Mettler , Bruce R.
Gynecologic ultrasound in emergency medicine. The abdominal plain film. What will be its role in the future? Stephen R Baker. Clinical policy: Critical issues in the evaluation and management of emergency department patients with suspected appendicitis. John M. Lipson , Ralph Marcus. Abdominal angina. Intensivist use of hand-carried ultrasonography to measure IVC collapsibility in estimating intravascular volume status: correlations with CVP.
Appendicitis is supposed to start with dull periumbilical pain that migrates with time to the right lower quadrant. Ovarian torsion is supposed to start with sudden, unilateral, lower abdominal pain that waxes and wanes and is associated with vomiting. Unfortunately, most diseases fail to present classically.
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The clinician simply has to consider serious diagnoses in patients at risk. Pain in various quadrants suggests varying diagnoses. Acute diverticulitis usually lives in the left lower quadrant while cholecystitis is usually felt in the epigastrium or right upper quadrant. Diagnosing a patient with a full-blown acute abdomen is easy.
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The past medical history can be important. Hypertension is a risk factor for abdominal aortic aneurysm. The physical exam should be focused and completed in a timely fashion. Abnormal vital signs or the general appearance of the patient including facial expression, skin color and temperature, and altered mentation should alert the clinician that a patient may be in extremis.
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A complete abdominal exam is essential. Bowel sounds must be assessed. Palpation for masses, pain, guarding and rebound is important. Classic teaching demands a rectal on every patient with abdominal pain. Literature suggests that rectal exam, at least in appendicitis, does not add any useful information. Certainly, a rectal exam is important when gastrointestinal GI bleeding or prostate issues are suspected. A pelvic exam should be performed when a gynecologic source of pain is suspected.
A young male with abdominal pain needs a testicular exam to exclude testicular torsion. Examination for hernias should be routine. Again, rapid initial diagnosis and treatment of the acute abdomen are crucial. Evaluation and treatment should be simultaneous. Diagnostic interventions include blood work and imaging. In adults older than 40, a 12 lead ECG can help exclude myocardial infarction as the cause of apparent severe abdominal pain. It is important to know if a patient with mesenteric ischemia is in atrial fibrillation. Usually, a complete blood count CBC , comprehensive metabolic profile and lipase are obtained.
For sepsis or mesenteric ischemia, a lactate should be ordered. A urine or serum pregnancy test is needed in the workup of ectopic pregnancy. Diagnostic imaging has advanced rapidly in the past three decades. Diagnostic ultrasound is the preferred modality for cholecystitis, pediatric appendicitis, ruptured ectopic, and ovarian torsion. Multislice helical CT scanning has made the diagnosis of an acute abdomen much more straightforward. In the majority of cases, intravenous IV contrast is sufficient. Oral contrast is time-consuming and not usually necessary. Hypotension and tachycardia suggest blood loss, hypovolemia, or sepsis and require prompt aggressive fluid resuscitation with adequate large bore IV access.
Broad-spectrum antibiotics covering gram-negative enteric organisms should be administered in a timely fashion when infection, peritoneal soilage, or sepsis is in the differential. Sick patients should be monitored with ongoing vital sign resuscitation. Adequate pain relief with opioids is a standard of care. The use of anti-emetics is likewise important. If a surgical emergency is suspected based on presentation or physical findings, a surgeon should be consulted in an emergent fashion.
The utility of acoustic radiation force impulse imaging in diagnosing acute appendicitis and staging its severity. References Publications referenced by this paper.
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Primary epiploic appendagitis: clini- J. RiouxM , P Langis. US of acute GI tract conditions. Puylaert JBCM. Spontaneously resolving appendicitis: frequency and natural history in 60 patients. Lodewijk P. The costs of CT procedures in an academic radiology department determined by an activity-based costing ABC method.
Harvey L Nisenbaum , Bernard A. Infarction of omentum and epiploic appendage: Diagnosis, epidemiology and natural history A. Breda Vriesman , P. Lohle , E.