Epidemiology and outcomes of acute abdominal pain in a large urban Emergency Department: retrospective analysis of 5,340 cases

Primary omental torsion with clinical masquerading as acute appendicitis and radiological key for diagnosis

Omental torsion is a medical condition characterized by the twisting of the omentum along its longitudinal axis, which leads to compromised blood flow. This condition is rarely diagnosed before surgery and can present symptoms similar to other causes of acute surgical abdomen. This report details a case of primary omental torsion initially suspected to be acute appendicitis. The patient was admitted to the hospital with symptoms of lower right quadrant abdominal pain and mild fever. Computed tomography imaging revealed a twisted mass of fatty tissue with surrounding fat stranding changes, but no signs of appendicitis were found, indicating omental torsion. The patient underwent surgery to remove the twisted and necrotic omentum, leading to an improvement in symptoms. This case highlights the challenges in diagnosis and the crucial role of computed tomography imaging in managing this rare condition.

Effectiveness of different appendiceal stump closure methods in laparoscopic appendectomy a network meta-analysis

PURPOSE

Choosing the best stump closure method for laparoscopic appendectomy has been a debated issue, especially for patients with acute appendicitis. The lack of consensus in the literature and the diverse techniques available have prompted the need for a comprehensive evaluation to guide surgeons in selecting the most optimal appendiceal stump closure method.

METHODS

A comprehensive search was conducted on multiple databases from inception until December 2023 to find relevant studies according to eligibility criteria. The primary outcome was the incidence of total complications.

RESULTS

25 studies with a total of 3308 patients were included in this study, overall complications did not reveal a significant advantage for any intervention (RR = 0.72, 95% CI: 0.53; 1.01), Superficial and deep infection risks were similar across all methods, Operative time was significantly longer with endoloop and Intracorporeal sutures (MD = 7.07, 95% CI: 3.28; 10.85) (MD = 26.1, 95% CI: 20.9; 31.29).

CONCLUSIONS

There are no significant differences in overall complications among closure methods. However, Intracorporeal sutures and endoloop techniques were associated with extended operative durations.

Signs and symptoms of serious illness in adults with acute abdominal pain presenting to ambulatory care: a systematic review

BACKGROUND

Acute abdominal pain is a common complaint, caused by a variety of conditions, ranging from acutely life-threatening to benign and self-limiting, with symptom overlap complicating diagnosis. Signs and symptoms may be valuable when assessing a patient to guide clinical work.

AIM

Summarising evidence on the accuracy of signs and symptoms for diagnosing serious illness in adults with acute abdominal pain in an ambulatory care setting.

DESIGN & SETTING

We performed a systematic review, searching for prospective diagnostic accuracy studies that included adults presenting with acute abdominal pain to an ambulatory care setting.

METHOD

Six databases and guideline registers were searched, using a comprehensive search strategy. We assessed the risk of bias, and calculated descriptive statistics and measures of diagnostic accuracy. Results were pooled when at least four studies were available.

RESULTS

Out of 18 923 unique studies, 16 studies with moderate to high-risk bias were included. Fourteen clinical features met our criteria, including systolic blood pressure <100 mmHg (positive likelihood ratio [LR+]7.01), shock index >0.85, uterine cervical motion tenderness (LR+5.62 and negative likelihood ratio [LR-]8.60), and a self-assessment questionnaire score >70 (LR+12.20) or <25 (LR-0.19). Clinical diagnosis made by the clinician had the best rule-in ability (LR+24.6).

CONCLUSIONS

We identified 14 signs and symptoms that can influence the likelihood of a serious illness, including pain characteristics, systemic signs, gynaecological signs, and clinician's overall assessment. The risk of bias was moderate to high, leading to uncertainty and preventing us from making firm conclusions. This highlights the need for better research in this setting.

Evaluation and mitigation of the limitations of large language models in clinical decision-making

Clinical decision-making is one of the most impactful parts of a physician's responsibilities and stands to benefit greatly from artificial intelligence solutions and large language models (LLMs) in particular. However, while LLMs have achieved excellent performance on medical licensing exams, these tests fail to assess many skills necessary for deployment in a realistic clinical decision-making environment, including gathering information, adhering to guidelines, and integrating into clinical workflows. Here we have created a curated dataset based on the Medical Information Mart for Intensive Care database spanning 2,400 real patient cases and four common abdominal pathologies as well as a framework to simulate a realistic clinical setting. We show that current state-of-the-art LLMs do not accurately diagnose patients across all pathologies (performing significantly worse than physicians), follow neither diagnostic nor treatment guidelines, and cannot interpret laboratory results, thus posing a serious risk to the health of patients. Furthermore, we move beyond diagnostic accuracy and demonstrate that they cannot be easily integrated into existing workflows because they often fail to follow instructions and are sensitive to both the quantity and order of information. Overall, our analysis reveals that LLMs are currently not ready for autonomous clinical decision-making while providing a dataset and framework to guide future studies.

Health care utilization of patients with acute abdominal pain before and after emergency department visits

BACKGROUND

Acute abdominal pain (AAP) is a major driver for capacity-use in emergency departments (EDs) worldwide. Yet, the health care utilization of patients with AAP before and after the ED remains unclear. The primary objective of this study was to describe adult patients presenting to the ED with AAP and their outpatient care (OC) use before and after the ED. Secondary objectives included description of hospitalization rates, in-hospital mortality, ED re-visits, and exploration of potential risk factors for hospitalization and ED re-visits.

METHODS

For the analysis, we combined routine hospital data from patients who visited 15 EDs in Germany in 2016 with their statutory health insurance OC claims data from 2014 to 2017. Adult patients were included based on a chief complaint or an ED diagnosis indicating unspecific AAP or the Manchester Triage System indicator "Abdominal pain in adults". Baseline characteristics, ED diagnosis, frequency and reason of hospitalization, frequency and type of prior-OC (prOC) use up to 3 days before and of post-OC use up to 30 days after the ED visit.

MAIN RESULTS

We identified 28,085 adults aged ≥ 20 years with AAP. 39.8% were hospitalized, 33.9% sought prOC before the ED visit (48.6% of them were hospitalized) and 62.7% sought post-OC up to 30 days after the ED visit. Hospitalization was significantly more likely for elderly patients (aged 65 and above vs. younger; adjusted OR 3.05 [95% CI 2.87; 3.25]), prOC users (1.71 [1.61; 1.90]) and men (1.44 [1.37; 1.52]). In-hospital mortality rate was 3.1% overall. Re-visiting the ED within 30 days was more likely for elderly patients (1.32 [1.13; 1.55) and less likely for those with prOC use (0.37 [0.31; 0.44]).

CONCLUSIONS

prOC use was associated with more frequent hospitalizations but fewer ED re-visits. ED visits by prOC patients without subsequent hospitalization may indicate difficulties of OC resources to meet the complex diagnostic requirements and expectations of this patient population. Fewer ED re-visits in prOC users indicate effective care in this subgroup.

Time to improve the management of patients with suspected acute appendicitis: a retrospective study

PURPOSE

Preoperative imaging is now recommended in patients with suspected acute appendicitis (AA) by the World Society of Emergency Surgery. Our aims were (i) to describe our local practice and (ii) to evaluate the efficiency of performing ultrasound (US) and/or computed tomography (CT) by assessing management failure, specificity and sensitivity, and length of stay in the emergency department (ED).

METHODS

This single-center retrospective study included all patients who underwent US or CT for the management of suspected AA. Patients were included if they were admitted to the ED in February or June between 2012 and 2021.

RESULTS

The study included 339 patients. US was performed in 278 patients (82%), of whom 91 also had a second-line CT (31.3%). There was a significant increase in the rate of CT over the inclusion period. Three percent (3%) of the patients had management failure and a higher age and CT or US + CT were significantly associated with the risk of management failure. Length of stay in the ED increased significantly when a second-line CT was performed. The sensitivity and specificity of US were 84.8% and 93.2%, respectively. Sensitivity was significantly different from CT (100%, p = 0.03) but not specificity (87.9%, p = 0.29). Both US and CT results were more likely to be considered for further management if positive. The vast majority of patients with negative or inconclusive results were admitted in surgical wards or underwent a second-line examination.

CONCLUSION

If available in the hospital together with CT, US should probably be performed systematically and as a first-line examination in patients with suspected acute appendicitis.

Beyond the revised atlanta classification: a comprehensive review of the imaging assessment of acute pancreatitis and its complications

While the Revised Atlanta Classification outlines the primary complications of acute pancreatitis, it is crucial to recognize additional factors that contribute to morbidity and mortality associated with acute pancreatitis. In this review, we discuss the imaging-based classification and staging of acute pancreatitis as described by the Revised Atlanta Classification, but also provide a comprehensive understanding of the pancreatic anatomy and its relation to surrounding structures, which is essential for imaging-based assessment of both acute pancreatitis and its complications. We further extend the discussion beyond common complications such as pseudocysts and walled-off necrosis to include lesser-known but significant complications such as peripancreatic infection, disconnected ductal disconnection syndrome, thrombosis, hemorrhage, and gastrointestinal complications. Additionally, illustrative examples are presented to highlight relevant points pertaining to real-life imaging assessment of acute pancreatitis and its complications.

