|Year : 2014 | Volume
| Issue : 3 | Page : 71-74
Role of laparoscopy in nonspecific abdominal pain
Mir Mujtaba Ahmad1, Hanief Mohamed Dar1, Malik Waseem2, Hilal wani1, Irfan Nazir1, Asif Jeelani1
1 Department of General Surgery, GMC, Srinagar, J and K, India
2 Department of SPM, GMC, Srinagar, J and K, India
|Date of Web Publication||15-Dec-2014|
Mir Mujtaba Ahmad
Lane No. 1, Tawheed Abad, Nowshehra, Srinagar 190 011, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Objective: The aim was to determine the role of laparoscopy in the management of nonspecific abdominal pain (NSAP). Background: NSAP constitutes a good proportion of surgical admissions, both in emergency and elective settings with considerable diagnostic dilemma. Patients and Methods: All patients who presented with pain abdomen with no immediate cause and were labeled as NSAP after clinical assessment and investigations and following that underwent laparoscopy to make a definitive diagnosis were included in the study. Results: A total of 88 patients were included in the study. There were 59 (67%) females and 29 (33%) males. The mean age was 26 years (range 18-58 year). The common mode of admission was out-patient department 69 (78.4%) patients. Twenty-five (28.4%) patients presented with NSAP in lower abdomen, followed by 21 (23.8%) with right lower abdominal pain and 19 (21.5%) with central pain radiating to right lower abdomen. Diagnosis was established in 75 (85.2%) patients. In 13 (14.7%) no pathology was found. The most common diagnosis was pathology of appendix in 29 (32.9%) patients followed by pelvic pathology in 18 (20.4%) and abdominal tuberculosis in 14 (15.9%) patients. Most 37 (42%) of the patients stayed in the hospital for 24 h. There was no readmission and no major postoperative complications. Conclusions: Laparoscopy has a definitive role in diagnostic dilemma associated with NSAP. It has at the same time role in treatment of the condition; hence laparoscopy has a diagnostic and a therapeutic implication in management of NSAP.
Keywords: Abdomen, laparoscopy, nonspecific abdominal pain
|How to cite this article:|
Ahmad MM, Dar HM, Waseem M, wani H, Nazir I, Jeelani A. Role of laparoscopy in nonspecific abdominal pain
. Saudi Surg J 2014;2:71-4
| Introduction|| |
Abdominal pain is a common complaint with which patients present to accident and emergency department.  Nearly one-quarter of patients has vague abdominal pain.  In chronic abdominal pain, more than 38% of the patients have no specific etiological diagnosis made at the end of the diagnostic workup. , Many organic and functional diseases can cause abdominal pain. Relatively young patients, especially females, with nonspecific abdominal pain (NSAP) constitute a significant proportion of emergency general surgical admissions. Many of these patients have persistent symptoms and are difficult to discharge, undergo multiple, often costly investigations and have repeat admissions. Most cases of NSAP mimic acute or chronic appendicitis. Most patients with NSAP are referred as possible cases of acute appendicitis, frequently with right iliac fossa (RIF) pain and tenderness. A number of these may erroneously undergo operation for suspected appendicitis and indeed, in one study, NSAP was eventually diagnosed in 33% of 135 patients are undergoing the appendicectomy.  These patients may undergo unnecessary appendectomy and may recur with symptoms even after surgery. A definitive diagnosis is not always possible, however, with noninvasive imaging tests including contrast radiology, computed tomography (CT), magnetic resonance imaging (MRI), and ultrasonography.  In addition, minimally invasive procedures like paracentesis, endoscopy fail to fetch a diagnosis as well at times. Laparoscopy is a method in which the peritoneal cavity can be visualized without making large surgical incisions. It has a diagnostic as well as a therapeutic potential. The diagnostic potential of laparoscopy has changed the management of many surgical diseases where conventional modalities of diagnosis are not helpful.  Diagnostic laparoscopy has a place in the algorithm to fetch diagnosis in many disease processes. Incorporation of diagnostic laparoscopy along with biopsy, may improve the management of NSAPs, by making a definite diagnosis, access for immediate treatment, reducing hospital stay and readmission rates and eventually having cost benefits. , It is a safe and effective tool and can establish the etiology and allows for appropriate interventions in such cases.  Even malignancies as rarest cause of NSAP have been documented, with some relationship with irritable bowel syndrome also in research. Normal diagnostic laparoscopy may allow the surgeon to discharge. patients early after giving symptomatic treatment. This study was conducted to highlight the role of laparoscopy in undiagnosed abdominal pains.
