Abdominal Pain labs

8/14/2019 Abdominal Pain labs

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Emergency Medicine

Abdominal Pain:Abdominal Pain:Laboratory TestLaboratory Test

Pearls and PitfallsPearls and PitfallsJoe Lex, MD, FAAEMTemple University Hospital

Philadelphia, PA USAEducation Chair, American Academy ofEmergency Medicine


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Abdominal PainAbdominal Pain

x 10% of EmergencyDepartment visits

x 40% diagnosed as

nonspecific

x 50% of those admitteddischarged with

change in diagnosis


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Differential IncludesDifferential Includes

x Diabeticketoacidosis

x Alcoholic

ketoacidosisx Uremia

x Sickle cell disease

x Porphyriax Systemic lupus

x Vasculitisx Glaucoma

x Hypertension

x Scorpion stingx Methanol

poisoning

x Black widowspider bite


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x Heavy metaltoxicity

x Acute coronary

syndromex Pneumonia

x Pulmonary

embolismx Testicular torsion

x Herniated thoracicdisc

x Streptococcal

pharyngitisx Rocky Mountain

spotted fever

x

Mononucleosisx Etc.


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and those are just theextraabdominal causes

of abdominal painx Id be happy with a test that could tell

me that the source of pain was reallythe abdomen.


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Literature Suggests We GetLiterature Suggests We Get

x White blood cellsx Electrolytes

x Glucose

x Renal functionsx Liver functions

x Amylase / lipase

x Pregnancy test

x Urinalysisx C-reactive protein

x Procalcitonin

x Lactatex Phosphorus

x Leukocyte elastase

x Others??


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Literature Suggests We GetLiterature Suggests We Get


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First and ForemostFirst and Foremost

x Female + ovaries = pregnancyxWhen patients said

My last period was on time.

I dont think Im pregnant.

I cant possibly be pregnant.

10% were pregnant.Ramoska EA, et al. Ann Emerg Med. 1989 Jan;18(1):48-50.Ramoska EA, et al. Ann Emerg Med. 1989 Jan;18(1):48-50.


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Gall BladderGall Bladder


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Gall Stones / ColicGall Stones / Colic

xNo pathognomonic studyx Lab studies should all benormal

ALT / AST: think hepatitis

alkaline phosphatase / bilirubin: thinkcommon bile duct obstruction

amylase / lipase: think pancreatitis


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Common Duct StonesCommon Duct Stones

x serum bilirubin in 32%x aminotransferases in 34%

x alkaline phosphatase in 22%

xCommon duct stones in 17.4%

xBest predictive value for duct stone:

alkaline phosphatase (46%)

Jarvinen H. Ann Clin Res. 1978 Dec;10(6):323-7.Jarvinen H. Ann Clin Res. 1978 Dec;10(6):323-7.


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Common Duct StonesCommon Duct Stones

x bilirubin and alkaline phosphataseassociated with common duct stones

xCombination of bilirubin level > 3.0

and alkaline phosphatase >250:>75% chance of common duct stone

x serum or urine amylase: little, if

any, value

Saltzstein EC, et al. Surg Gynecol Obstet. 1982 Mar;154(3):381-4.Saltzstein EC, et al. Surg Gynecol Obstet. 1982 Mar;154(3):381-4.


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CholecystitisCholecystitis

40 patients: pathologically confirmedacute cholecystitis

x Fever at presentation: 10%

x Leukocytosis at presentation: 60%

xNo single / combination of clinical /laboratory findings at time ofpresentation identified all patients

Singer AJ, et al. Ann Emerg Med. 1996 Sep;28(3):267-72.Singer AJ, et al. Ann Emerg Med. 1996 Sep;28(3):267-72.


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CholecystitisCholecystitis

Acute cholecystitis nongangrene:

71% lack fever

32% lackleukocytosis

28% lack feverand leukocytosis

Acute cholecystitis gangrene:

59% lack fever

27% lackleukocytosis

6% lack fever

and leukocytosis

Gruber PJ, et al. Ann Emerg Med. 1996 Sep;28(3):273-7.Gruber PJ, et al. Ann Emerg Med. 1996 Sep;28(3):273-7.


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HepatitisHepatitis


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HepatitisHepatitis

xALT usually >AST Both 10 100 times normal

x prothrombin time first sign ofcomplicated course

xWBC / differential not helpful


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Spot Urine DipstickSpot Urine Dipstick

x70 74% sensitive for serumbilirubin

x43 53% sensitive for other liverenzyme abnormalities

x77 87% specific for hepatitis

Kupka T, et al. Ann Emerg Med. 1987 Nov;16(11):1231-5.Kupka T, et al. Ann Emerg Med. 1987 Nov;16(11):1231-5.