Rupture Endometriomas Presenting as Acute Abdomen Infection in Hasty and Limited Resources Setting: A Pitfall Not to Miss - A Case Report

Introduction

Abdominal pain is a diagnostic problem that requires immediate care and treatment for surgeons and gynecologists. The causes of abdominal pain in women of childbearing age range from benign and temporary to potentially life threatening. Rare etiologies such as spontaneous ruptured endometrioma are often not included in the radar of diagnosis due to their rarity and non-specific signs and symptoms in the patient. This case report aimed to show a resemblance between the clinical symptoms of acute abdomen in diffuse peritonitis due to hollow viscus perforation and spontaneous ruptured endometrioma.

Case Description

A 42-year-old woman presented to our hospital with abdominal pain. She had a history of fever for two weeks. She came from a tropical rural area where typhoid fever is common. She was advised to undergo emergency laparotomy because of the suspicion of diffuse peritonitis due to a hollow viscus perforation due to typhoid infection. Because of acute abdominal pain, a vertical incision was made to explore her abdominal cavity, and chocolate-like fluid and ovarian cysts were found during surgery. The diagnosis was changed to diffuse peritonitis due to spontaneous rupture of the endometrioma bilaterally.

Conclusion

This case suggests that the exact diagnosis and cause of abdominal pain varies. As the current gold standard for endometrioma is laparoscopy, surgeons must prepare a collaborative approach to the cause of the disease.

Machine learning based prediction models for analyzing risk factors in patients with acute abdominal pain: a retrospective study

Background

Acute abdominal pain (AAP) is a common symptom presented in the emergency department (ED), and it is crucial to have objective and accurate triage. This study aims to develop a machine learning-based prediction model for AAP triage. The goal is to identify triage indicators for critically ill patients and ensure the prompt availability of diagnostic and treatment resources.

Methods

In this study, we conducted a retrospective analysis of the medical records of patients admitted to the ED of Wuhan Puren Hospital with acute abdominal pain in 2019. To identify high-risk factors, univariate and multivariate logistic regression analyses were used with thirty-one predictor variables. Evaluation of eight machine learning triage prediction models was conducted using both test and validation cohorts to optimize the AAP triage prediction model.

Results

Eleven clinical indicators with statistical significance (p < 0.05) were identified, and they were found to be associated with the severity of acute abdominal pain. Among the eight machine learning models constructed from the training and test cohorts, the model based on the artificial neural network (ANN) demonstrated the best performance, achieving an accuracy of 0.9792 and an area under the curve (AUC) of 0.9972. Further optimization results indicate that the AUC value of the ANN model could reach 0.9832 by incorporating only seven variables: history of diabetes, history of stroke, pulse, blood pressure, pale appearance, bowel sounds, and location of the pain.

Conclusion

The ANN model is the most effective in predicting the triage of AAP. Furthermore, when only seven variables are considered, including history of diabetes, etc., the model still shows good predictive performance. This is helpful for the rapid clinical triage of AAP patients and the allocation of medical resources.

Elevating healthcare through artificial intelligence: analyzing the abdominal emergencies data set (TR_ABDOMEN_RAD_EMERGENCY) at TEKNOFEST-2022

OBJECTIVES

The artificial intelligence competition in healthcare at TEKNOFEST-2022 provided a platform to address the complex multi-class classification challenge of abdominal emergencies using computer vision techniques. This manuscript aimed to comprehensively present the methodologies for data preparation, annotation procedures, and rigorous evaluation metrics. Moreover, it was conducted to introduce a meticulously curated abdominal emergencies data set to the researchers.

METHODS

The data set underwent a comprehensive central screening procedure employing diverse algorithms extracted from the e-Nabız (Pulse) and National Teleradiology System of the Republic of Türkiye, Ministry of Health. Full anonymization of the data set was conducted. Subsequently, the data set was annotated by a group of ten experienced radiologists. The evaluation process was executed by calculating F1 scores, which were derived from the intersection over union values between the predicted bounding boxes and the corresponding ground truth (GT) bounding boxes. The establishment of baseline performance metrics involved computing the average of the highest five F1 scores.

RESULTS

Observations indicated a progressive decline in F1 scores as the threshold value increased. Furthermore, it could be deduced that class 6 (abdominal aortic aneurysm/dissection) was relatively straightforward to detect compared to other classes, with class 5 (acute diverticulitis) presenting the most formidable challenge. It is noteworthy, however, that if all achieved outcomes for all classes were considered with a threshold of 0.5, the data set's complexity and associated challenges became pronounced.

CONCLUSION

This data set's significance lies in its pioneering provision of labels and GT-boxes for six classes, fostering opportunities for researchers.

CLINICAL RELEVANCE STATEMENT

The prompt identification and timely intervention in cases of emergent medical conditions hold paramount significance. The handling of patients' care can be augmented, while the potential for errors is minimized, particularly amidst high caseload scenarios, through the application of AI.

KEY POINTS

• The data set used in artificial intelligence competition in healthcare (TEKNOFEST-2022) provides a 6-class data set of abdominal CT images consisting of a great variety of abdominal emergencies. • This data set is compiled from the National Teleradiology System data repository of emergency radiology departments of 459 hospitals. • Radiological data on abdominal emergencies is scarce in literature and this annotated competition data set can be a valuable resource for further studies and new AI models.

Early versus delayed appendicectomy for appendiceal phlegmon or abscess

BACKGROUND

This is an update of a Cochrane review first published in 2017. Acute appendicitis (inflammation of the appendix) can be simple or complicated. Appendiceal phlegmon and appendiceal abscess are examples of complicated appendicitis. Appendiceal phlegmon is a diffuse inflammation in the bottom right of the appendix, while appendiceal abscess is a discrete inflamed mass in the abdomen that contains pus. Appendiceal phlegmon and abscess account for 2% to 10% of acute appendicitis. People with appendiceal phlegmon or abscess usually need an appendicectomy to relieve their symptoms (e.g. abdominal pain, loss of appetite, nausea, and vomiting) and avoid complications (e.g. peritonitis (infection of abdominal lining)). Surgery for people with appendiceal phlegmon or abscess may be early (immediately after hospital admission or within a few days of admission), or delayed (several weeks later in a subsequent hospital admission). The optimal timing of appendicectomy for appendiceal phlegmon or abscess is debated.

OBJECTIVES

To assess the effects of early appendicectomy compared to delayed appendicectomy on overall morbidity and mortality in people with appendiceal phlegmon or abscess.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, two other databases, and five trials registers on 11 June 2023, together with reference checking to identify additional studies.

SELECTION CRITERIA

We included all individual and cluster-randomised controlled trials (RCTs), irrespective of language, publication status, or age of participants, comparing early versus delayed appendicectomy in people with appendiceal phlegmon or abscess.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included eight RCTs that randomised 828 participants to early or delayed appendicectomy for appendiceal phlegmon (7 trials) or appendiceal abscess (1 trial). The studies were conducted in the USA, India, Nepal, and Pakistan. All RCTs were at high risk of bias because of lack of blinding and lack of published protocols. They were also unclear about methods of randomisation and length of follow-up. 1. Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon We included seven trials involving 788 paediatric and adult participants with appendiceal phlegmon: 394 of the participants were randomised to the early appendicectomy group (open or laparoscopic appendicectomy as soon as the appendiceal mass resolved within the same admission), and 394 were randomised to the delayed appendicectomy group (initial conservative treatment followed by delayed open or laparoscopic appendicectomy several weeks later). There was no mortality in either group. The evidence is very uncertain about the effect of early appendicectomy on overall morbidity (risk ratio (RR) 0.74, 95% confidence interval (CI) 0.19 to 2.86; 3 trials, 146 participants; very low-certainty evidence), the proportion of participants who developed wound infections (RR 0.99, 95% CI 0.48 to 2.02; 7 trials, 788 participants), and the proportion of participants who developed faecal fistulas (RR 1.75, 95% CI 0.36 to 8.49; 5 trials, 388 participants). Early appendicectomy may reduce the abdominal abscess rate (RR 0.26, 95% CI 0.08 to 0.80; 4 trials, 626 participants; very low-certainty evidence), reduce the total length of hospital stay by about two days (mean difference (MD) -2.02 days, 95% CI -3.13 to -0.91; 5 trials, 680 participants), and increase the time away from normal activities by about five days (MD 5.00 days; 95% CI 1.52 to 8.48; 1 trial, 40 participants), but the evidence is very uncertain. 2. Early versus delayed laparoscopic appendicectomy for appendiceal abscess We included one trial involving 40 paediatric participants with appendiceal abscess: 20 were randomised to the early appendicectomy group (emergent laparoscopic appendicectomy), and 20 were randomised to the delayed appendicectomy group (initial conservative treatment followed by delayed laparoscopic appendicectomy 10 weeks later). There was no mortality in either group. The trial did not report on overall morbidity, various complications, or time away from normal activities. The evidence is very uncertain about the effect of early appendicectomy on the total length of hospital stay (MD -0.20 days, 95% CI -3.54 to 3.14; very low-certainty evidence).

