Abdominal pain among children re-evaluation of a diagnostic algorithm

STUDY IN PAEDIATRIC AGE GROUP UNDERGOING EMERGENCY LAPAROTOMY : OBSERVATIONAL STUDY

INTRODUCTION: Acute abdomen can be defined as “syndrome included by wide variety of pathological conditions that require emergent medical or more often surgical management.” Acute abdomen is caused due to gastrointestinal diseases such as intestinal obstruction and perforation peritonitis. AIM: The aim of our study was to observe the common cause in paediatric age group undergoing emergency laprotomy in our institutions. MATERIAL AND METHODS:This prospective study included 77children aged below or equal to 15years, underwent emergency laprotomy for acute intestinal conditions between January 2019 to December 2019 in RIMS,RANCHI. We excluded neonates ,patients of jejunoileal colonic atresia and stenosis, anorectal malformation(ARM), congenital pouch colon, neonatal necrotizing enterocolitis(NEC), hirschprung’s disease, gastrointestinal tumor. RESULTS: Total of 77 laprotomies were performed in emergency in children below or equal to 15 years age,59(76.62% ) were boys and 18(23.37% )were girls with male:female ratio of 3.2:1. 36(46.75%) cases were done for acute intestinal obstruction and 41(53.24%) cases were done for perforation peritonitis.20(25.97%)emergency laprotomy was performed in the age group 1-5 years and 57(74.02% ) were performed in the age group 5-15 years. Causes in order of frequency for intestinal obstruction were intussusceptions, post operative band/adhesion, abdominal tb obstruction, meckel’s diverticulum and worm obstruction. Causes in order of frequency for perforation peritonitis were typhoid, abdominal tb, appendicular perforation and abdominal trauma. CONCLUSION: In our study maximum emergency laprotomy was performed in male patients with male:female ratio of 3.2:1. Perforation peritonitis was more common than acute intestinal obstruction. 5-15 year age group were more commonly affected. Typhoid ileal perforation was the most common cause for emergency laprotomy followed by intussusception.

Approach to Acute Abdominal Pain: Practical Algorithms

Context:

Acute abdominal pain is one of the most common complaints of patients admitted to emergency units. This study aimed to propose a new approach to abdominal pain by designing a more structured diagnostic workup for physicians.

Evidence acquisition:

A comprehensive review of relevant articles and algorithms presented in books and websites was conducted. Approaches which were relevant to the study concept, were selected.

Results:

Seven algorithms were introduced with respect to the site of abdominal tenderness. The mainstay of these algorithms was differential diagnosis of the tenderness site.

Conclusion:

Based on the findings, the designed approach can prevent confusion among physicians and reduce requests for many unnecessary paraclinical tests, which delay the final diagnosis and impose unacceptable costs on patients and healthcare systems.

Accuracy of the new radiographic sign of fecal loading in the cecum for differential diagnosis of acute appendicitis in comparison with other inflammatory diseases of right abdomen: a prospective study

RATIONALE

To assess the importance of the new radiographic sign of faecal loading in the cecum for the diagnosis of acute appendicitis, in comparison with other inflammatory diseases, and to verify the maintenance of this radiographic sign after surgical treatment of appendicitis.

METHODS

470 consecutive patients admitted to the hospital due to acute abdomen were prospectively studied: Group 1 [n=170]--diagnosed with acute appendicitis, subdivided into: Subgroup 1A--[n=100]--submitted to an abdominal radiographic study before surgical treatment, Subgroup 1B--[n=70]--patients who had plain abdominal X-rays done before the surgical procedure and also the following day; Group 2 [n=100]--right nephrolithiasis; Group 3 [n=100]--right acute inflammatory pelvic disease; Group 4 [n=100]--acute cholecystitis. The patients of Groups 2,3 and 4 were submitted to abdominal radiography during the pain episode.

RESULTS

The sign of faecal loading in the cecum, characterized by hypo transparency interspersed with multiple small foci of hyper transparent images, was present in 97 patients of Subgroup 1A, in 68 patients of Subgroup 1B, in 19 patients of Group 2, in 12 patients of Group 3 and in 13 patients of Group 4. During the postoperative period the radiographic sign disappeared in 66 of the 68 cases that had presented with the sign. The sensitivity of the radiographic sign for acute appendicitis was 97.05% and its specificity was 85.33%. The positive predictive value for acute appendicitis was 78.94% and its negative predictive value was 98. 08%.

DISCUSSION

The radiographic image of faecal loading in the cecum is associated with acute appendicitis and disappears after appendectomy. This sign is uncommon in other acute inflammatory diseases of the right side of the abdomen.