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Spot Urine DipstickSpot Urine Dipstick

x83 86% positive predictivevalues for detecting at least oneLFT abnormality

x85% negative predictive value forserum bilirubin elevations, but

lower for other LFTsKupka T, et al. Ann Emerg Med. 1987 Nov;16(11):1231-5.Kupka T, et al. Ann Emerg Med. 1987 Nov;16(11):1231-5.


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Typical AST / ALT ValuesTypical AST / ALT Values

Johnston DE. Am Fam Physician. 1999 Apr 15;59(8):2223-30.Johnston DE. Am Fam Physician. 1999 Apr 15;59(8):2223-30.


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Right Lower QuadrantRight Lower Quadrant


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AppendixAppendix


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White Cells and AppendicitisWhite Cells and Appendicitis

x Typical range: 12,00018,000 / mm3

x Leukocytosis in 75 80%

x Immature white cells in 75 80%

xSame as in gastroenteritis, pelvicinflammatory disease, rupturedovarian cyst, ectopic pregnancy, etc.


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xProgressive increase in white cellcount over time: unreliable

xElderly (>60!) with appendicitis:normal white cell count 45% of time

Thimsen DA, et al. Am Surg. 1989 Jul;55(7):466-8.Thimsen DA, et al. Am Surg. 1989 Jul;55(7):466-8.

Scott JH 3rd, et al. J Urol. 1983 May;129(5):1015.Scott JH 3rd, et al. J Urol. 1983 May;129(5):1015.

Freund HR, et al. Am Surg. 1984 Oct;50(10):573-6.Freund HR, et al. Am Surg. 1984 Oct;50(10):573-6.


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xProportion of patients with elevatedwhite cell count and perforation equalto proportion perforated with normal

white cell count


Graham JM, et al. Am J Surg. 1980 Feb;139(2):247-50.Graham JM, et al. Am J Surg. 1980 Feb;139(2):247-50.

Young DV. Am J Surg. 1989 Apr;157(4):428-30.Young DV. Am J Surg. 1989 Apr;157(4):428-30.

Coleman C, et al. Am Surg. 1998 Oct;64(10):983-5.Coleman C, et al. Am Surg. 1998 Oct;64(10):983-5.


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xWhite cell count does not effect

surgeons decision to operateEnglish DC, et al. Am Surg. 1977 Jun;43(6):399-402.English DC, et al. Am Surg. 1977 Jun;43(6):399-402.

Doraiswamy NV. Br J Surg. 1977 May;64(5):342-4.Doraiswamy NV. Br J Surg. 1977 May;64(5):342-4.

Hoffmann J, et al. Br J Surg. 1989 Aug;76(8):774-9.Hoffmann J, et al. Br J Surg. 1989 Aug;76(8):774-9.

xWhite cell count normal early in 80%,eventually rises over 24 hours


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xWhite cell count and differentialnormal in 4 11% of patients withappendicitis

Arnbjornsson E, et al. Acta Chir Scand. 1983;149(8):789-91.Arnbjornsson E, et al. Acta Chir Scand. 1983;149(8):789-91.

Sasso RD, et al. Am J Surg. 1970 Nov;120(5):563-6.Sasso RD, et al. Am J Surg. 1970 Nov;120(5):563-6.

Raftery AT. Br J Surg. 1976 Feb;63(2):143-4.Raftery AT. Br J Surg. 1976 Feb;63(2):143-4.


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Other Laboratory StudiesOther Laboratory Studies

xC-reactive protein and leukocyteelastase: not consistently reliable torule in or rule out appendicitis

BUT

Paajanen H, et al. J Am Coll Surg. 1997 Mar;184(3):303-8.Paajanen H, et al. J Am Coll Surg. 1997 Mar;184(3):303-8.

Eriksson S, et al. Eur J Surg. 1995 Dec;161(12):901-5.Eriksson S, et al. Eur J Surg. 1995 Dec;161(12):901-5.


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Triple TestTriple Test

if white cell count


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Urine and AppendicitisUrine and Appendicitis

xProven appendicitis: 20 30% haveblood, white cells, or bacteria in urine

xRetrocecal appendicitis: abnormal

urine in 50%

Scott JH 3rd, et al. J Urol. 1983 May;129(5):1015.Scott JH 3rd, et al. J Urol. 1983 May;129(5):1015.

Jones WG, et al. J Urol. 1988 Jun;139(6):1325-8.Jones WG, et al. J Urol. 1988 Jun;139(6):1325-8.

Arnbjornsson E. Am J Surg. 1988 Feb;155(2):356-8.Arnbjornsson E. Am J Surg. 1988 Feb;155(2):356-8.