AUTHORS' CONCLUSIONS

For the comparison of early versus delayed open or laparoscopic appendicectomy for paediatric and adult participants with appendiceal phlegmon, very low-certainty evidence suggests that early appendicectomy may reduce the abdominal abscess rate. The evidence is very uncertain whether early appendicectomy prevents overall morbidity or other complications. Early appendicectomy may reduce the total length of hospital stay and increase the time away from normal activities, but the evidence is very uncertain. For the comparison of early versus delayed laparoscopic appendicectomy for paediatric participants with appendiceal abscess, data are sparse, and we cannot rule out significant benefits or harms of early versus delayed appendicectomy. Further trials on this topic are urgently needed and should specify a set of criteria for use of antibiotics, percutaneous drainage of the appendiceal abscess prior to surgery, and resolution of the appendiceal phlegmon or abscess. Future trials should include outcomes such as time away from normal activities and length of hospital stay.

Somatic symptom severity, depression and anxiety associations with pancreatitis and undifferentiated abdominal pain in surgical inpatients

BACKGROUND

Somatic Symptom Disorder is a psychiatric diagnosis that describes the experience of physical symptoms and associated distress, that is disproportionate to recognized organic pathology. Somatic symptom severity (SSS) may be associated with some surgical diagnoses; particularly the complex pain associated with pancreatitis, or the diagnostic ambiguity of undifferentiated abdominal pain (UAP). We aimed to estimate the prevalence of SSS in different diagnostic groups in surgical inpatients with abdominal pain; and to estimate the magnitude and direction of any association of SSS, anxiety and depression.

METHODS

Cross sectional analysis (n = 465) of adult admissions with non-traumatic abdominal pain, at a tertiary hospital in Australia. We estimated SSS with the Patient Health Questionnaire-15 (PHQ-15), depression with the Patient Health Questionnaire (PHQ-9) and anxiety with the General Anxiety Disorder (GAD-7), at standard cut-points ≥ 10; comparing acute pancreatitis (n = 20), chronic pancreatitis (n = 18) and UAP (n = 64) versus other causes of abdominal pain.

RESULTS

Somatic symptoms were common, 52% having moderate and 19.6% severe SSS. There was an association between moderate SSS and pancreatitis (OR 2.11, 95% CI 1.05-4.25) and depressive symptoms and chronic pancreatitis (OR = 3.47, 95% CI 1.31-9.24). There was no significant association between the four mental health categories and UAP.

CONCLUSIONS

SSS and psychological comorbidity were common in a surgical inpatients admitted for abdominal pain and equally represented across most diagnostic sub-groups. However, the pancreatitis sub-group had greater proportions with clinically significant SSS and depression, suggesting that they have a higher requirement for psychological assessment and intervention.

Evaluation of point-of-care ultrasound use in the diagnostic approach for right upper quadrant abdominal pain management in the emergency department: a prospective study

Point-of-care ultrasound (PoCUS) is commonly used at the bedside in the emergency department (ED) as part of clinical examinations. Studies frequently investigate PoCUS diagnostic accuracy, although its contribution to the overall diagnostic approach is less often evaluated. The primary objective of this prospective, multicenter, cohort study was to assess the contribution of PoCUS to the overall diagnostic approach of patients with right upper quadrant abdominal pain. Two independent members of an adjudication committee, who were blind to the intervention, independently evaluated the diagnostic approaches before and after PoCUS for the same patient. The study included 62 patients admitted to the ED with non-traumatic right upper quadrant abdominal pain from September 1, 2022, to March 6, 2023. The contribution of PoCUS to the diagnostic approach was evaluated using a proportion test assuming that 75% of diagnostic approaches would be better or comparable with PoCUS. Wilcoxon signed-rank tests evaluated the impact of PoCUS on the mean number of differential diagnoses, planned treatments, and complementary diagnostic tests. Overall, 60 (97%) diagnostic approaches were comparable or better with PoCUS (χ2 = 15.9, p < 0.01). With PoCUS, the mean number of differential diagnoses significantly decreased by 2.3 (95% CI - 2.7 to - 1.5) (p < 0.01), proposed treatments by 1.3 (95% CI - 1.8 to - 0.9) (p < 0.01), and complementary diagnostic tests by 1.3 (95% CI - 1.7 to - 1.0) (p < 0.01). These findings show that PoCUS positively impacts the diagnostic approach and significantly decreases the mean number of differential diagnoses, treatments, and complementary tests.

Epstein-Barr in a Patient Presenting with Right Upper Quadrant Pain: A Case Report from the Emergency Department

BACKGROUND

Right upper quadrant abdominal pain and elevated cholestasis blood tests are usually associated with bacterial calculous cholecystitis. However, viral infections, such as Epstein-Barr virus (EBV) can also manifest with a similar clinical picture and is an important differential diagnosis.

CASE REPORT

This case report discusses a young woman presenting to the emergency department with acute right upper quadrant abdominal pain. The initial assessment revealed a positive Murphy's sign, elevated white blood count, and a cholestatic pattern on liver function tests, leading one to suspect bacterial calculous cholecystitis and initiating antibiotic therapy. However, clinical examination also revealed tonsillar exudates and differential white blood cell count revealed monocytosis and lymphocytosis rather than a high neutrophil count. The patient tested positive for EBV. Furthermore, ultrasound and magnetic resonance imaging revealed gallbladder wall edema with no gallstones, leading one to conclude that the clinical manifestation and laboratory results were due to an EBV infection. Antibiotic therapy was ceased and the patient did not require surgical intervention. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Calculous bacterial cholecystitis usually entails antibiotic therapy and cholecystectomy. It is important to be aware of the differential diagnosis of EBV, as it usually does not require either of these and resolves spontaneously.

Impact of emergency physician performed ultrasound in the evaluation of adult patients with acute abdominal pain: a prospective randomized bicentric trial

BACKGROUND

Abdominal pain is common in patients visiting the emergency department (ED). The aim of this study was to assess the diagnostic contribution of point-of-care ultrasound (POCUS) in patients presenting to the ED with acute abdominal pain.

METHODS

We designed an interventional randomized, controlled, open label, parallel-group, trial in two French EDs. We included adult patients presenting to the ED with acute abdominal pain. Exclusion criteria were a documented end-of-life, an immediate need of life-support therapy and pregnant or breast-feeding women. Patients were randomized in the experimental group (i.e., workup including POCUS) or control group (usual care). The primary objective of the study was to assess the added value of POCUS on diagnostic pathway in the ED, according to the diagnostic established a posteriori by an adjudication committee. The primary endpoint was the proportion of exact preliminary diagnosis between the 2 groups. The preliminary diagnosis made after clinical examination and biological results with POCUS (intervention arm) or without POCUS (usual care) was considered exact if it was similar to the adjudication committee diagnosis.

RESULTS

Between June 2021 11th and June 2022 23th, 256 patients were randomized, but five were not included in the primary analysis, leaving 125 patients in the POCUS group and 126 patients in the usual care group (130 women and 121 men, median [Q1-Q3] age: 42 [30;57]). There was no difference for exact diagnosis between the two groups (POCUS 70/125, 56% versus control 78/126 (62%), RD 1.23 [95% CI 0.74-2.04]). There was no difference in the accuracy for the diagnosis of non-specific abdominal pain nor number of biological or radiological exams. Diagnostic delays and length of stay in the ED were also similar.

CONCLUSIONS

In this trial, systematic POCUS did not improve the rate of diagnostic accuracy in unselected patients presenting to the ED with acute abdominal pain. However, as it was a safe procedure, further research should focus on patients with suspected etiologies where POCUS is particularly useful.

TRIAL REGISTRATION

 This trial was registered on ClinicalTrials.gov on 2022/07/20 ( https://clinicaltrials.gov/study/NCT04912206?id=NCT04912206&rank=1 ) (NCT04912206).

The utility of the abdominal series in the emergency setting: a retrospective review

PURPOSE

The abdominal series (AXR) remains a frequently ordered test in the emergency department (ED), despite existing literature questioning its utility. The aim of this study was to characterize the use of the AXR in the ED by quantifying how often it is ordered and the frequency of subsequent imaging. Additionally, a time estimate in ED associated with the AXR was quantified. We hypothesized that there would be a low clinical utility of the AXR, and long associated time period spent in the ED.

METHODS

A retrospective audit of AXRs performed in the ED from January to December 2019 was performed. The local picture archiving and communication system (PACS) and electronic medical record were used to collect the variables.

RESULTS

Of 701 AXRs, 438 (62.4%) were reported normal, and 263 (37.6%) were abnormal. A Chi Squared test showed that the two variables (abdominal series result and follow up imaging completion) were significantly related, with p < 0.001. However, the effect size was small (Nagelkerke R square = 0.022). The average time spent in the ED for these patients was 7.27 h, and the average time between the AXR being ordered and interpreted was 1.31 h.

CONCLUSION

The majority of AXRs were reported as normal. Our results showed that AXR had a statistically significant, but low clinically significant predictive ability on subsequent imaging ordering. This supports our hypothesis that the AXR is of low clinical utility with respect to the rate of ordering follow up imaging. The AXR also translated to a quantifiable time interval during the patient's stay in ED. Minimizing overuse of the AXR may result in a decrease in patient duration in the ED.

