This year, the Davos Medical Forum once again offered a wealth of practice-relevant topics for primary care providers. The varied program included presentations on common diseases as well as specific workshops and interactive seminars. Presentation by Prof. Frank Lammert is about common and rare causes of acute abdomen.
A classic emergency situation of great clinical relevance was the subject of the presentation by Prof. Frank Lammert of Saarland University Hospital, Homburg, because the acute abdomen requires immediate clinical (and instrumental) diagnostics and rapid decisions. Prof. Lammert defines “the acute abdomen” as a provisional term for initially indistinguishable sudden abdominal pain (<24 h) until it is finally resolved. “However, this definition only covers a portion of emergency patients. Especially with older patients, the situation is more difficult because the symptoms are often nonspecific and weak,” he points out. Furthermore, from an internal medicine point of view, it is important to distinguish the acute abdomen from an abdomen that has to be handed over directly to the surgeon. Another problem he sees is that too many acute abdomens occur because patients were not treated in a timely manner or properly beforehand.
The leading symptom of acute abdomen is pain, and the pain character may be visceral or somatic. Visceral causes an uncharacteristic abdominal complaint mediated by the autonomic nervous system. When inflammation spreads to the peritoneum, the spinal nerves are activated, resulting in the more localizable somatic pain. Pain migration from the mid-abdomen to the right lower abdomen is classic in appendicitis. Concomitantly associated are peritoneal symptoms (defensive tension), motility disturbance (paralysis), vomiting and loss of stool, deterioration of the general condition and circulatory disturbances up to shock.
Pain therapy as early as possible
As a first important measure, a strong analgesic should be administered as early as possible, Prof. Lemmert further explains: “This is not contraindicated, as is sometimes assumed. Morphine can also be used well, this is evidence-based” [1]. Meta-analyses would show that investigability remains assured and diagnosis is not missed more frequently. As a second urgent measure, the speaker mentions an immediate antibiotic therapy in case of suspected sepsis, and this before any other measures. In sepsis, mortality increases by 8% with each hour; this is also evidence-based [2].
Repeat physical examination several times
As for the general diagnosis, an abdomen-centered history should be taken. It is important here to repeat the physical examinations several times, because the time course of pain and other symptoms can help to classify the acute abdomen correctly. At the same time, physical examinations should not be overrated. Their informative value is limited and they are not always successful. There is a negative appendectomy rate in clinics (>10%) and the value of auscultation of bowel sounds is proving to be questionable, with a sensitivity of just 22 to 42% [3].
Laboratory tests should be kept small: Initially, BB, CRP, lipase, BG, lactate, supplemented with liver and kidney values and troponin may be sufficient. If the small laboratory is normal, then the situation is not serious. But it should be noted that in older patients, inflammation levels may be completely normal. The third pillar of therapy is imaging, with sonography leading the way, followed by CT. CT achieves the highest sensitivity of 94% in diagnosis [4] and should be used if sonography is negative. However, one should keep in mind that CT is superior, but also expensive and radiant.
Five particularly risky constellations
It is recommended, because it is very helpful, explains Prof. Lammert, to consciously recall five specific risk constellations for the diagnosis, because one does not automatically think of them: these are the perforated abdominal aortic aneurysm in the older smoker, acute pancreatitis, also more likely in men, but then with alcohol consumption, or in women with gallstones, the perforated gastric or duodenal ulcer, mesenteric ischemia and intestinal obstruction.
Gallstones are the most common differential diagnosis (21%) in acute abdomen in the elderly patient (>50 years). In second place is nonspecific pain (16%), i.e., there is no acute situation, and in third place is appendicitis (15%). This ranking also applies to younger patients, but here the distribution is different: 40% nonspecific pain, 32% appendicitis, and 6% gallstones [5]. “That means a patient under the age of 50 with an acute abdomen is actually rarely seriously ill, or if it is, it’s appendicitis,” Prof. Lammert notes with a wink.
Literature:
- Manterola C, Vial M, Moraga J, Astudillo P: Analgesia in patients with acute abdominal pain. Cochrane Database Syst Rev. 2011; (1): CD005660.
- Whiles BB, Deis AS, Simpson SQ: Increased time to initial antimicrobial administration is associated with progression to septic shock in severe sepsis patients. Crit Care Med 2017; 45(4): 623-629.
- Felder S, et al: Usefulness of bowel sound auscultation: a prospective evaluation. J Surg Educ 2014; 71(5): 768-73.
- Laméris W, et al: Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study. BMJ 2009; 338: b2431.
- Telfer S, et al: Acute abdominal pain in patients over 50 years of age. Scand J Gastroenterol Suppl. 1988; 144: 47-50.
HAUSARZT PRAXIS 2017; 12(4): 54-55