| Patients and Methods|| |
This study was conducted out in Postgraduate Department of Surgery in GMC, Srinagar for a period of 2 years June 2010 to May 2012. All patients of either sex and age, who presented with vague abdominal pain new onset or chronic, admitted through emergency or outpatient department in whom history, clinical examination and routine diagnostic investigations failed to make a definite diagnosis, were included. After taking detailed history and clinical examination, relevant blood investigations, X-ray abdomen and ultrasound and CT scan were performed. In any chronic abdominal condition in which the cause was unknown, Laparoscopy was performed after completion of all the necessary hematological, biochemical, radiological, and ascetic fluid analysis, gastrointestinal endoscopic and imaging techniques, and Mantoux test (techniques when indicated). Therapeutic intervention was performed depending on the underlying pathology with open laparotomy or laparoscopic. A proforma was used to keep a record of all the patients in terms of history, clinical examination, investigations and laparoscopic findings. The time for hospital stay was considered as time from admission until discharge. A preanesthetic check-up was done in all the patients to assess ASA category of patient and to rule out any contraindications to laparoscopy. A single antibiotic for prophylaxis was given preoperatively after a test dose. Patients were informed about the possibility of conversion of laparoscopic surgery to an open procedure depending on preoperative findings and consent was taken. Pneumoperitoneum was created using veress needle in periumblical region, camera port was introduced through periumblical incision, followed by insertion of additional ports where therapeutic intervention was required. The findings on laparoscopy were recorded. Biopsy specimen if obtained was sent for histopathology to confirm the diagnosis. Outcome measures included diagnosis made, duration of surgery, duration of hospital stay and postoperative complications. Data were analyzed using Statistical Package for the Social Sciences Version 15. Descriptive statistics such as frequency, percentage, mean etc. were calculated.
| Results|| |
The common mode of admission was through outpatient department (n = 68-78.4%). The common clinical presentations were vague abdominal pain in the lower abdomen in 25 (28.4%) patients, with right lower abdominal pain in 21 (23.8%) and 19 (21.5%) with central pain radiating to right lower abdomen as shown in [Table 1].
In 38 (43.1%) patients abdominal ultrasound was normal. The most common finding noted on ultrasound abdomen and pelvis was distended bowel loops in RIF. Benign hypertrophy of the prostate was reported in two patients. Ultrasound pelvis in 51 of 59 females was normal. In the remaining patients minimal free fluid in cul-de-sac was reported. All subjects underwent CT scanning, out of which, 63 (52.5%) patients had a change in findings when compared with the findings on ultrasonography.
The CT scan was better able to suggest dilatation of gut loops and retroperitoneal/mesenteric lymphadenopathy. Twenty-four subjects out of 88 cases (27.2%) had altogether new findings, while 64 (72.7%) cases had findings similar to the radiological means. Twenty-five out of these 64 had new findings along with the previous findings. Therefore, 49 out of the 88 subjects had new findings. After diagnostic laparoscopy, tissue diagnosis was achieved in 75 of the 88 subjects (85%).
Laparoscopic results showed inflamed appendix, appendicular fecoliths, enlarged mesenteric lymph nodes, salpingitis, omentum at deep ring, adhesions in pelvis, fluid in cul-de-sac and ovarian cyst, diverticulitis as indicated in [Table 2].
Final diagnosis was made in 75 (85.2%) patients. In 13 patients (14.7%) no diagnosis was established. All laparoscopic findings were confirmed by histopathology. Inflamed appendix was the most common diagnosis made in 15 (17%) patients with rest of diagnoses tabulated in [Table 3].