Role of Fecal Calprotectin in Patients Presenting to the Emergency Department with Abdominal Pain with or without Diarrhea or Rectal Bleeding

BACKGROUND AND OBJECTIVE

Abdominal pain is a frequent reason for admission to the Emergency Department. It may be a symptom of an underlying "organic" disease or a "functional" manifestation without an underlying anatomic or physiologic alteration. The evaluation of patients with abdominal pain is a challenge for the emergency physician and the selection of patients for second-level radiological examinations or endoscopic procedures is not always easy to perform. Faecal calprotectin could be a useful diagnostic marker to distinguish between "organic" or "functional" form and its determination could be helpful to select patients for further examinations in the context of an emergency setting.

MATERIALS AND METHODS

This is an observational and retrospective study on 146 patients with abdominal pain and/or diarrhea (with or without rectal bleeding) admitted to the Emergency Department of Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, who collected a fecal sample to evaluate fecal calprotectin. We evaluated and correlated the level of fecal calprotectin with the final diagnosis they received.

RESULTS

50/146 patients (34,24%) received a diagnosis of acute diverticulitis, in particular, 14/50 (28%) were complicated and 36/50 (72%) were uncomplicated; 4/146 (2,7%) were cholangitis, 32/146 (21,9%) were colitis, 6/146 (4,1%) gastritis, 42/146 (28,7%), Irritable bowel syndrome and 12/146 (8,2%) Inflammatory bowel disease. For the differential diagnosis between Irriable or inflammatory bowel diseses, our study showed a VPP and a VPN of 100% meanwhile for the differential diagnosis between Acute complicated and uncomplicated diverticulitis, our study showed a VPP of 40% and a VPN of 84%.

CONCLUSION

In the emergency setting, faecal calprotectin could be a helpful marker to select patients with abdominal pain who need second-level radiological examinations or endoscopic procedures, guiding the emergency physician in the evaluation of such a complex and wideranging symptom.

Level of Knowledge and Attitude Toward Acute Abdomen Among the Public: A Nationwide Study

Introduction Treatment of patients suffering from acute abdominal pain (AAP) is often challenging due to its wide range of associated illnesses, which could delay or prevent the identification of the correct diagnosis. Multiple diagnoses should be considered, particularly those in life-threatening situations needing urgent intervention. Aim This study aimed to assess the level of knowledge among the general population related to acute abdomen and which specialty should be sought for consultation in AAP situations. Subject and methods This cross-sectional study was conducted among the general population living in Saudi Arabia. A self-administered questionnaire was sent to the Saudi population through the Google survey. The questionnaire included basic demographic characteristics (i.e., age, gender, etc.), perceived causes, barriers, the most common symptoms of AAP, and a five-item questionnaire to assess the general population's knowledge about AAP. Results Of the 2,703 respondents, 68.1% were females, and 42.4% were aged between 18 and 25 years old. The digestive system disorders (esophagus, stomach, intestine, and colon) were the most perceived causes that led to AAP (76.6%). The overall mean knowledge score was 1.35 (SD 1.07) out of five points. Accordingly, nearly all (87.2%) were considered to have poor knowledge, 9.5% were considered to have moderate knowledge, and only 3.3% were considered to have good knowledge. Being younger, being a male, and living in the Central Region were the factors associated with increased knowledge. Conclusion There was a lack of knowledge about AAP among the general population in Saudi Arabia. Younger age, gender males, and living in the Central Region were identified as the significant factors of increased knowledge. It is necessary to increase the knowledge of the population regarding acute abdomen. Media awareness campaigns may play a significant role in providing the necessary information to the general public.

Causal effects of gut microbiota on appendicitis: a two-sample Mendelian randomization study

Background

Previous research has posited a potential correlation between the gut microbiota and the onset of appendicitis; however, the precise causal connection between appendicitis and the gut microbiota remains an unresolved and contentious issue.

Methods

In this investigation, we performed a Mendelian randomization (MR) analysis employing publicly accessible summary data extracted from genome-wide association studies (GWAS) to elucidate the potential causal nexus between the gut microbiota and the development of appendicitis. We initially identified instrumental variables (IVs) through a comprehensive array of screening methodologies, subsequently executing MR analyses using the Inverse Variance Weighted (IVW) technique as our primary approach, supplemented by several alternative methods such as MR Egger, weighted median, simple mode, and weighted mode. Additionally, we implemented a series of sensitivity analysis procedures, encompassing Cochran's Q test, MR-Egger intercept test, Mendelian Randomized Polymorphism Residual and Outlier (MR-PRESSO) test, and a leave-one-out test, to affirm the robustness and validity of our findings.

Results

Our investigation indicates that an elevated prevalence of Deltaproteobacteria, Christensenellaceae, Desulfovibrionaceae, Eubacterium ruminantium group, Lachnospiraceae NK4A136 group, Methanobrevibacter, Desulfovibrionales, and Euryarchaeota is inversely associated with the risk of appendicitis. Conversely, we observed a positive correlation between an increased abundance of Family XIII, Howardella, and Veillonella and the susceptibility to appendicitis. Sensitivity analyses have corroborated the robustness of these findings, and Mendelian randomization analyses provided no indications of reverse causality.

Conclusion

Our Mendelian randomization (MR) analysis has unveiled potential advantageous or detrimental causal associations between the gut microbiota and the occurrence of appendicitis. This study offers novel theoretical and empirical insights into the understanding of appendicitis pathogenesis, along with its implications for preventive and therapeutic strategies.

ACUTE ABDOMEN IN INTENSIVE CARE UNIT: ETIOLOGY, COMORBIDITY AND SEVERITY OF 1,523 PATIENTS

BACKGROUND

Clinical features and outcomes of patients admitted to the intensive care unit due to acute abdomen are important to be investigated.

AIMS

To evaluate the outcomes of critically ill subjects with acute abdomen according to etiology, comorbidity and severity.

METHODS

Outcomes of 1,523 patients (878 women, mean age 66±18 years) consecutively admitted to a specialized gastrointestinal intensive care unit with different causes of acute abdomen from January 2012 to December 2019, were retrospectively evaluated according to etiology, comorbidity and severity.

RESULTS

The most common causes of acute abdomen were obstructive and inflammatory, particularly large bowel obstruction (27%), small bowel obstruction (18%) and acute pancreatitis (17%). Overall mortality was 13%. Surgery was required in 34% of patients. Median length of stay in the hospital was 9 [1-101] days. On univariate analysis mortality was significantly associated with age, APACHE II, Charlson comorbidity index, requirement for surgery and malignancy (p<0.0001), but only APACHE II, Charlson comorbidity index and surgical interventional remained significant on multivariate analysis.

CONCLUSIONS

Critically ill patients admitted to the intensive care unit with acute abdomen constitute a heterogeneous group of subjects with different prognosis. Mortality is more related to the severity of the disease, comorbidity and need for surgery than to the etiology of the acute abdomen.

Stumped by Appendicitis: A Rare Cause of Acute Abdominal Pain

Acute appendicitis is one of the most common diagnoses in the emergency department. As with other surgical procedures, post-appendectomy complications are numerous and can be either immediate or delayed. Stump appendicitis is an underreported and underrecognized complication that is often diagnosed radiologically while ruling out other diagnoses. We report a case of a 26-year-old male presenting with acute right lower quadrant abdominal pain. Although he initially denied any surgical history, a focused abdominal exam revealed an incisional scar which turned out to be the result of an appendectomy nine years ago. The patient was worked up for alternate causes of right lower quadrant pain. Investigations revealed high inflammatory markers and hematuria. We proceeded with a non-contrast CT scan to rule out vesicoureteric junction stone. Instead, the scan was suggestive of stump appendicitis. The patient was admitted and treated conservatively. Maintaining a high index of suspicion for stump appendicitis, especially in patients with a clinical picture typical of appendicitis but a history of appendectomy, is key to making an early diagnosis and avoiding further complications.

Interval appendectomy as a safe and feasible treatment approach after conservative treatment for appendicitis with abscess: a retrospective, single-center cohort study

Emergency appendectomy (EA) is the gold standard management for acute appendicitis (AA). However, whether EA or interval appendectomy (IA) after conservative treatment is the optimal approach in AA with abscess remains controversial. This study compared IA and EA in patients presenting with AA accompanied by abscess. This was a retrospective single-center study including 446 consecutive patients undergoing appendectomy between April 2009 and March 2023. AA with abscess was defined as a pericecal abscess observed by computed tomography or abdominal ultrasonography, and patients with signs of peritoneal irritation were excluded. Perioperative outcomes were compared between the patients who directly underwent EA and those who underwent IA after conservative treatment. Among 42 patients (9.4%) with AA and abscess, 34 and 8 patients underwent IA and EA, respectively. The rates of ileocecal resection and postoperative complications were lower in the IA group than in the EA group (3% vs. 50%, P < 0.001 and 9% vs. 75%, P < 0.001, respectively). Colonoscopy before IA was performed in 16 of the 17 patients aged ≥ 40 years in the IA group, and one patient underwent ileocecal resection because of suspicious neoplasm in the root of the appendix. IA after conservative treatment might be considered as the useful therapeutic option for AA with abscess. Colonoscopy during the waiting period between the initial diagnosis and IA should be considered in patients aged ≥ 40 years who may have malignant changes. Implementing IA as a first-line treatment will be beneficial to both patients and healthcare providers.

