Plain X ray in suspected bowel obstruction. Is that all?

Clinical Scenario

A 67 y/o woman arrives in the ED at 5pm because of diffused abdominal pain since 2 hours. She has nausea and she refers costipation from the day before. 

She has a history of hysterectomy 5 years before because of fibroma.

Vital signs are normal, she presents pale and sufferer for pain, the abdomen is distendend and palpation cause pain all over it. 

Bowel movements are present but abnormal. 

Plain x ray shows 2 little fluid levels without the evidence of dilated loops of bowel, so radiologist describe it as negative.

Has plain x ray changed your previous clinical judgment about the suspect of bowel obstruction?

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How have you come to the hospital?

Clinical Scenario

It’s just started your night shift, Sara is a young EP, she is going home after an hard day.  Hello - she says tired - could you help me? There is a guy with abdominal pain and nausea. I think it could be appendicitis, but there is not fever and not leukocytosis. 

Have you asked if he arrived by car? - You say

No, why? 


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Imaging strategies of suspected acute colonic diverticulitis: how does it work?

Clinical scenario

A 66 yo man complains of left lower quadrant (LLQ) pain, anoressia and fever, it is the first time. The pain is acute, there is not vomit, temperature is 38°C. Abdomen is treatable, with severe pain and tenderness localized at LLQ , there is not history of prior abdominal surgery. Probably this patient suffers of an acute colonic diverticulitis (ACD).

Is Computer Thomography (CT) the imaging procedure of choice for this patient? 

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Diagnosis of diverticulitis with hands and blood tests. Is it a good idea?

Clinical Scenario

A 66 yo man complains of left lower quadrant (LLQ) abdominal pain from 4/5 hours. The pain is described as crampy initially, than continuous, there is not vomit. Temperature is 37.5°C. Abdomen is treatable, with moderate pain and tenderness localized at LLQ , there is not history of prior abdominal surgery. 

ED US excluded the specter of an AAA.

WBC 13.000/μl

CPR: 51 mg/L

Probably this patient suffers of an acute diverticulitis. 

Is it an urgent imaging necessary to confirm the diagnosis? 

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Does procalcitonin have a role in the management of acute appendicitis?

Clinical scenario

A 18 yo man comes to the ED in the morning because of low abdominal pain, fever and nausea. At palpation there is mild pain in the right inferior quadrant, not guarding.

Could procalcitonin (PTC) helps to exclude quickly an acute appendicitis?

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Is CRP correlated to CT result in the evaluation of abdominal pain?

A 74 yo/man complained of diffuse abdominal pain. The pain was intermittent and accompained by vomiting. He has no history of abdominal pain or abdominal surgery.

On examinations the patient presented non icteric, afebrile, not tachicardic. 

The abdomen was mildly distensed with midline tenderness. 

The US evidenced a normal aorta diameter. 

Abdominal x ray showed non specific bowel gas pattern. 

CRP value was 7 mg/L.

The radiologist says it is a little value to perform an abdominal CT, we see tomorrow…..

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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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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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Intestinal Ischemia and Lactate

A 84 y/o woman comes accompained by relatives for abdominal pain.

She is oriented and cooperative, she suffers pain (NRS 10/10).
Abdomen is treatable, but very painful in the lower quadrants, you see green watering diarrhea, she has not fever.
Abdominal Radiograph shows air/fluid levels
WBC: 35000/μl PCR: 22 mg/L Lactate: 1,7


Can you rule out intestinal ischemia?

Conclusion 

The performance of lactate and other serological markers is disappointing and not particularly helpful to rule out intestinal ischemia.

Bibliography 

NJ Evennett, MS Petrov, A Mittal, JA Windsor

Systematic Review and Pooled Estimates for the Diagnostic Accuracy of Serological Markers for Intestinal Ischemia

World J Surg (2009) 33:1374–1383 

Ilenia Spallino

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Acute appendicitis and Symptoms

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

Read more...