The maximum duration of laparoscopic surgery was 108 min. Among the postoperative complications 7 (7.9%) patients developed wound infection, 6 (6.8%) had fever and chest infection, 4 (4.5%) with fever alone. Follow-up was done on weekly basis for 2 months, then on monthly basis for 4 months. No major complications were noted and four patients came back with complaints of recurrent pain who were subjected to further investigations like CT, MRI, magnetic resonance cholangiopancreatography to ascertain a diagnosis.
| Discussion|| |
Vague abdominal pain is a diagnostic dilemma. In many cases despite all the routine laboratory investigations and ultrasonography, cases remain undiagnosed. The problem posed by patients with NSAP is considerable. It accounts for an estimated 13-40% of all emergency surgical admissions.  The abdominal disease is obscure, and patients usually undergo a battery of hi-tech investigations and even exploratory laparotomy for definitive diagnosis. It can all be unyielding for the surgeon as well as patient. In such conditions, diagnostic laparoscopy is a better choice. It can directly visualize the abdominal cavity, provide adequate material for histopathological assessment, and in good hands is an excellent therapeutic tool with cosmetic acceptable scars.
Literature review reveals various outcomes of laparoscopy in patients of undiagnosed vague abdominal pain to support its use in recurrent vague abdominal pain. Some studies clearly support the role of laparoscopy in such diagnostically challenging situations and have shown a good accuracy in fetching a diagnosis in NSAPs. , Some other studies were not as supportive.  The overall success in our study was 87.3% which validates use of this diagnostic modality. A study by Lippert et al. showed that diagnostic difficulties are more in young females with lower abdominal pain and inconsistent features of appendicitis.  Diagnostic laparoscopy seems to be a better option to evaluate vague lower abdominal pain in this gender class. This is similar to the study carried by Ou and Rowbotham in which diagnostic laparoscopy provided a definitive diagnosis in 76 of the 77 cases (98.7%).  In our study, more than half (59 out of 88) of patients were females. This strengthens the observation that vague abdominal pain was common diagnostic problem in this group. In our study laparoscopy provided a definitive diagnosis in 51 (86.4%) out of 59 female patients. In a similar study appendix as pathology was found in 73% cases, whereas in another study it was found in 39% patients. , These were higher when compared to our study in which appendicular pathology was found in 32.9% (n = 29) cases. In our study, the appendicular pathology was appendicitis in majority of cases with pelvic position of appendix common along with subserosal and reterocecal appendix. Females with findings of pelvic pathology and pelvic inflammatory disease (PID) were the second most common diagnosis reached with 18 (20.4%) and abdominal tuberculosis was found in 14 (15.9%) patients in a study which is similar to our results.  Three male patients in the present study presented with a complaint of right groin pain that radiated to RIF. On diagnostic laparoscopy, findings were of omentum protruding into deep ring in one patient and small bowel along with omentum in two others. Transabdominal preperitoneal was done in all the three patients with no postoperative complications. Our results were in concordance to a study revealing similar results.  Early laparoscopy also has the benefit that a number of therapeutic options are available.  In this study, diagnostic laparoscopy became therapeutic. Ovarian cysts can be drained and treated with immediate relief of symptoms.  Purulent fluid collections secondary to PID or diverticulitis can be drained. Early recognition of PID enables early treatment that is important if complications such as infertility are to be minimized. Patients with an inflamed appendix can be removed safely and effectively laparoscopically. Laparoscopic adhesiolysis is possible. 
In our study, there were some minor postoperative complications noted including wound infection and fever while the laparoscopy failed to make any diagnosis in 13 patients, which were put on follow-up for further assessment to fetch a diagnosis. Five were unmarried females of child bearing age, three were male of age group <12 years, whereas the other females had a history of cesarean section with normal barium studies. All of these patients attended the follow-up clinic for 6 weeks and then were being evaluated with other modalities during follow-up.
| Conclusions|| |
Laparoscopy provided diagnosis in a large number of patients. It is a good tool for diagnosis and therapeutic surgery. It may be considered as first line operative investigation for undiagnosed recurrent vague abdominal pain with no specific etiology.
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[Table 1], [Table 2], [Table 3]