Ignoring non-specific abdominal pain in emergency department patients may be related to decreased quality of life. A follow up of an underestimated problem

Patients suffering from chronic pain have a high prevalence of depression, resulting in a significant impact on overall quality of life. Our aim was to investigate how long term acute non-specific abdominal pain (NSAP) affected overall physical and mental well-being in patients admitted to our emergency department (ED).

[Abdominal pain - differential diagnoses and diagnostic strategies in patients with chronic symptoms]

Abdominal pain is a very common complaint in a primary care consultation. The causes of abdominal pain are extremely diverse and range from conditions that require urgent surgical remedy to those without serious underlying pathology where the problem either settles spontaneously, or becomes chronic without any abnormalities on laboratory or clinical workup. While tests are helpful in confirming diagnoses, clinical judgement based on a careful history and physical examination remains extremely important in choosing from the extremely wide differential diagnoses and in the management of the condition. In this article, we will deal with chronically recurrent intermittent abdominal pain. Our aim is especially to provide guidance on the possibility that abdominal pain is a symptom of chronic inflammatory bowel disease (IBD) or an identifiable functional condition and when the diagnosis of irritable bowel syndrome should be made.

[Functional abdominal pain]

Functional abdominal pain is an inhomogeneous group of disorders concerning aetiology and clinical presentation. Support for classification is provided by the ROME-Foundation with its criteria catalogue, ROME-III being the most recent one. However, basic approach consists of exclusion of somatic or psychiatric as well as psychosomatic disorders that are sharply defined and readily diagnosable. This article outlines a pragmatic gastroenterological approach by exemplary means of dyspepsia and irritable bowel syndrome. Dyspepsia includes a broad complex of mainly epigastric located symptoms, whereas irritable bowel syndrome is symptomatic with altered bowel habits and mid-abdominal pain in the majority. Gastreoenterologic therapy modalities are mainly based on empirical and symptomatic grounds, more than on precisely explaining pathophysioligic understanding.

[Adhesions and abdominal pain]

Adhesions occur with a high incidence after intra-abdominal surgery but can also develop due to infections, radiation or for idiopathic reasons. The formation of adhesions is initiated by tissue damage and is the result of peritoneal tissue repair involving the activation of the inflammatory system and the coagulation cascade. Acute small bowel obstruction is one of the most common complications and should be diagnosed rapidly using clinical examination and radiological imaging. A complete obstruction is life threatening and in a high percentage of patients requires rapid surgical intervention by laparotomy or laparoscopy depending on the clinical situation and the patients history. Despite numerous investigations, there is no reliable, commonly used method to prevent intra-abdominal adhesions. Minimizing tissue damage and foreign body exposure, avoiding spillage of intestinal and biliary contents as well as a laparoscopic approach seem to have a beneficial effect on the formation of intra-abdominal adhesions.

Decision making in patients with acute abdominal pain at a university and at a rural hospital: Does the value of abdominal sonography differ?

Introduction and objectives Abdominal sonography is regarded as a quick and effective diagnostic tool for acute abdominal pain in emergency medicine. However, final diagnosis is usually based on a combination of various clinical examinations and radiography. The role of sonography in the decision making process at a hospital with advanced imaging capabilities versus a hospital with limited imaging capabilities but more experienced clinicians is unclear. The aim of this pilot study was to assess the relative importance of sonography and its influence on the clinical management of acute abdominal pain, at two Swiss hospitals, a university hospital (UH) and a rural hospital (RH). Methods 161 patients were prospectively examined clinically. Blood tests and sonography were performed in all patients. Patients younger than 18 years and patients with trauma were excluded. In both hospitals, the diagnosis before and after ultrasonography was registered in a protocol. Certainty of the diagnosis was expressed on a scale from 0% to 100%. The decision processes used to manage patients before and after they underwent sonography were compared. The diagnosis at discharge was compared to the diagnosis 2 – 6 weeks thereafter. Results Sensitivity, specificity and accuracy of sonography were high: 94%, 88% and 91%, respectively. At the UH, management after sonography changed in only 14% of cases, compared to 27% at the RH. Additional tests were more frequently added at the UH (30%) than at the RH (18%), but had no influence on the decision making process-whether to operate or not. At the UH, the diagnosis was missed in one (1%) patient, but in three (5%) patients at the RH. No significant difference was found between the two hospitals in frequency of management changes due to sonography or in the correctness of the diagnosis. Conclusion Knowing that sonography has high sensitivity, specificity and accuracy in the diagnosis of acute abdominal pain, one would assume it would be an important diagnostic tool, particularly at the RH, where tests/imaging studies are rare. However, our pilot study indicates that sonography provides important diagnostic information in only a minority of patients with acute abdominal pain. Sonography was more important at the rural hospital than at the university hospital. Further costly examinations are generally ordered for verification, but these additional tests change the final treatment plan in very few patients.

Arterial Hypertension Refractory to Renal Denervation, Abdominal Pain and Claudication: Any Coral’ations?

Coral reef aorta is a rare form of calcifying atherosclerosis typically involving the supra and juxtarenal aorta. P atients classically present with refractory hypertension, intermittent claudication and abdominal angina. The treatment is either surgical via transaortic endarterectomy or through transferal endovascular stentgraft placement. Here we describe the case of a 45yearold female patient infected with human immuno deficiency virus, with resistant hypertension, lower limb and abdominal claudication, who was successfully treated with endovascular stent placement. We f urther provide a brief overview of the disease characteristics and treatment options.

