|Year : 2020 | Volume
| Issue : 2 | Page : 86-89
Clinical, laboratory, and imaging predictors of surgical exploration in nontraumatic acute abdomen
Abhiram Ramesh Mundle, Satish Deshmukh, Murtaza Akhtar
Department of Surgery, NKP Salve Institute of Medical Sciences, Lata Mangeshkar Hospital, Nagpur, Maharashtra, India
|Date of Submission||18-Mar-2020|
|Date of Decision||25-Jul-2020|
|Date of Acceptance||11-Dec-2020|
|Date of Web Publication||24-Feb-2021|
Dr. Satish Deshmukh
Department of Surgery, NKP Salve Institutre of Medical Sciences, Lata Mangeshkar Hospital, Nagpur - 440 019, MH
Source of Support: None, Conflict of Interest: None
Introduction: Acute abdominal pain (AAP) accounts for a substantial proportion of patients arriving at a surgical emergency department. As AAP may be caused by both life-threatening diseases and conditions that are spontaneously resolved, a correct diagnosis is of importance for the prognosis of the patient.
Materials and Methods: Clinical, laboratory, and imaging studies were done in patients presenting with a history of acute, nontraumatic pain in the abdomen in the Department of Surgery of NKP SIMS and Lata Mangeshkar Hospital, Nagpur, over a period of 2 years.
Results: A total of 400 patients with a mean age of 38.05 ± 11.45 with a male: female ratio of 2.07:1 were enrolled. Of them, 233 patients underwent exploration and 167 were managed conservatively. During univariate analysis, age group, pulse rate, temperature, hemoglobin, total leukocyte count (TLC), tenderness, guarding, distension, bowel sounds, chest radiograph, and abdominal radiograph were found to be significant. On multivariate analysis, hemoglobin, TLC, tenderness, distension, and abdomen radiograph were significantly associated with exploration.
Conclusion: In a patient of nontraumatic acute abdomen, clinical predictors such as tenderness and distension, laboratory predictors such as hemoglobin and TLC, and abdominal standing radiograph as an imaging predictor were the most statistically significant for exploration.
Keywords: Acute abdomen, nontraumatic, predictors, surgical exploration
|How to cite this article:|
Mundle AR, Deshmukh S, Akhtar M. Clinical, laboratory, and imaging predictors of surgical exploration in nontraumatic acute abdomen. Saudi Surg J 2020;8:86-9
|How to cite this URL:|
Mundle AR, Deshmukh S, Akhtar M. Clinical, laboratory, and imaging predictors of surgical exploration in nontraumatic acute abdomen. Saudi Surg J [serial online] 2020 [cited 2021 Apr 11];8:86-9. Available from: https://www.saudisurgj.org/text.asp?2020/8/2/86/310124
| Introduction|| |
Acute abdominal pain (AAP) accounts for a substantial patient load in the emergency department. AAP could either be caused by life-threatening or self-resolving conditions. Accurate diagnosis is the key in the management of these cases by identifying the factors associated with surgical exploration. There is a paucity of literature comparing and evaluating the role of clinical, laboratory, and imaging modalities to arrive at an early diagnosis in nontraumatic acute abdomen. Hence, the need to carry out a study to identify the predictors of surgical exploration associated with nontraumatic acute abdomen.
| Materials And Methods|| |
The study was conducted in the department of surgery of a tertiary care academic hospital in Central India over a period of 2 years. It was an observational analytical study. All the patients presenting with nontraumatic AAP to the surgery outpatient department or emergency department and getting admitted in surgery wards, aging from 18 to 70 years, were included in the study. Patients presenting with obstetric or gynecological causes of abdominal pain and acute or chronic abdominal pain were excluded from the study.
Based on all clinical, laboratory, and imaging findings, the patients were divided into two groups, i.e., conservative management and surgical exploration groups.
As patients were divided into two groups, i.e., surgical exploration and conservative, an intergroup univariate analysis was carried out. The continuous variables between the two groups were analyzed using Student's t-test and categorical variable by Fisher's exact test or Chi-square test. The factors statistically significant with surgical exploration were fed into a multivariate model to find out the most significant factors associated with surgical exploration in nontraumatic acute abdomen.
| Observation And Results|| |
Out of the total number of 400 patients fulfilling the inclusion and exclusion criteria enrolled prospectively, 233 (58.25%) patients underwent surgical exploration, whereas the remaining 167 (41.75) patients were managed conservatively. The mean age of the enrolled patients was 38.05 ± 11.45 years, with a range from 18 years to 66 years. The maximum number of patients, i.e., 329 (82.25%), presented in the age group of 20–50 years.
The male: female ratio was 2.07:1. Surgical exploration was done in 233 patients, of which 162 (69.53%) were male and 71 (30.47) were female. The mean pulse rate at the time of admission was 86.5 ± 17.74. One hundred and fourteen patients had tachycardia (pulse rate >90/min), of which 94 had surgical exploration and 20 were in the conservative management group.