Evaluation of Factors Predicting Successful Outcome in Patients Undergoing Expectant Management of Uncomplicated Acute Appendicitis

BACKGROUND

Expectant management, or non-operative management (NOM), with standalone intravenous antibiotic therapy, has emerged as an effective alternative to appendectomy for the treatment of uncomplicated acute appendicitis. Various clinical, biochemical, and radiological factors have been implicated in predicting the success or failure of outcomes. Therefore, it is important to identify patients at the onset who are likely to have successful outcomes for conservative management of uncomplicated acute appendicitis.

METHODS

We prospectively enrolled 85 surgical patients diagnosed with uncomplicated acute appendicitis in our study. On admission, clinical features such as duration of symptoms, pulse rate (PR), history of fever within 24 hours of admission, modified Alvarado score and adult appendicitis score, biochemical parameters such as C-reactive protein (CRP), and hematological parameters such as total leukocyte count (TLC) were recorded. Radiological imaging of patients, namely ultrasonography and contrast-enhanced CT abdomen to evaluate appendix diameter and mural enhancement, was also undertaken. The outcome of expectant management for these patients (success or failure) was recorded, and the above-mentioned factors were evaluated to find a possible correlation with successful expectant management.

RESULTS

We found that among 85 patients, 77.6% had a successful NOM of appendicitis, whereas 22.4% had a failed NOM of appendicitis. The duration of symptoms, pulse rate, fever within 24 hours of admission, TLC, percentage of neutrophils, CRP level, appendix diameter, modified Alvarado score, and adult appendicitis score were found to be statistically significant predictors of successful NOM of appendicitis according to univariate analysis. According to multivariable analysis, pulse rate and appendix diameter value were found to be statistically significant predictors of successful NOM of appendicitis. With each beat per minute (bpm) increase in pulse rate, there was a 0.30% decrease in the probability of a successful NOM of appendicitis. With each mm increase in appendix diameter, there was an 82% decrease in the probability of a successful NOM of appendicitis.

CONCLUSION

From our study, it can be concluded that patients who met the following criteria, i.e., duration of symptoms before presenting to surgical emergency less than two days, presence of fever within 24 hours of presenting to surgical emergency, pulse rate >90 bpm, TLC >12000 cells/dL, CRP >20 mg/L, appendix diameter >10 mm, modified Alvarado score ≥ 9, and adult appendicitis score ≥ 18, have a higher probability of failure of NOM and hence should be excluded from expectant management.

Could it be hereditary angioedema?-Perspectives from different medical specialties

Hereditary angioedema (HAE) is a rare autosomal dominant disease, with patients often suffering with associated symptoms for many years before receiving a correct diagnosis. The symptoms greatly impact a patient's quality of life (QoL) and include excruciating abdominal pain and angioedema of the skin and submucosa. Angioedema of the larynx represents a significant mortality risk in undiagnosed patients, and a large proportion of patients with HAE receive incorrect diagnoses and undergo unnecessary surgery. HAE-specific treatments can control and prevent acute life-threatening episodes, in addition to improving QoL, emphasizing the value of early diagnosis for patients. Diagnostic delay may be due to a lack of HAE awareness by healthcare professionals and the similarity of HAE symptoms with those of more common conditions, complicating differential diagnosis. The multifaceted nature of the condition may result in visits to one of many different medical settings, for example: the Emergency Room, pediatrics, general practice, otolaryngology, gastroenterology, and dermatology. Therefore, it is crucial that physicians in multiple healthcare specialties are aware of the disease to ensure that patients with HAE receive a timely diagnosis. Using patient cases from various medical specialties, this review highlights the necessity for cross-specialty awareness of HAE and outlines the essential information for the various healthcare professionals that may encounter a patient with HAE symptoms, in order to effectively treat and/or diagnose HAE.

A Novel Approach to Assessing and Conservatively Treating Anterior Cutaneous Nerve Entrapment Syndrome: A Case Study

Anterior cutaneous nerve entrapment syndrome (ACNES) is a common source of chronic abdominal pain and is often underdiagnosed despite numerous and potentially invasive diagnostic evaluations and tests. We present a case report describing a novel, conservative, and non-invasive approach to diagnose and treat recurrent ACNES in a young and active patient. We describe a treatment-based diagnostic approach to confirm potential ACNES pain generators while recording pre- and post-treatment pain scores. After each maneuver, the patient was reassessed which allowed the working diagnosis to clinically evolve demonstrating the pathologic interrelationship between different skeletal structures and myofascial tissues contributing to irritation of the anterior cutaneous nerve. This treatment-based technique also made it possible to identify referred pain from a condition with overlapping symptoms originating from a different anatomic site. Treatment consisted of sequenced osteopathic manipulation techniques, active release techniques, instrument-assisted soft tissue mobilization, directional cupping, stretching, and strengthening exercises. The combination of sequenced treatments over the course of six physical therapy visits spanning 10 weeks resulted in 100% pain reduction and complete resolution of functional limitations. The patient was able to complete all work requirements and physical activity without pain. A sequenced treatment-based diagnostic approach to this case allowed us to more accurately identify all involved anatomic regions of pain and anatomic segments of pathology that were contributing to the abdominal pain or referring pain. No diagnostic imaging, invasive test, or injection was needed to properly diagnose and treat this case of ACNES. A proper understanding and application of osteopathic manipulation, active release techniques, instrument-assisted soft tissue mobilization, cupping, and exercises successfully resolved the contributing pain conditions and provided the patient important and useful tools and strategies to prevent recurrence.

The Association of Polish Surgeons (APS) clinical guidelines for the use of laparoscopy in the management of abdominal emergencies. Part II

Introduction

Over the past three decades, almost every type of abdominal surgery has been performed and refined using the laparoscopic technique. Surgeons are applying it for more procedures, which not so long ago were performed only in the classical way. The position of laparoscopic surgery is therefore well established, and in many operations it is currently the recommended and dominant method.

Aim

The aim of the preparation of these guidelines was to concisely summarize the current knowledge on laparoscopy in acute abdominal diseases for the purposes of the continuous training of surgeons and to create a reference for opinions.

Material and methods

The development of these recommendations is based on a review of the available literature from the PubMed, Medline, EMBASE and Cochrane Library databases from 1985 to 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. The recommendations were formulated in a directive form and evaluated by a group of experts using the Delphi method.

Results and conclusions

There are 63 recommendations divided into 12 sections: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia, acute cholecystitis, acute appendicitis, acute mesenteric ischemia, abdominal trauma, bowel obstruction, diverticulitis, laparoscopy in pregnancy, and postoperative complications requiring emergency surgery. Each recommendation was supported by scientific evidence and supplemented with expert comments. The guidelines were created on the initiative of the Videosurgery Chapter of the Association of Polish Surgeons and are recommended by the national consultant in the field of general surgery. The second part of the guidelines covers sections 6 to12 and the following challenges for surgical practice: acute appendicitis, acute mesenteric ischemia, abdominal injuries, bowel obstruction, diverticulitis, laparoscopy in pregnancy and postoperative complications requiring a reoperation.

Early Management of Severe Biliary Infection in the Era of the Tokyo Guidelines

Sepsis of biliary origin is increasing worldwide and has become one of the leading causes of emergency department admissions. The presence of multi-resistant bacteria (MRB) is increasing, and mortality rates may reach 20%. This review focuses on the changes induced by the Tokyo guidelines and new concepts related to the early treatment of severe biliary disease. If cholecystitis or cholangitis is suspected, ultrasound is the imaging test of choice. Appropriate empirical antibiotic treatment should be initiated promptly, and selection should be performed while bearing in mind the severity and risk factors for MRB. In acute cholecystitis, laparoscopic cholecystectomy is the main therapeutic intervention. In patients not suitable for surgery, percutaneous cholecystostomy is a valid alternative for controlling the infection. Treatment of severe acute cholangitis is based on endoscopic or transhepatic bile duct drainage and antibiotic therapy. Endoscopic ultrasound and other new endoscopic techniques have been added to the arsenal as novel alternatives in high-risk patients. However, biliary infections remain serious conditions that can lead to sepsis and death. The introduction of internationally accepted guidelines, based on clinical presentation, laboratory tests, and imaging, provides a framework for their rapid diagnosis and treatment. Prompt assessment of patient severity, timely initiation of antimicrobials, and early control of the source of infection are essential to reduce morbidity and mortality rates.

Performance and diagnostic accuracy of scoring systems in adult patients with suspected appendicitis

BACKGROUND

This study aims to determine the most accurate appendicitis scoring system and optimal cut-off points for each scoring system.

