Diagnostic Tests for Chronic appendicitis
Chronic appendicitis Tests: Book Excerpts
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Chronic appendicitis Diagnosis: Book Excerpts
Diagnostic Tests for Chronic appendicitis: Online Medical Books
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ABDOMINAL PAIN, CHRONIC RECURRENT:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Routine laboratory tests include a CBC, sedimentation rate, urinalysis, urine culture, sensitivity, colony count, chemistry panel, serum amylase and lipase, pregnancy test, stool for occult blood, and stools for ovum and parasites. A chest x-ray, EKG, and flat plate of the abdomen should also be done. A urine porphobilinogen will help exclude porphyria.
If these tests are negative, then an upper gastrointestinal (GI) series, esophagogram, and gallbladder ultrasound would be done for upper abdominal pain; an IVP would be done for flank pain; and a barium enema and sigmoidoscopy would be performed for lower abdominal pain.
If these studies are inconclusive, a gastroenterologist should be consulted for endoscopic procedures. If there is upper abdominal pain, esophagoscopy, gastroscopy, and duodenoscopy would be performed. Endoscopic retrograde cholangiopancreatography (ERCP) may be required to diagnose cholangitis or common duct stones. If there is lower abdominal pain, colonoscopy would be performed. A CT scan of the abdomen and pelvis is a useful diagnostic tool also. Gallium scans may detect a diverticular abscess or other localized area of chronic inflammation. Pelvic ultrasound may be useful in lower abdominal pain, especially in females. Aortography and angiography will be useful in abdominal angina. Lymphangiography can be helpful in discovering retroperitoneal tumors. Ultimately, exploratory laparotomy may still be necessary in some cases.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
ABDOMINAL PAIN, ACUTE:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
It is wise to consult a general surgeon at the outset. All patients with acute abdominal pain should have a stat, flat, and upright plate of the abdomen, a chest x-ray to rule out pneumonia, an electrocardiogram (EKG) to rule out myocardial infarction, and a complete blood count (CBC), urinalysis, amylase, and chemistry panel. Sometimes lateral decubitus films of the abdomen are necessary to show the step ladder pattern of intestinal obstruction. A pregnancy test is ordered when age and sex dictate it!
When these tests fail to confirm the clinical diagnosis, x-ray contrast studies or ultrasound may be necessary. For example, an intravenous pyelogram (IVP) can be done for a suspected renal calculus. Serial cardiac enzymes may confirm a myocardial infarction. Gallbladder ultrasound can be done to confirm cholecystitis and cholelithiasis. A nuclear scan of the gallbladder with iminodiacetic acid derivatives is very accurate in detecting acute cholecystitis. Ultrasonography may also help diagnose impending rupture of an abdominal aneurysm or ectopic pregnancy. A peritoneal tap may diagnose a ruptured ectopic pregnancy. Laparoscopy should also be considered. A urine porphobilinogen helps exclude porphyria. A double enema may help diagnose intestinal obstruction. A computed tomography (CT) scan of the abdomen is the next logical step.
If the diagnosis remains in doubt, an exploratory laparotomy must be done before the patient's condition deteriorates. The only case where this might be risky is acute pancreatitis. If this is suspected and the serum amylase is repeatedly normal, a quantitative urine amylase or peritoneal tap may confirm the diagnosis. Endoscopy may need to be done to diagnose a peptic ulcer, gastritis, gastric tumor, or reflux esophagitis. In obscure cases of appendicitis and diverticulitis, a contrast barium enema may help confirm the diagnosis. Angiography can diagnose an aneurysm or mesenteric infarction.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Abdominal pain:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient has no life-threatening signs or symptoms, take his history. Ask him if he has had this type of pain before. Have him describe the pain — for example dull, sharp, stabbing, or burning. Ask if anything relieves the pain or makes it worse. Ask the patient if the pain is constant or intermittent and when the pain began. Constant, steady abdominal pain suggests organ perforation, ischemia, or inflammation or blood in the peritoneal cavity. Intermittent, cramping abdominal pain suggests that the patient may have obstruction of a hollow organ.
If pain is intermittent, find out the duration of a typical episode. In addition, ask the patient where the pain is located and if it radiates to other areas.
Find out if movement, coughing, exertion, vomiting, eating, elimination, or walking worsens or relieves the pain. The patient may report abdominal pain as indigestion or gas pain, so have him describe it in detail.
Ask the patient about substance abuse and any history of vascular, GI, GU, or reproductive disorders. Ask the female patient about the date of her last period, changes in her menstrual pattern, or dyspareunia.
