis?

Conclusion 

No finding from the history significantly decreases or increase the probability of septic arthritis (SA), included hystory of HIV infection; only recent joint surgery (<3 months ago) or a joint prosthesis with skin infection, significantly increases the risk of septic arthritis, but attention, the absence does not rule out SA!

Data about physical examination and hystory are inconcludent, the presence or absence of classical clinical signs (pain with motion, limited motion, tender swelling, joint effusion, increased heat redness, fever > 37.5°C, axial load pain) is not useful to rule in or rule out septic arthritis.

Serum test like WBC, ESR, CRP are not useful, instead Procalcitonin is generally specific with very poor sensitivity. 

…..So what?

To be continued...

Bibliography 

C. R. Carpenter et al;

Evidence-based Diagnostics: Adult Septic Arthritis

Acad Emerg Med Aug 2011, vol 18 n 8. 

Ilenia Spallino

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Soft tissue abscess: clinical plus ultrasound evaluation

Male 65 y/o, he complains pain and swelling in left groin, he has history of hypertension. He has not fever. Clinical examination shows swelling, skin is hot and  eritematous.






Is it an abscess, a cellulitis or something else? 

Conclusion 

To use ultrasound on eritematous and swelling skin is very helpful 

Abscesses presents as a spherical structure with “pus in movement”.  

Celluliti’s morphology, instead, has a “cooblestoning effect”, with diffuse hyperechogenicity of subcutaneous fat.

Ultrasonography is a useful adjunct to clinical evaluation of soft tissue infection, it increases diagnostic accuracy and guides treatment decision.

Bibliography 

BT Squire, JC Fox, C Anderson

ABSCESS: applied bedside sonography for convenient evaluation of superficial soft tissue infections

Acad Emerg Med July 2005, Vol. 12, No. 7 

DW Struk, PL Munk

Imaging of softs tissue infections

Radiol Clin of N Am vol 39 n2 Mar 2001

see previous...

Ciro Paolillo

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Soft tissue abscess the clinical evaluation

Male 65 y/o, he complains pain and swelling in left groin, he has history of hypertension. He has not fever. Clinical examination shows swelling, skin is hot and eritematous.








Is it an abscess, a cellulitis or something else?

 

Conclusion 

Differentiating a soft tissue abscess from cellulitis is important because each disorder requires a different treatment.

Clinical examination alone has small role for this scope.

May we need something else?

Bibliography 

BT Squire, JC Fox, C Anderson

ABSCESS: Applied Bedside Sonography for Convenient Evaluation of Superficial Soft Tissue Infections

ACAD EMERG MED July 2005, Vol. 12, No. 7 

To be continued...

Ciro Paolillo

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Acute appendicitis and signs

A 21 y/o man presents to the ED with pain in right low quadrant (RLQ) , anorexia, nausea and vomiting. His abdomen is soft, with a mild tenderness in RLQ, the psoas sign is positive. The pain is aggravate by cough. You perform kindly a rectal examination with pain. 

Are this signs useful for the diagnosis of acute appendicitis?

Conclusion 

No clinical signs alone is able to rule in or out an acute appendicitis. Rectal examination, still diffused, is not of any utility. 

May we need somwthing else?

Bibliography 

Meta-analysis of the clinical and laboratory diagnosis of appendicitis

British Journal of Surgery 2004; 91: 28-37

R.E.B. Anderson

Ciro Paolillo

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