METHODS

This single-centred prospective cohort study was conducted from January-to-June 2021, involving all patients admitted on suspicion of appendicitis. All patients were scored according to the Alvarado score, Appendicitis Inflammatory Response (AIR) score, Raja Isteri Pengiran Anak Saleha (RIPASA) score and Adult Appendicitis score (AAS). The final diagnosis for each patient was recorded. Sensitivity and specificity were calculated for each system. Receiver operating characteristic (ROC) curve was constructed for each scoring system, and the area under the curve (AUC) was calculated. Optimal cut-off scores were calculated using Youden's Index.

RESULTS

A total of 245 patients were recruited with 198 (80.8%) patients underwent surgery. RIPASA score had higher sensitivity and specificity than other scoring systems without being statistically significant (sensitivity 72.7%, specificity 62.3%, optimal score 8.5, AUC 0.724), followed by the AAS (sensitivity 60.2%, specificity 75.4%, optimal score 14, AUC 0.719), AIR score (sensitivity 76.7%, specificity 52.2%, optimal score 5, AUC 0.688) and Alvarado score (sensitivity 69.9%, specificity 62.3%, optimal score 5, AUC 0.681). Multiple logistic regression revealed anorexia (p-value 0.018), right iliac fossa tenderness (p-value 0.005) and guarding (p-value 0.047) as significant clinical factors independently associated with appendicitis.

CONCLUSION

Appendicitis scoring systems have shown moderate sensitivity and specificity in our population. The RIPASA scoring system has shown to be the most sensitive, specific and easy-to-use scoring system in the Malaysian population whereas the AAS is most accurate in excluding low-risk patients.

The Association of Polish Surgeons (APS) clinical guidelines for the use of laparoscopy in the management of abdominal emergencies. Part I

Introduction

Over the past three decades, almost every type of abdominal surgery has been performed and refined using the laparoscopic technique. Surgeons are applying it for more procedures, which not so long ago were performed only in the classical way. The position of laparoscopic surgery is therefore well established, and in many operations it is currently the recommended and dominant method.

Aim

The aim of the preparation of these guidelines was to concisely summarize the current knowledge on laparoscopy in acute abdominal diseases for the purposes of the continuous training of surgeons and to create a reference for opinions.

Material and methods

The development of these recommendations is based on a review of the available literature from the PubMed, Medline, EMBASE and Cochrane Library databases from 1985 to 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. Recommendations were formulated in a directive form and evaluated by a group of experts using the Delphi method.

Results and conclusions

There are 63 recommendations divided into 12 sections: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia, acute cholecystitis, acute appendicitis, acute mesenteric ischemia, abdominal trauma, bowel obstruction, diverticulitis, laparoscopy in pregnancy, and postoperative complications requiring emergency surgery. Each recommendation was supported by scientific evidence and supplemented with expert comments. The guidelines were created on the initiative of the Videosurgery Chapter of the Association of Polish Surgeons and are recommended by the national consultant in the field of general surgery. The first part of the guidelines covers 5 sections and the following challenges for surgical practice: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia and acute cholecystitis. Contraindications for laparoscopy and the ERAS program are discussed.

A brief review of diagnostic properties of point-of-care ultrasound for adult bowel intussusception: Making the case for ultrasound

Undifferentiated abdominal pain in adults is a common chief complaint in acute care clinics and emergency departments worldwide, representing up to 10% of visits to emergency departments. Many patients have a non-specific presentation and an initial workup with labwork, urine analysis or X-ray might not reveal a specific diagnosis. Although bowel intussusception is a primarily pediatric disease, adult intussusception is a recognized but rare cause of bowel obstruction often requiring surgical intervention. However, recent data from advanced multi-detector computed tomography imaging shows that milder or recurring cases in adults have been underrecognized. Multi-detector computed tomography is still the imaging gold standard for detecting intussusception in adults, but new data showed that sonographers with basic training using the point-of-care ultrasound approach have a reasonable accuracy in detecting this pathology. As the point-of-care ultrasound for undifferentiated abdominal pain is an emerging core skill in the acute care setting, knowledge of sonographic signs of intestinal intussusception should be included in the skill set of physicians. Sonographic findings in adults mimic pediatric cases, but different location patterns and higher malignancy rates exist in adults. In this manuscript, we will review the current literature on adult intussusception and summarize key knowledge of intestinal intussusception in adults. We will present four adult patients diagnosed with different types of adult acute bowel intussusception using the point-of-care ultrasound and describe a focused scanning approach with typical sonographic findings.

Is gallbladder PoCUS diagnostic accuracy accessible to medical students after PoCUS training exclusively on healthy volunteers? A pilot randomized control trial

BACKGROUND

Point-of-care ultrasound (PoCUS) is increasingly used in clinical practice and is now included in many undergraduate curricula. Here, we aimed to determine whether medical students who participated in a PoCUS teaching program with several practical training sessions involving healthy volunteers could achieve a good level of diagnostic accuracy in identifying gallbladder pathologies. The intervention group (IG) was trained exclusively on volunteers with a healthy gallbladder, whereas the control group (CG) had access to volunteers with a pathological gallbladder as recommended in most PoCUS curricula.

MATERIALS AND METHODS

Twenty medical students were randomly assigned to the IG and CG. After completing the training program over 2 months, students were evaluated by three independent examiners. Students and examiners were blind to group allocation and study outcome. Sensitivity and specificity of students' PoCUS gallstone diagnosis were assessed. Secondary outcomes were students' confidence, image quality, acquisition time, and PoCUS skills.

RESULTS

Sensitivity and specificity for gallstone diagnosis were, respectively, 0.85 and 0.97 in the IG and 0.80 and 0.83 in the CG. Areas under the curve (AUC) based on the receiver operating characteristic curve analysis were 0.91 and 0.82 in the IG and CG, respectively, with no significant difference (p = 0.271) and an AUC difference of -0.092. No significant between-group difference was found for the secondary outcomes.

CONCLUSIONS

Our pilot study showed that medical students can develop PoCUS diagnostic accuracy after training on healthy volunteers. If these findings are confirmed in a larger sample, this could favor the delivery of large practical teaching sessions without the need to include patients with pathology, thus facilitating PoCUS training for students.

An Occlusive Form of Acute Gangrenous Appendicitis With Periappendicular Abscess in an Elderly Patient: A Case Report and Literature Review

Acute appendicitis represents one of the common causes of admission to the emergency department. In rare cases, patients with appendicitis can suffer complications such as intestinal obstruction. These particular cases of occlusive appendicitis with a periappendicular abscess usually occur in elderly patients and can develop in an aggressive form, nonetheless with a favorable evolution. We present a case of an 80-year-old male patient, reporting symptoms similar to an occlusive digestive pathology: abdominal pain, intestinal transit disorders, and fecal vomiting. A computerized tomography scan suggested a mechanical bowel obstruction. The patient had an exploratory laparotomy indication to find the cause of the obstruction. The peritoneal cavity inspection revealed an occlusive form of acute gangrenous appendicitis with a periappendicular abscess. An appendectomy was performed. In conclusion, as surgeons, we must always take into consideration that acute appendicitis can represent a cause of intestinal obstruction, especially in elderly patients.

Brazilian registry of patients with porphyria: REBRAPPO study

BACKGROUND

Porphyrias are a rare group of disease due to inherited defects of heme synthesis with important systemic manifestations and great burden of disease for patients and families due to the exceptional course of disease with disabling chronic symptoms interposed by life-threatening acute attacks. Unfortunately, the porphyrias are usually underrecognized reflecting a lack of medical and disease awareness as well as few studies about natural history in large cohorts of patients. The main aim of this article is present consistent data about natural history and burden of disease in a large Brazilian cohort.

METHODS

We conducted a national cross-sectional registry with retrospective clinical data of Brazilian patients with porphyria collected with Brazilian patients Association with Porphyria in collaboration with a tertiary care center for rare diseases.

RESULTS

A cohort of 172 patients was analyzed in which 148 (86%) patients had the diagnosis of acute hepatic porphyria [AHP] that needed a mean of 62.04 medical visits and 9.6 years to achieve a definitive diagnosis. About AHP cohort, the most common first clinical manifestation were abdominal pain in 77 (52%) patients and acute muscle weakness in 23 (15.5%) with 73 (49.3%) patients presenting only one attack during disease course and 37 (25%) exhibiting 4 or more attacks in the last year. Of note, 105 patients with AHP reported chronic manifestations and the scores for quality of life are lower when compared with general healthy population.

CONCLUSIONS

Brazilian patients with AHP had a higher prevalence of chronic disabling manifestations and a poor quality of life like other cohorts and a higher proportion of patients with recurrent attacks than previously reported.

[The abdominal pain unit as a treatment pathway : Structured care of patients with atraumatic abdominal pain in the emergency department]

BACKGROUND

Patients with atraumatic abdominal pain are common in the emergency department and have a relatively high hospital mortality, with a very wide spectrum of different causes. Rapid, goal-directed diagnosis is essential in this context.

METHODS

In a Delphi process with representatives of different disciplines, a diagnostic treatment pathway was designed, which is called the Abdominal Pain Unit (APU).

RESULTS

The treatment pathway was designed as an extended event process chain. Crucial decision points were specified using standard operating procedures.