Ask the patient about appetite changes. Ask about the onset and frequency of nausea or vomiting. Find out about increased flatulence, constipation, diarrhea, and changes in stool consistency. When was the last bowel movement? Ask about urinary frequency, urgency, or pain. Is the urine cloudy or pink?
Perform a physical examination. Take the patient’s vital signs, and assess skin turgor and mucous membranes. Inspect his abdomen for distention or visible peristaltic waves and, if indicated, measure his abdominal girth.
Auscultate for bowel sounds and characterize their motility. Percuss all quadrants, noting the percussion sounds. Palpate the entire abdomen for masses, rigidity, and tenderness. Check for costovertebral angle (CVA) tenderness, abdominal tenderness with guarding, and rebound tenderness. (See Abdominal pain: Common causes and associated findings, pages 14 to 17.)
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Abdominal pain:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient has no life-threatening signs or symptoms, take his history. Ask him if he has had this type of pain before. Have him describe the pain—for example, is it dull, sharp, stabbing, or burning? Ask if anything relieves the pain or makes it worse. Ask the patient if the pain is constant or intermittent and when the pain began. Constant, steady abdominal pain suggests organ perforation, ischemia, or inflammation or blood in the peritoneal cavity. Intermittent, cramping abdominal pain suggests the patient may have an obstruction of a hollow organ.
If pain is intermittent, find out the duration of a typical episode. In addition, ask the patient where the pain is located and if it radiates to other areas.
Find out if movement, coughing, exertion, vomiting, eating, elimination, or walking worsens or relieves the pain. The patient may report abdominal pain as indigestion or gas pain, so have him describe it in detail.
Ask the patient about substance abuse and any history of vascular, GI, GU, or reproductive disorders. Ask the female patient the date of her last menses and if she has had changes in her menstrual pattern or dyspareunia.
Also ask about appetite changes and the onset and frequency of nausea or vomiting. Find out about increased flatulence, constipation, diarrhea, and changes in stool consistency. When was his last bowel movement? Ask about urinary frequency, urgency, or pain. Is the urine cloudy or pink?
Perform a physical examination. Take the patient’s vital signs, and assess skin turgor and mucous membranes. Inspect his abdomen for distention or visible peristaltic waves and, if indicated, measure his abdominal girth.
Auscultate for bowel sounds and characterize their motility. Percuss all quadrants, noting the percussion sounds. Palpate the entire abdomen for masses, rigidity, and tenderness. Check for costovertebral angle (CVA) tenderness, abdominal tenderness with guarding, and rebound tenderness. (See Abdominal pain: Causes and associated findings, pages 16 to 21.)
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Abdominal Pain:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A thorough, targeted physical examination, directed by a complete history, leads to a correct diagnosis in most cases (2).
Complete vital signs are essential. Tachycardia or hypotension can indicate hypovolemia and the need for urgent intervention (Chapter 7.12). Rapid, shallow breaths occur with peritoneal irritation. Inspect the abdomen for distention (obstruction), pulsations (AAA), or scars from past surgery. High-pitched hyperactive bowel sounds occur with bowel obstruction. Palpation and percussion help localize tenderness, organomegaly, and masses. Pain with movement, rebound tenderness, or rigidity are indicative of peritonitis and should prompt surgical consultation.
Cardiovascular, pulmonary, and digital rectal and genitourinary examinations should be included in all evaluations of significant abdominal pain. The pelvic examination must be done to exclude ectopic pregnancy and PID. Among patients in whom pregnancy is a possibility, the presence of peritoneal signs, cervical motion tenderness, or lateral (or bilateral) abdominal or pelvic tenderness should raise concern about possible ectopic pregnancy (3).
Testing
A. Clinical laboratory tests. Human chorionic gonadotrophin should be obtained if the patient has any potential for pregnancy. If appendicitis is suspected, sensitivity approaches 96% when both the total white blood cell count and neutrophil counts are elevated. Overall, however, hemograms do not by themselves often result in a change of disposition. Serum electrolytes are generally of little diagnostic value, except for the anesthesia provider if surgery is contemplated.
Urinalysis may identify urinary infection or calculi. Liver function tests in patients with right upper quadrant pain may help differentiate hepatitis and hepatobiliary disease (Chapter 9.8). Serum amylase is not a specific test for pancreatitis; it can be elevated in many other conditions that cause abdominal pain. Serum lipase has a higher sensitivity and specificity for pancreatitis than total amylase (4).