Importance of the new radiographic sign of fecal loading in the cecum in the presence of acute appendicitis in comparison with other inflammatory diseases of the right abdomen

BACKGROUND

The value of plain abdominal radiography in acute appendicitis has not been completely studied. Therefore, the purpose of this investigation was to verify a new radiographic sign: the presence of fecal loading in the cecum for the diagnosis of acute appendicitis in comparison with other diseases of the right abdomen.

METHODS

A total of 470 consecutive patients of both sexes admitted to the hospital due to acute abdominal pain were prospectively studied. Group 1 (n=170), the acute appendicitis group, included patients subjected to an abdominal radiographic study a few hours before surgical treatment; group 2 (n=100) had right nephrolithiasis; group 3 (n=100) had right acute inflammatory pelvic disease; and group 4 (n=100) had acute cholecystitis.

RESULTS

The sign of fecal loading in the cecum was present in 165 patients in group 1, in 19% of those in group 2, in 12% of those in group 3, and in 13% in group 4. The sensitivity of the radiographic sign for acute appendicitis was 97.05% and its specificity was 85.33%. The positive predictive value of this sign for acute appendicitis was 78.94% and its negative predictive value was 98.08%. This sign disappeared in 66 (94.28%) of the 70 patients who had plain abdominal radiographs on the first postoperative day.

CONCLUSIONS

The radiographic image of fecal loading in the cecum is associated with acute appendicitis and disappears after appendectomy. This sign is uncommon in other acute inflammatory diseases of the right side of the abdomen.

Diagnostic pitfalls and accuracy of diagnosis in acute abdominal pain

OBJECTIVE

To identify the differential diagnostic difficulties in acute abdominal pain at the emergency department and during hospitalization.

MATERIAL AND METHODS

Patients with abdominal pain lasting for up to 7 days were registered during 1997-2000 and re-evaluated one year after discharge (n=2851).

RESULTS

Diagnoses with low sensitivity at the emergency department but markedly increased sensitivity at discharge were non-specific abdominal pain with a sensitivity value at the emergency department of 0.43, appendicitis 0.80, gallstones 0.68, constipation 0.74 and peptic ulcer 0.26. Corresponding kappa-values were 0.48, 0.74, 0.84, 0.88 and 0.93, respectively. Malignancy, gynaecological complaints, dyspepsia, urinary tract infection and diverticulitis displayed fairly good concordance between the preliminary and discharge judgements, but the predictive diagnostic value was still low at discharge. Sensitivity values at discharge were 0.40, 0.75, 0.73, 0.77 and 0.83, respectively. Among 479 surgically treated patients, 104 initially received a diagnosis usually not requiring surgery and had a median delay until operation of 22 h (95% CI 30-50 h), compared with 8 h (12-18 h) for referrals.

CONCLUSIONS

Non-specific abdominal pain is the main differential diagnostic problem in the emergency department also for diagnoses requiring surgery. Constipation is a diagnostic pitfall and when making this diagnosis a careful re-evaluation is necessary.

Nova imagem radiográfica de apendicite aguda: acúmulo fecal no ceco

OBJETIVO: Apesar das características radiográficas da apendicite aguda estarem bem documentadas, o valor da radiografia simples de abdome ainda não foi completamente estudado. Nesse sentido, o objetivo do presente trabalho foi verificar um novo sinal radiográfico caracterizado pela imagem de acúmulo fecal no ceco. MÉTODO: Foram estudados prospectivamente 170 pacientes consecutivos, de ambos os sexos, internados com abdome agudo e dor localizada no flanco direito, distribuídos em dois grupos: Grupo 1 (n = 100) - portadores de apendicite aguda, submetidos a um estudo radiográfico do abdome antes do tratamento cirúrgico, Grupo 2 (n = 70) - submetidos a dois estudos radiográficos do abdome:antes da operação e outro no dia seguinte à cirurgia. Todas as radiografias foram simples, em incidência ântero-posterior. RESULTADOS: A presença do sinal de acúmulo fecal no ceco esteve presente em 97 (97%) pacientes do Grupo 1 e em 68 (97,14%) pacientes do Grupo 2. No pós-operatório, dos 68 pacientes que apresentaram o sinal radiográfico, esse desapareceu em 66 casos. A sensibilidade do sinal radiográfico para apendicite aguda foi de 97,05 %. CONCLUSÕES: A imagem radiográfica de acúmulo fecal no ceco associa-se a apendicite aguda. Essa imagem geralmente desaparece após o apêndice cecal ser removido.