DISCUSSION

The APU treatment pathway establishes a consistent treatment structure for patients with atraumatic abdominal pain. It has the potential to improve the quality of care and reduce intrahospital mortality over the long term.

A Predictive Tool for Choledocholithiasis in Patients Undergoing Emergency Cholecystectomy

Background: Management of acute cholecystitis with emergency laparoscopic cholecystectomy has been established; however, detection and management of concurrent choledocholithiasis are debated. The aim of this study is to develop a more accurate choledocholithiasis predictive model. Materials and Methods: A 9-year audit of emergency cholecystectomies and evaluation of preoperative factors in predictive models. Receiver Operating Curve (ROC) analysis/Youdon Index was used to identify thresholds maximizing these associations for continuous variables. Results: 1601/1828 patients were analyzed. Patients who were diagnosed with choledocholithiasis were more likely to be febrile on admission, have a higher C-reactive Protein, and higher median bilirubin (25.0 μmol/L versus 11.0 μmol/L, P < .001). When excluding bilirubin, multivariate analysis detected several significant variables, including fever, biliary tree dilatation, or a common bile duct stone seen on ultrasound. When bilirubin was included into the model, bilirubin of 20-39 μmol/L (odds ratio [OR] 2.44, 95% confidence interval [CI]: 1.74-3.44) and ≥40 μmol/L (OR 4.84, 95% CI: 3.40-6.91) were shown to have increased likelihood of choledocholithiasis detection on intraoperative cholangiogram, with the ROC model having a significant C-statistic of 0.796 (P < .001). Discussion: A perfect predictive model for concurrent choledocholithiasis in acute cholecystitis does not exist; however, the results from this study are encouraging that high and low predictive groups can be established.

Serum pentraxin-3 in diagnosing acute appendicitis in patients with acute abdominal pain: A systematic review and meta-analysis of diagnostic test accuracy

BACKGROUND

Acute appendicitis is one of many common reasons for acute abdominal pain, and its exact diagnosis is still debatable amongst clinicians. This systematic review and meta-analysis of diagnostic test accuracy aim to look at serum pentraxin-3 performance in diagnosing acute appendicitis in patients with acute abdominal pain.

METHODS

This systematic review is registered on the International Prospective Register of Systematic Reviews (CRD42022338296). The primary outcome of this study is to examine the sensitivity, specificity, and post-test probability of serum pentraxin-3 (the index test) in patients with acute appendicitis. We searched various academic databases such as Pubmed, MEDLINE, Cochrane Library, Science Direct, Google Scholar, ScieLO, MedRxiv, BioRxiv, and Research Square. Two independent authors reviewed, selected the articles, and extracted the data. The analysis was done using STATA software using the "midas" and "metandi" commands.

RESULTS

Five articles fulfilled our inclusion criteria with 520 patients, and 27.5% of them were children. The combined sensitivity is 90.3% (95% confidence interval 78.6-95.9), and the combined specificity is 91.2% (95% confidence interval 22.1-99.7). The area under the curve is 0.94 (95% confidence interval 0.92-0.96). Fagan's Nomogram showed that the positive likelihood ratio is 10.38 (95% confidence interval 0.38-284.76) with an 87% post-test probability, while the negative likelihood ratio is 0.11 (95% confidence interval 0.04-0.27) with a 7% post-test probability. The combined negative predictive value is 0.89 (95% confidence interval 0.81-0.98), and the positive predictive value is 0.90 (95% confidence interval 0.81-0.98).

CONCLUSION

Serum pentraxin-3 could only be used as a confirmation test for acute appendicitis but not exclude it.

Incidence of acute diverticulitis compared to appendicitis in emergency wards: a 10-year nationwide register and cohort study from Finland

BACKGROUND

The two most common abdominal infections in emergency departments (ED) are acute appendicitis (AA) and sigmoid diverticulitis (AD). The frequency of ED visits for diverticulitis has increased strongly in many countries during recent decades. The aim of this study was to analyze the nationwide changes in AD rate requiring hospital admission compared to AA during a 10-year study period.

METHODS

Register data of AD and AA in the whole of Finland were obtained between the years 2009 and 2018. Changes in the incidence and surgical treatment of AD in the whole country were compared to those of AA. Patient demographics and treatment of AD were analyzed in greater detail from a smaller cohort (n = 614).

RESULTS

The incidence of AD increased from 262 to 413 cases (58%) per 100,000 inhabitants during 10 years and emergency surgery for AD decreased from 27 to 24 cases per 100,000 (11%). The incidence of AA remained stable and varied from 118 to 124 annual cases per 100,000 inhabitants. In a patient cohort of AD (n = 614), most of the patients (68%) had only one episode of diverticulitis during 10 years; 16% were operated urgently, with a mortality of 8%. Disease-specific mortality increased from 0% to 5.7% along with patient age when comparing the age groups <50 years and > 70 years, respectively.

CONCLUSIONS

Our study indicates that the incidence of acute diverticulitis is still increasing and is now 2-3 times higher than that of appendicitis in emergency departments.

The impact of the COVID-19 outbreak on emergency general surgery in the first German "hotspot region" Aachen-Heinsberg-A multicentre retrospective cohort study

This study aimed to observe the impact of the COVID-19 outbreak on acute general surgery in the first German "hotspot" regions of Heinsberg and Aachen, during the first months of the pandemic. The incidence and severity of acute appendicitis, acute cholecystitis and mechanical bowel obstruction, were compared between March and May 2020 and a control period (same months of the previous three years). Pre-, intra- and postoperative data was compared between three regional hospitals of Heinsberg and the closest maximum care, university hospital. A total of 592 operated patients were included, 141 belonging to the pandemic cohort and 451 to the historic cohort. The pandemic group showed higher rates of clinical peritonitis (38% vs. 27%, p = 0.015), higher rates of mean white blood cell count (13.2±4.4 /nl vs. 12.3±4.7 /nl, p = 0.044) and mean C-reactive protein (60.3±81.1 mg/l vs. 44.4±72.6 mg/l, p = 0.015) preoperatively. Specifically in patients with acute appendicitis, there were less patients with catarrhal appendicitis (23% vs. 35%, p = 0.021) and a tendency towards more advanced histological findings in the pandemic cohort. In the university hospital, a 42% reduction in acute operated cases was observed at the onset of the pandemic (n = 30 in 2020 vs. n = 52 in 2019), whereas in the peripheral hospitals of Heinsberg there was only a 10% reduction (n = 111 in 2020 vs. n = 123 in 2019). The onset of the COVID-19 pandemic in our region was accompanied by advanced preoperative and intraoperative findings in patients undergoing emergency general surgery. A greater reduction in acute operated surgical cases was observed at the university hospital, in contrast to the smaller hospitals of Heinsberg, suggesting a possible shift of emergency patients, requiring immediate operation, from maximum care hospital to the periphery.

Acupressure versus parecoxib sodium in acute renal colic: A prospective cohort study

Background

Here provides a complementary treatment, acupressure at the Qiu acupoint, a novel acupoint, which potentially alleviates renal colic.

Materials and methods

90 patients were included in this study. Acupressure-group patients (n = 46) were administered acupressure at the Qiu acupoint following a preset protocol. Parecoxib sodium-group patients (n = 44) were administered parecoxib sodium (40 mg) (via the direct intravenous route). The visual analog scale (VAS) was used to evaluate pain intensity at baseline and at 1, 5, 10, 20, 30, and 120 min after initiating the intervention. Linear mixed effects model was performed to detect the rate of decrease of VAS per time and their covariant effect on the efficacy of acupressure.

Results

No significant statistical differences in baseline data and VAS scores were observed. The acupressure group obtained lower VAS scores at the 1st, 5th, 10th, and 20th minute than the parecoxib sodium group after initiating the intervention (mean: 4.33 vs. 7.61, mean difference (MD): 3.29, 95% CI: 0.23, 2.84; mean: 2.65 vs. 7.61, MD: 4.96, 95% CI: 4.44, 5.49; mean: 1.63 vs. 6.59, MD: 4.96, 95% CI: 4.48, 5.44; mean: 1.26 vs. 3.64 MD: 2.38, 95% CI: 1.87, 2.88; P < 0.05). The markedly effective rate was similar between the two groups. The linear mixed effects model demonstrated that acupressure at the Qiu point was significantly faster than parecoxib sodium in decreasing VAS scores with an estimate of -2.05 (95% CI: -2.51, -1.59, p = 0.000), especially within 10 minutes with an estimate of 0.18 (95% CI: 0.12, 0.25, p = 0.000).

Conclusion

Acupressure at the Qiu acupoint is significantly faster than parecoxib sodium in decreasing VAS scores within 10 minutes.

Clinical trial registration

http://www.chictr.org.cn/, identifier 2100047168.

Validity of Machine Learning in Detecting Complicated Appendicitis in a Resource-Limited Setting: Findings from Vietnam

Background

Complicated appendicitis, a potentially life-threatening condition, is common. However, the diagnosis of this condition is mainly based on physician's experiences and advanced diagnostic equipment. This study built and validated machine learning models to facilitate the detection of complicated appendicitis.