Abdominal tenderness was found in 333 patients, of which 227 underwent surgical exploration and 106 had conservative management (P = 0.001). Abdominal distension was seen in 60 patients in the surgical group and in 8 in the conservative group. Abdominal guarding was present in 75 patients in the exploration group and 39 in the conservative group. Eighteen patients had abdominal rigidity in the exploration group and none in the conservative group [Table 1].
|Table 1: Distribution according to abdominal signs at the time of admission|
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The mean hemoglobin was 12.96 ± 1.93 in the conservative group and 13.39 ± 1.82 in the surgical exploration group; the difference was statistically significant (P = 0.023). The mean leukocyte count in the exploratory group was 11967.82 ± 4231.55 and in the conservative group was 10700.6 ± 3018.48.
Chest X-ray was done in all patients presenting with nontraumatic acute abdomen, out of which 23 showed gas under the right dome of the diaphragm and were hence taken up for surgical exploration. Standing X-ray of the abdomen was performed in all patients to rule out intestinal obstruction. Out of the 91 patients in whom features of intestinal obstruction were found, 81 underwent surgical exploration.
The clinical, laboratory, and imaging factors found to be significant on univariate analysis were fed into a multivariate model, and the results are shown in [Table 2].
|Table 2: Multivariate analysis using binary logistic regression for association between surgical exploration and predictive factors|
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The above clinical (abdominal tenderness, guarding, and distension), laboratory (hemoglobin and total leukocyte count), and imaging (chest radiograph and abdomen standing radiograph) were found to the associated with surgical exploration.
| Discussion|| |
Acute abdomen remains a common abdominal emergency and its diagnosis continues to remain difficult due to the variable clinical presentation and etiologies. Accurate diagnosis helps in identifying the patients who need conservative treatment or surgical intervention. Delay in instituting surgical intervention would lead to increased chances of complications, while blanket policy of surgical exploration would result in negative exploration and physical and financial burden to the patient.
Availability of advanced laboratory and imaging investigations can lead to accurate diagnosis, but in the vast Indian populace, its availability is not assured, hence need to identify clinical, laboratory, and imaging parameters to predict who among all acute abdomen will need surgical exploration. This was the rationale of the present study, and the factors studied were demographic, clinical, laboratory, and imaging parameters.
The mean age of the patients in the present study was 37.87 ± 11.94 years, with a range of 18–66 years, which was consistent with data in literature.,,, On further evaluation, based on decade-wise distribution, the maximum number of patients, i.e., 329 (82.25%), presented in the age group of 20–50 years. This was consistent with the data in literature where, in the study by Chanana et al., a maximum number of patients (56.8%) were in the age group of 20–40 years.
There was a male preponderance with a male: female ratio of 2.28:1 in the present study. Similarly, all the other studies,,,, to which comparison was done showed a male preponderance. This male preponderance could be explained on the basis that female gynecological patients were excluded from the study.
In the present study, pain in the abdomen being the inclusion criterion was observed in all the patients (100%), which was observed in all the studies compared in literature.,,, Vomiting was seen in 29% of patients, which was not matching with the data in literature where it ranged from 43.9% to 72%.,,, Abdominal distension was observed in 17% of patients, which is consistent with the data in literature.,,, The difference in symptomatology could be explained due to varied etiologies in the population included in these studies.
Clinical examination forms an important link in establishing the diagnosis of acute abdomen. In the present study, tachycardia on admission was a general finding on examination, which was observed in almost 40% of all cases. This finding was quite consistent with the statistics quoted in literature.,,, On local examination, abdominal distension, abdominal tenderness, and abdominal guarding were the three most important findings, which were observed in 25.75%, 97.42%, and 32.18% of patients, respectively. Abdominal tenderness was an important clinical finding, which was observed in practically all studies in literature ranging from 93.6% to 99%.,,,
A chest X-ray posteroanterior view and an abdomen X-ray anteroposterior view in standing position including both domes of diaphragms were done in all the patients. Twenty-three out of 23 patients who had perforation peritonitis had free gas under the diaphragm.
X-ray abdomen in standing position was done in all patients of nontraumatic acute abdomen to rule out suspected cases of intestinal obstruction. Out of the 91 patients in whom significant findings were observed, 81 underwent surgical exploration and 12 were managed conservatively. It showed a statistical significance with P = 0.001. Studies by Brewer BJ et al. and Gaskill CE et al. showed similar results, but the studies conducted were only descriptive., X-ray chest and abdomen is useful in the diagnosis of acute abdomen when suspecting bowel perforation. A study by Bansal J et al. showed similar results.
| Conclusion|| |
Acute abdomen has an element of Pandora's box. Accurate diagnosis is now possible but will require advanced imaging investigations like contrast-enhanced computerized tomography. Clinical features and laboratory and imaging indicators could be helpful in planning these advanced imaging modalities. The present study did find these clinical, laboratory, and imaging factors, however, these factors though statistically significant were not clinically important in deciding the course of management.
Though a descriptive study, we did an intergroup analysis between the surgical exploration and conservative management groups to find out the factors most significantly association in surgical exploration of a patient. We included all gastrointestinal and genitourinary causes of AAP where there is a need to take up only gastrointestinal causes of AAP in a follow-up study for better statistically significant results.
The predictors found useful for surgical interventions in patients with acute abdomen should be used and replicated in a larger sample to arrive at an algorithm that will have wider and more generalized application.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]