Acute Cytomegalovirus Hepatitis in an Immunocompetent Host as a Reason for Upper Right Abdominal Pain

Cytomegalovirus infections are widely distributed with a seroprevalence of up to 100%. The majority of the cases take a silent course or deal with unspecific clinical symptoms. Complications in immunocompetent patients are rare but may affect the liver and lead up to an acute organ failure. In this case report, we describe a 35-year-old immunocompetent female with an acute cytomegalovirus infection presenting as acute hepatitis with ongoing upper right abdominal pain after cholecystectomy. Upper right abdominal pain is a common symptom with a wide range of differential diagnoses. If common reasons can be excluded, we want to sensitize for cytomegalovirus infection as a minor differential diagnosis even in immunocompetent patients.

Why do children have chronic abdominal pain, and what happens to them when they grow up? Population based cohort study

Objective: To test the hypotheses that children with abdominal pain have anxious parents and come from families with high rates of physical illness and that they grow up to suffer from high rates of medically unexplained symptoms and psychiatric disorders.

Unusual case of abdominal pain following liver transplant: causality or casualty?

This is an unusual case of chronic abdominal pain following two liver transplants with at least three potential causes: traumatic neuroma, intussusception of the small bowel of the Roux loop and biliary cast. Surgical removal of the latter two factors led to resolution of the pain. The management of the clinical case is discussed.

A Randomized Double-Blind Placebo-Controlled Trial of Lactobacillus reuteri for Chronic Functional Abdominal Pain in Children

Background: Functional abdominal pain (FAP) is one of the most common diseases, and large percentages of children suffer from it. Objectives: The purpose of the study was to evaluate the effect of Lactobacillus reuteri in treatment of children with functional abdominal pain. Patients and Methods: This study was a randomized double-blind placebo-controlled trial. Children aged 4 to 16 years with chronic functional abdominal pain (based on Rome III criteria) were enrolled in the study. They were randomly divided into two groups, one receiving probiotic and the other placebo. Results: Forty children received probiotic and forty others placebo. There were no significant differences in age, weight, sex, location of pain, associated symptoms, frequency and intensity of pain between the groups. The severity and frequency of abdominal pain in the first month compared to baseline was significantly less and at the end of the second month, there was no significant difference between both groups compared to the end of the first month. Conclusions: This study showed that the severity of pain was significantly reduced in both groups. There was no significant difference in pain scores between them. The effect of probiotic and placebo can probably be attributed to psychological effect of the drugs.

‘Care in a chair’ – The impact of an overcrowded emergency department on the time to treatment and length of stay of self-presenting patients with abdominal pain

Objectives The aim in this study was to investigate the impact of overcrowding on the Australasian Triage Score’s (ATS) time to treatment target and the National Emergency Access Target (NEAT) for patients who self-present to the Emergency Department (ED) with abdominal pain. Background The causes and effects of ED overcrowding have been well described in the literature. It is a widespread phenomenon throughout the world and it can cause serious harm to patients and have a negative impact on access to emergency care. There is however, little research investigating the effect of overcrowding when patients self-present to the ED and experience a delay in being allocated a cubicle. Methods A retrospective analysis of 12-months of computerised records was carried out in order to determine if self-presenting patients with abdominal pain allocated a category 3 triage score who were required to ‘queue’ for a cubicle would meet ATS target and NEAT requirements. A multiple regression analysis was used to determine whether or not queuing for an ED cubicle, age and gender were predictors of meeting the ATS guidelines and NEAT requirements. Results Three hundred and five patients met the inclusion criteria and were included in the study. Of these 149 patients waited more than 15 min to be allocated a cubicle while 156 did not experience any delay. A multiple regression analysis revealed that gender and age were not predictive of meeting the ATS target and NEAT requirements, while delay in allocation to a cubicle was a significant predictor of not being assessed within 30 min and discharged within 4 h. Furthermore, 61.2% of patients allocated to the waiting room queue for any amount of time were admitted to the ward. Conclusion Queuing in the waiting room for an ED bed was a significant predictor of whether or not category three patients with abdominal pain had treatment commenced within 30 min of presentation and was associated with a longer total ED length of stay.

Abdominal epilepsy as an unusual cause ofabdominal pain: a case report.

Introduction: Abdominal pain, in etiology sometimes difficult to be defined, is a frequent complaint in childhood. Abdominal epilepsy is a rare cause of abdominal pain. Objectives: In this article, we report on 5 year old girl patient with abdominal epilepsy. Methods: Some investigations (stool investigation, routine blood tests, ultrasonography (USG), electrocardiogram (ECHO) and electrocardiograpy (ECG), holter for 24hr.) were done to understand the origin of these complaints; but no abnormalities were found. Finally an EEG was done during an episode of abdominal pain and it was shown that there were generalized spikes especially precipitated by hyperventilation. The patient did well on valproic acid therapy and EEG was normal 1 month after beginning of the treatment. Discussion: The cause of chronic recurrent paroxymal abdominal pain is difficult for the clinicians to diagnose in childhood. A lot of disease may lead to paroxysmal gastrointestinal symptoms like familial mediterranean fever and porfiria. Abdominal epilepsy is one of the rare but easily treatable cause of abdominal pain. Conclusion: In conclusion, abdominal epilepsy should be suspected in children with recurrent abdominal pain.