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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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Differential IncludesDifferential Includes
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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Differential IncludesDifferential Includes
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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Abdominal PainAbdominal Pain
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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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Abdominal PainAbdominal Pain
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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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White Cells and AppendicitisWhite Cells and Appendicitis
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
White Cells and AppendicitisWhite Cells and Appendicitis
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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White Cells and AppendicitisWhite Cells and Appendicitis
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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White Cells and AppendicitisWhite Cells and Appendicitis
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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Abdominal PainAbdominal Pain
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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%
Abdominal PainAbdominal Pain
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Abdominal PainAbdominal Pain
DiffuseDiffuse
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DiffuseDiffuse
DiffuseDiffuse
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DiffuseDiffuse
Small Bowel ObstructionSmall Bowel Obstruction
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Small Bowel ObstructionSmall Bowel Obstruction
xWBC: not sensitive, not specificxHemoglobin: high if dry, low if
bleeding
xAmylase, lactate, creatinephosphokinase: elevated late
xElectrolytes, renal function: if
prolonged volume loss
Small Bowel ObstructionSmall Bowel Obstruction
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Small Bowel ObstructionSmall Bowel Obstruction
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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