Gardikis S, et al. Int Urol Nephrol. 2002;34(2):189-92.Gardikis S, et al. Int Urol Nephrol. 2002;34(2):189-92.


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EpigastriumEpigastrium


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PancreasPancreas

A l El d i


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Amylase Elevated inAmylase Elevated in

x Pancreatitisx Exctopic

pregnancy

xMacroamylasemia

x Parotitis

x Renal failure

x Bowel obstructionor infarct

x Perforated ulcer

xAcute peritonitis

x Mesentericischemia

x

Other causesVissers RJ, et al. J Emerg Med. 1999 Nov-Dec;17(6):1027-37Vissers RJ, et al. J Emerg Med. 1999 Nov-Dec;17(6):1027-37

SA l N t V S iti


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Amylase Not Very SensitiveAmylase Not Very Sensitive

xRises within 6 to 24 hoursxPeaks in 48 hours

xNormalizes in 5 to 7 days

xSensitivity decreases after first 24 to48 hours

Ranson JH. World J Surg. 1997 Feb;21(2):136-42.Ranson JH. World J Surg. 1997 Feb;21(2):136-42.

A l N t V S ifiA l N t V S ifi


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Amylase Not Very SpecificAmylase Not Very Specific

xAmylase normalnormal in 25 % of patientswith acute pancreatitis

xHighly specific if elevated 5 times

above upper limit of normal

Vissers RJ, et al. J Emerg Med. 1999 Nov-Dec;17(6):1027-37Vissers RJ, et al. J Emerg Med. 1999 Nov-Dec;17(6):1027-37

Li S iti it / S ifi itLi S iti it / S ifi it


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Lipase Sensitivity / SpecificityLipase Sensitivity / Specificity

xElevated in pancreatitis, bowelobstruction, perforated ulcer

x Just as sensitive as amylase

xProbably more specificmore specific thanamylase (80 99%)

xAt five times upper limit of normal:

60% sensitive, 100% specific

Vissers RJ, et al. J Emerg Med. 1999 Nov-Dec;17(6):1027-37Vissers RJ, et al. J Emerg Med. 1999 Nov-Dec;17(6):1027-37

Bili P titi L bBili P titi L b


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Biliary Pancreatitis: LabsBiliary Pancreatitis: Labs

Tenner S, et al. Am J Gastroenterol. 1994 Oct;89(10):1863-6.Tenner S, et al. Am J Gastroenterol. 1994 Oct;89(10):1863-6.

89%93%38%Bilirubin 2.8 mg/dL

87%95%24%Alk Phos >300 U/L

87%95%44%AST

95%96%48%ALT >150 mm/LPPVSpecificitySensitivity


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Ul DiUlcer Disease


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Ulcer DiseaseUlcer Disease

H li b t l iHelicobacter pylori


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Helicobacter pyloriHelicobacter pylori

95-100%95%$250Urea breath test

90%80%$10Whole blood(qualitative)

90%90-95%$75Serum(quantitative)

50-100%70-100%$10Serum

(qualitative)

SpecificitySensitivityCostUS$Test

Falsenegativein515%

Falsenegativein515%



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DiffuseDiffuse


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DiffuseDiffuse

DiffuseDiffuse


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DiffuseDiffuse

Small Bowel ObstructionSmall Bowel Obstruction


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xWBC: not sensitive, not specificxHemoglobin: high if dry, low if

bleeding

xAmylase, lactate, creatinephosphokinase: elevated late

xElectrolytes, renal function: if

prolonged volume loss



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xHistory, physical, temperature, x-ray,white blood count, serum amylase:cannot differentiate simple bowel

obstruction from strangulated bowel

Deutsch AA, et al. Postgrad Med J. 1989 Jul;65(765):463-7.Deutsch AA, et al. Postgrad Med J. 1989 Jul;65(765):463-7.


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Nonspecific Abdominal PainNonspecific Abdominal Pain


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Nonspecific Abdominal PainNonspecific Abdominal Pain

xMost common in youngx Low social class

xPsychiatric disorders

BUT

If older than 50 years, 10% shown tohave intra-abdominal cancer withinnext year

Other Causes PainOther Causes Pain


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Other Causes PainOther Causes Pain

xDiverticulitis

x Rupturedabdominal aorticaneurysm

x Perforated viscus

x Regional enteritis

x Psoas abscess

x Endometriosis

xMittelschmerz

x Splenic rupture /infarct

x

Cecal volvulusx Gastric volvulus

x Sigmoid volvulus

x

Rectus hematomax Etc.


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Abdominal Pain labs

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