Traditionally surgeons understand the importance of the “Early Diagnosis of the Acute Abdomen,” the title of the classic book by Zachary Cope that we all read in medical school that seems to have disappeared from the contemporary curriculum.
Emergency Departments (ED) administered by hospitals and hospital systems are now frequently the first line of defense for the diseased and processes causing the frequent complaint of acute abdominal pain. The CT scan and sometimes the Sonogram, is assumed to make all diagnoses and physical examination as described by Cope takes a back seat.
However, knowledgeable and attentive clinical evaluation and prompt treatment plans still solves the serious problems sent to the ED. Patient and referring physicians expect that the concerned orientation that we share towards urgency, which prompts your referral to “the emergency room”’ will be continued in the emergency room. We expect that there will be an expeditious diagnostic process, stabilization and prompt indicated treatment (medical and/or surgical). We all hope that patients have a courteous, reassuring and timely experience that enhances their confidence in physicians, hospitals, a urgent care centers. If surgery is indicated, a positive experience will augment confidence and satisfaction as well as a good result. The ED experience, however, is at times disconcerting and disturbing. Our experiences lead patients and physicians to concerns about ED processes and priorities.
I believe that the personal attention of the Attending Physician and the Consulting Surgeon, the traditional care that we all have provided for decades is a better model.
The Agency for Health Care and Quality has published Emergency Department (ED) Guidelines in a Brochure to improve triage. Acute abdominal pain is covered by Level 2 or 3 definitions. Do most ED’s use these national recommendations? We have been taught to be concerned about a previously well patient who complains of severe abdominal pain for over six hours. No Acute Abdominal Pain should be categorized at less than #3. Diagnosis requires more than the broad, generic label: ”Abdominal Pain,” especially on a CT scan requisition.
Level 1 involves catastrophes that all appreciate almost intuitively.
Level 2 requires immediate attention to diagnosis and treatment.
Delays at Level 3, which, at first, might appear less urgent, can progress to level 2 during a prolonged the Emergency visit. The identification of Level 3 in the ED and estimation of the risk of deteriorization is a function of triage and then organized and timely throughput at sequential levels of contact in the ED. The change in condition can be insidious or abrupt.
The Brochure states, ”ER Triage Nurses are reluctant to assign level 2 to patients when the ED is crowded.” Level 2 requires “as soon as possible” attention because there is “threat to life or limb” with signs and symptoms that include severe pain/distress, unstable vital signs, dehydration (tachycardia and hypotension) sepsis, cerebral and cardiopulmonary impact, or other comorbidities (DMI) especially in the elderly.
Search the web to understand "peritonitis."
Example of Level 3: Persistent and localized RLQ pain, onset 12 hrs, no signs of peritonitis, without dehydration, sepsis, vomiting or fever. This can unpredictably become level 2 with increased temperature, dehydration, rapid pulse rate, low blood pressure, confusion, flushing, shaking chills and progressive peritonitis. This transition can occur between arrival in the ED and definitive treatment. Identification of change depends on continuous monitoring while the ED process proceeds. Only sequential clinical evaluation, continuity of care and communication can determine change in status. Missed detection can be catastrophic.
A speedy transition of care can improve the opportunity for stabilization and avoid progression of disease and distension, thus decreasing risk and the need for a large abdominal incision, rather than solution by Laparoscopy in a stable patient without sepsis.
Per Zachery Cope (whose book has been published in over 20 editions, ”the surgeon has the opportunity of correlating the symptoms with pathology.” The surgeon’s experience and clinical evaluation over time is combined with the experience of treating the pathology in the operating room (OR) and seeing the postoperative result. The decision how and when to treat processes like acute appendicitis, complicated diverticulitis, intestinal obstruction, perforations depends on prompt diagnosis and stabilization to treat or avoid deteriorization.
Ref: Early Diagnosis of the Acute Abdomen, Revision by Z. cope. Oxford University Press. 1987. (ISBN 10:0195042891)
Illustrations of Issues involving the Acute Abdomen
Patients and Physicians notice various changes in ED processes and the methods of treatment of the Acute Abdomen as well as other acute events.
In 1949, in his 500 page book dealing with “Acute Appendicitis and its Complications,” Frederick Boyce, MD (Charity Hospital, New Orleans) wrote “acute appendicitis is an inherently serious, urgent and potentially deadly disease.” This is still true depending on geography and type of acute care setting. Mortality and morbidity for a complicated appendicitis is an ongoing concern. Our surgical and diagnostic techniques have improved treatment and comfort for early cases; but complicated appendicitis is still dangerous. Before CT scan clinical diagnostic accuracy was 85%. The diagnostic process is only one concern.
Professor Alton Ochsner, MD, in his foreword to Boyce’s book, emphasized ”With the widespread use of antibiotics, every physician has come to believe that acute appendicitis is no longer a serious disease.” Today we have a paradoxical experience. Physicians are usually concerned that acute appendicitis should be treated promptly by surgeons, while some surgeons advocate temporizing with nonsurgical measures and antibiotics. This concept has reappeared and is a source of controversy at many levels of care.
Ref: Acute Appendicitis and Its Complications. Boyce, MD, Frederick F. Oxford University Press, 1949.
Early Diagnosis of the Acute Abdomen
Examples: 1- Acute Appendicitis
Case A: An 18 year old Italian woman had been treated with antibiotics for acute appendicitis, diagnosed by Ultrasound in Trieste, Italy and improved. A few months later, coming to NY to visit relatives, on disembarking had severe pain that was caused by perforated, gangrenous appendicitis with abscess, extensive scarring and adhesions that required emergent laparoscopic removal.
Case B: A 23 year old man had acute appendicitis diagnosed by CT scan in NYC, was treated with antibiotics, improved, felt better, and was discharged from care. Six months later he returned to the ED with 4 days history of severe progressive pain. A gangrenous, fibrosed, perforated appendix with abscess and adhesions was removed and contained cancer. This required further major surgery.
In both cases, laparoscopic appendectomy would have removed disease in an earlier and less complicated condition with minimal risk, rapid discharge and recovery.
Example 2- When treating Complicated Diverticulitis, past experience, knowledge of the evolution of treatment, the surgical literature and new surgical technique impacts judgment. Over the past 40 years treatment had tended toward decreasing the number of planned surgical procedures. Acute diverticulitis is frequently modulated with antibiotics with/without timely drainage of abscess by Interventional Radiology (IR). With conversion to interval, elective timing of surgery, laparoscopic technique can be used with a primary anastomosis (intestinal continuity). In the past these procedures were staged in two or three operations, frequently with colostomies. With advanced disease, staging might still be necessary. Surgical judgment is important initially.
Example 3- Small bowel obstructions frequently occur after previous recent or remote surgery, from tumors and inflammations causing blockage or as a secondary manifestation of other processes like appendicitis or diverticulitis. Long intestinal tubes used to relieve blockage for a half century are no longer available. If distension can be controlled, laparoscopic procedures can frequently resolve small bowel obstruction due to adhesions or small bowel tumors. These cases must be fastidiously differentiated from those who have life threatening presentation of small bowel obstruction which requires immediate surgical intervention. The decision of surgery or nonsurgical support might change slowly or quickly. Surgery can be avoided in many cases BUT this decision results from conscientious and continuous clinical evaluation. Laparoscopic resolution can be done in many patients when prepared and stable and the “window of opportunity” is identified by the surgeon. Some dictums emphasize immediate surgery based on the concept of ”don’t let the sunset on intestinal obstruction” which might be safer in situations lacking experience abdominal surgeons.