B. Diagnostic imaging
1. Plain films. Plain radiographs have utility primarily when attempting to identify specific abdominal pathology such as renal stones, perforated viscus, or bowel obstruction. They can detect as little as 5 ml of free air. Up to five air-fluid levels of less than 2.5 cm in length may be normal; however, dilation of the small bowel beyond 2.5 cm suggests obstruction.
2. Ultrasonography. Abdominal and pelvic sonograms are rapid, inexpensive, and noninvasive. They are especially accurate in detecting hepatobiliary, pancreatic, aortic, pelvic, and renal pathology.
3. Computed tomography (CT). Consider for patients with challenging presentations. CT is valuable in identifying abscesses, hematomas, and pancreatitis, and in evaluating solid organs and the abdominal vascular system; it is remarkably useful in evaluating patients with trauma. Magnetic resonance imaging has not proved particularly beneficial in the evaluation of acute abdominal pain.
Diagnostic assessment
The critical key is to identify the patient with an acute surgical abdomen. Physical examination coupled with a careful history narrows the differential diagnosis so that confirmation can be made by appropriately selected laboratory and imaging studies. In most cases, a good clinical history augmented by a focused physical examination leads to a correct diagnosis with limited need for further testing. Extremes of age, an impaired immune system, use of pain medications, and obesity can complicate the evaluation. Surgical consultation should be obtained immediately for patients with abdominal pain accompanied by peritoneal signs or shock.
References
1. Powers RD, Guertler AT. Abdominal pain in the ED: stability and change over 20 years. Am J Emerg Med 1995;13:301–303.
2. Silen W, ed. Cope’s early diagnosis of the acute abdomen, 19th ed. New York: Oxford University Press, 1996.
3. Dart RG. Predictive value of history and physical examination in patients with suspected ectopic pregnancy. Ann Emerg Med 1999;33;283–290.
4. Gwozdz GP, Steinberg WM, Werner M, Henry JP, Pauley C. Comparative evaluation of the diagnosis of acute pancreatitis based on serum and urine enzyme assays. Clin Chim Acta 1990;187:243–254.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Chronic/Recurrent Abdominal Pain:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Examining a patient during an episode of pain is important for diagnosis. A significant proportion of patients with chronic abdominal pain will remain undiagnosed despite extensive testing. For these patients, repeated history and examination, during which one looks for new symptoms or any change in the pattern of symptoms, may eventually yield a formulation.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Acute Abdominal Pain:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Acute abdominal pain is a classic symptom that can herald conditions ranging from the trivial to the life-threatening. The accurate diagnosis and timely management of abdominal pain requires an understanding of the mechanisms of pain, recognition of typical patterns of clinical presentation, a broad differential of common causes, and an index of suspicion for variant presentations and unusual causes. The ultimate disposition decision may require a repeated history and physical examination over several hours. Narcotic analgesics should be withheld until a diagnosis is established because they can mask the expression of diagnostic characteristics of the disease. History indicates the diagnosis in 85% to 90% of cases. Consider organs located in the region of maximal pain and the time-course of onset. An intrathoracic source must always be considered with upper abdominal pain. Physical examination can demonstrate peritoneal inflammation and rebound tenderness by eliciting pain with gentle percussion of the abdomen as opposed to sharp release of the depressed hand. Muscular rigidity or “guarding” is an early sign of peritoneal inflammation. Auscultation may reveal silence, consistent with ileus or advanced peritonitis, hyperactive high-pitched sounds with early bowel obstruction, or a friction rub with splenic infarct or hepatic metastases. Pelvic and rectal examinations are mandatory in every patient who has abdominal pain.
Parietal pain, caused by inflammation of the parietal peritoneum, is
a sharp, steady, aching pain, well-localized over the inflamed area, and
accentuated by pressure. Tonic reflex spasm of the abdominal musculature is present. Visceral pain, caused by obstruction of a hollow viscera, is classically intermittent and cramping, but distension may produce dull, steady pain. The patient with visceral pain will writhe incessantly, while the patient with parietal pain lies still in bed. Referred pain is aching and perceived to be near the surface, accompanied by skin hyperalgesia and increased tone of the abdominal wall. Vascular occlusion can be recognized by severe pain out of proportion to physical findings in a patient with vascular disease or atrial fibrillation. Visceral pain is perceived at the level the nerves enter the spinal cord. An example is gallbladder pain which may be first perceived at the scapula, then later in the right upper quadrant when the somatically innervated overlying parietal peritoneum is inflamed.