Methods

A retrospective cohort study was conducted based on medical charts of all patients undergoing a laparoscopic appendectomy at a city hospital during 2016-2020. The synthetic minority over-sampling technique (SMOTE) was used to adjust for the imbalance. Multiple classification approaches were used to train and validate models including support vector machine (SVM), decision tree (DT), K-nearest neighbor (KNN), logistic regression (LR), artificial neural network (ANN), and gradient boosting (GB).

Results

Among 1,950 patients included in the data analysis, there were 483 patients identified as having complicated appendicitis (24.8%). Based on data without SMOTE adjustment for imbalance, the accuracy levels and AUCs were high in all models using different parameters, ranging from 0.687 to 0.815. After adjusting for imbalance data using SMOTE, AUC and accuracy levels in the models using imbalance adjusted data were higher. Of these, the GB had all AUC and accuracy values of approximately 0.8 or more in both adjusted and unadjusted data.

Conclusions

Machine learning approaches including SVM, DT, logistic, KNN, ANN, and GB have a high level of validity in classifying patients with complicated appendicitis and patients without complicated appendicitis. Among these, GB had the highest level of validity and should be used or further validated. Our study indicates the beneficial potentials of machine learning techniques in a clinical setting in general and in the diagnosis of complicated appendicitis in particular.

Assessment of the Diagnostic Value of Novel Biomarkers in Adult Patients With Acute Appendicitis: A Cross-Sectional Study

Background Acute appendicitis (AA) is one of the most frequent causes of abdominal pain requiring emergency intervention in adults. Approximately one-third of cases present with atypical clinical symptoms. This study aims to compare the monocyte-to-lymphocyte ratio (MLR), red cell distribution width (RDW) to lymphocyte ratio (RLR), and systemic immune inflammation index (SII) with other biomarkers in distinguishing patients with and without AA. Methodology A total of 347 patients (AA 125, nonspecific abdominal pain 90, and control group 132) were enrolled in the study according to the cross-sectional study design. Receiver operating characteristic (ROC) analysis was used to determine the cutoff in diagnostic value measurements. Statistical significance was determined by the statistics of sensitivity, specificity, positive predictive value, and negative predictive value. Comparison of ROC curves of C-reactive protein (CRP), white blood cell (WBC), neutrophil count (NEU), neutrophil-to-lymphocyte ratio (NLR), MLR, and SII was evaluated with the pairwise comparison of ROC curves and 95% confidence interval. Results In detecting AA, CRP, WBC, NEU, NLR, MLR, and SII have excellent diagnostic power (area under the curve [AUC] 0.80-0.88), while RDW, lymphocyte count, monocyte (MON) count, and RLR had acceptable diagnostic power (AUC 0.70-0.77). When the power in the diagnosis of AA was compared, a significant difference was found between CRP and NEU, CRP and SII, WBC and NEU, and WBC and SII. Conclusions The diagnosis of AA remains dependent on many factors. Inflammatory biomarkers assist this process. MLR and SII may be recommended to use in diagnosing AA in adults, along with other clinical findings. RLR is adequate but not superior.

Estimating the potential overdiagnosis and overtreatment of acute appendicitis in Thailand using a secondary data analysis of service utilization before, during and after the COVID-19 lockdown policy

Introduction

Acute appendicitis is one of the most common surgical emergencies; however, optimal diagnosis and treatment of acute appendicitis remains challenging. We used the coronavirus disease 2019 (COVID-19) lockdown policy as a natural experiment to explore potential overdiagnosis and overtreatment of acute appendicitis in Thailand. The aim of this study was to estimate the potential overdiagnosis and overtreatment of acute appendicitis in Thailand by examining service utilization before, during, and after the COVID-19 lockdown policy.

Methods

A secondary data analysis of patients admitted with acute appendicitis under the Universal Coverage Scheme (UCS) in Thailand over a 6-year period between 2016 and 2021 was conducted. The trend of acute appendicitis was plotted using a 14-day rolling average of daily cases. Patient characteristics, clinical management, and outcomes were descriptively presented and compared among three study periods, namely pre-pandemic, lockdown, and post-lockdown.

Results

The number of overall acute appendicitis cases decreased from 25,407 during pre-pandemic to 22,006 during lockdown (13.4% reduction) and 21,245 during post-lockdown (16.4% reduction). This reduction was mostly due to a lower incidence of uncomplicated acute appendicitis, whereas cases of generalized peritonitis were scarcely affected by the pandemic. There was an increasing trend towards the usage of diagnostic computerized tomography for acute appendicitis but no significant difference in treatment modalities and complication rates.

Conclusion

The stable rates of generalized peritonitis and complications during the COVID-19 lockdown, despite fewer admissions overall, suggest that there may have been overdiagnosis and overtreatment of acute appendicitis in Thailand. Policy makers could use these findings to improve clinical practice for acute appendicitis in Thailand and support the efficient utilization of surgical services in the future, especially during pandemics.

Correlation of Severity of Renal Colic With Clinical, Laboratory, and Radiological Parameters: An Emergency Department-Based Prospective Observational Study

Introduction In this study, we investigated the correlation of severity of renal colic with clinical parameters like pain characteristics, haematuria and pyuria, laboratory parameters such as inflammatory markers, and radiological parameters including site and size of stone and hydronephrosis. Methods The Visual Analogue Scale (VAS) determined the pain severity. Detailed history and clinicodemographic profiling of the patient was done, laboratory investigations were done, ultrasound and non-contrast computed tomography of kidney-ureter-bladder were done and all the parameters were duly noted and correlated with the pain severity. Result The mean age of the 183 patients was 43.96 ± 15.16 years, and 62.8% were male. The patients' mean VAS score at presentation was 8.57 ± 1.08. The mean VAS score was found to be statistically higher in patients having a first episode of renal colic, solitary kidney, pyuria, raised creatinine, severe hydronephrosis, and stones located at the renal pelvis. In addition, higher VAS scores led to more surgical interventions. Conclusion The correlation of pain severity of renal colic with various parameters can aid in the development of quick diagnostic and therapeutic protocols for patients presenting to the emergency department with renal stone disease. This study shows that pain scores can correlate with various parameters and predict the outcome and complications in these patients.

Ambulatory Laparoscopic Appendectomy: Does the Conventional Approach Need a Reappraisal?

A Deucalione, acute abdomen remains significant in abdominal pain. The entity of acute abdomen accounts for up to 10% of all emergency admissions. The differences between countries' income and level of prosperity are pertinent, particularly in terms of severity, radiological modalities, and surgical management of the condition. Of note, surgical modalities have been the most widely used treatment modality, and current evidence indicates that the laparoscopic approach, per se, is the most effective surgical therapy with a lower incidence of wound infection, post-intervention morbidity, shorter hospital stay, and better quality of life scores compared to the conventional method. In light of this, the present study aimed to evaluate ambulatory appendectomy in a series of sequential laparoscopic appendectomies (LApp), which included both complicated and uncomplicated cases.

Administrative codes may have limited utility in diagnosing biliary colic in emergency department visits: A validation study

Backgrounds/Aims

Biliary colic is a common cause of emergency department (ED) visits; however, the natural history of the disease and thus the indications for urgent or scheduled surgery remain unclear. Limitations of previous attempts to elucidate this natural history at a population level are based on the reliance on the identification of biliary colic via administrative codes in isolation. The purpose of our study was to validate the use of International Statistical Classification of Diseases and Related Health Problems codes, 10th Revision, Canadian modification (ICD-10-CA) from ED visits in adequately differentiating patients with biliary colic from those with other biliary diagnoses such as cholecystitis or common bile duct stones.

Methods

We performed a retrospective validation study using administrative data from two large academic hospitals in Toronto. We assessed all the patients presenting to the ED between January 1, 2012 and December 31, 2018, assigned ICD-10-CA codes in keeping with uncomplicated biliary colic. The codes were compared to the individually abstracted charts to assess diagnostic agreement.

Results

Among the 991 patient charts abstracted, 26.5% were misclassified, corresponding to a positive predictive value of 73% (95% confidence interval 73%–74%). The most frequent reasons for inaccurate diagnoses were a lack of gallstones (49.8%) and acute cholecystitis (27.8%).

Conclusions

Our findings suggest that the use of ICD-10 codes as the sole means of identifying biliary colic to the exclusion of other biliary pathologies is prone to moderate inaccuracy. Previous investigations of biliary colic utilizing administrative codes for diagnosis may therefore be prone to unforeseen bias.

Acute Portal Vein Thrombosis Secondary to COVID-19 Vaccination

Portal vein thrombosis (PVT) is a partial or complete occlusion of the hepatic portal vein most frequently seen in patients with cirrhotic liver disease. Various non-cirrhotic conditions including inherited prothrombic blood disorders, neoplasms, and inflammatory diseases create hypercoagulable states that predispose individuals to blood clotting. Rarely does an exhaustive workup leave the etiology of a PVT unknown or unclear, and even more uncommon is a potential new etiology suspected. Our patient is a 34-year-old female, with no significant risk factors for pathologic clotting, who was diagnosed with an acute PVT several days after receiving the Moderna coronavirus disease 2019 (COVID-19) vaccine.