If the patient is well one moment, then has excruciating pain, which is maximal at onset, consider a ruptured hollow viscera or a vascular event, such as myocardial infarction or ruptured aortic aneurysm.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Abdominal pain:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Perform a physical assessment. Take the patient’s vital signs, and assess skin turgor and mucous membranes. Inspect his abdomen for distention or visible peristaltic waves and, if indicated, measure his abdominal girth.
Auscultate for bowel sounds and characterize their motility. Percuss all quadrants, noting the percussion sounds. Palpate the entire abdomen for masses, rigidity, and tenderness. Check for costovertebral angle (CVA) tenderness, abdominal tenderness with guarding, and rebound tenderness. (See Assessing abdominal vascular sounds.)
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Abdominal Pain:
Diagnostic Approach: Acute Abdominal Pain
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Completehistory and reliable physical exam are far more valuable than anylab test or radiograph in diagnosis.Ability of physician to make diagnosislargely depends on consideration of all possibilities, knowledgeof how they present, and planned orderly approach.Age, type of onset, character and locationof pain, and associated findings are useful in diagnosis.Abdominal pain of sudden onset is mostlikely to occur with intussusception, perforation of viscus, ortorsion of fallopian tube or ovary. Pain of gradual onset usuallyoccurs with appendicitis, pancreatitis, and cholecystitis. Severeintermittent pain may occur with gastrointestinal, genitourinary,or biliary tract obstruction.Pain of peritonitis is diffuse, constant,and exacerbated by movement.More recurrent or chronic pain usuallyoccurs with constipation, sickle cell pain episodes, and inflammatorybowel disease.Lesions of stomach, duodenum, pancreas,and biliary tract commonly cause epigastric pain. Small bowel andproximal colon lesions usually produce umbilical pain. Distal colonlesions may cause hypogastric pain, whereas rectal lesions may producesacral pain.Irritation of diaphragm may cause shoulderpain, and gallbladder disease may produce pain at right scapula.Lesions involving ureter or femalegenital tract may produce lower abdominal and pelvic pain.Most important diagnostic goal is todistinguish abdominal pain that may be life threatening.2 clinicalcircumstances represent potentially serious disease and requireimmediate investigation: (a) abdominal pain associated with biliousvomiting, persistent vomiting, or abdominal distension, and (b)abdominal pain associated with either localized or diffuse reboundtenderness. Very few clinical problems require such urgent operativeintervention that orderly approach needs to be abandoned. Only exceptionis massive exsanguinating hemorrhage. Children in whom the diagnosis is uncertainshould be admitted to hospital and observed.Period of active observation is extremeimportance and is safe.Most causes can be diagnosed at thebedside by careful and often repeated clinical observations.Initial lab tests are CBC with differential,UA, urine culture, analysis of stool for blood, ESR, chest and abdominalradiography, and abdominal U/S.
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Abdominal pain:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient has no life-threatening signs or symptoms, take his history. Ask him if he has had this type of pain before. Have him describe the pain in his own words. Ask him if the pain is dull, sharp, stabbing, or burning and to rate his pain on a scale, such as the visual analog scale, FACES pain scale, or verbal numeric scale for intensity of pain. Ask if anything relieves the pain or makes it worse. Ask the patient if the pain is constant or intermittent and when the pain began. Constant, steady abdominal pain suggests organ perforation, ischemia, or inflammation or blood in the peritoneal cavity. Intermittent, cramping abdominal pain suggests that the patient may have obstruction of a hollow organ.
If pain is intermittent, find out the duration of a typical episode. In addition, ask the patient to point where the pain is located and if it radiates to other areas.
Find out if movement, coughing, exertion, vomiting, eating, elimination, or walking worsens or relieves the pain. The patient may report abdominal pain as indigestion or gas pain, so have him describe it in detail.
Ask the patient about substance abuse and any history of vascular, GI, GU, or reproductive disorders. Ask the female patient about the date of her last menstrual cycle, changes in her menstrual pattern, or dyspareunia.
Ask the patient about appetite changes. Ask about the onset and frequency of nausea or vomiting. Find out about increased flatulence, constipation, diarrhea, and changes in stool consistency. When was the last bowel movement? Ask about urinary frequency, urgency, or pain. Is the urine cloudy or pink?
Perform a physical examination. Take the patient's vital signs, and assess skin turgor and mucous membranes. Inspect his abdomen for distention or visible peristaltic waves and, if indicated, measure his abdominal girth.
Auscultate for bowel sounds and characterize their motility. Percuss all quadrants, noting the percussion sounds. Palpate the entire abdomen for masses, rigidity, and tenderness. Check for costovertebral angle (CVA) tenderness, abdominal tenderness with guarding, and rebound tenderness.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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