Tehran University Medical Journal

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Background: About one-forth of the patients admitted to the emergency department complain of acute abdominal pain. According to surgical records, most surgeons believe that pain relief for these patients may interfere with the clinical examinations and the final diagnoses. As a result, analgesics are withheld in patients with acute abdominal pain until the determination of a definite diagnosis and suitable management plan. The purpose of this study was to evaluate the effect of analgesics on the evaluation course and treatment in acute abdomen.

Methods: Two hundred patients at a surgical emergency department with acute abdominal pain were enrolled in this prospective study and randomly divided into two groups at the time of admission. The case group consisted of 98 patients who received intravenous analgesia immediately after admission. The other 102 patients in the control group did not receive analgesia until a definite diagnosis was made. Diagnostic and therapeutic procedures were similar between the two groups. The primary and final diagnoses, and the time intervals between the admission and definite diagnosis, and that between admission and surgery were gathered and analyzed.

Results: The mean time to definitive diagnosis was 1.7 and 2.04 hours in the case and control groups, respectively. There was no statistically significant relationship between analgesic use and gender, age, time to definite diagnosis, or accuracy of the diagnosis. In fact, the time required to achieve a definite diagnosis and the time between admission and surgery were less in the group that had received analgesics.

Conclusions: In spite of the fact that analgesics remove the very symptoms that brings patients to the emergency room, appropriate use of analgesics does not reduce diagnostic efficiency for patients with acute abdominal pain.

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Background: Acute abdominal pain is a common complaint in an emergency setting. An immediate and precise diagnosis is necessary for reducing morbidity and mortality. Several studies have reported that CT scan increases diagnostic accuracy for patients with acute abdominal pain. This study was designed to evaluate the sensitivity, specificity and accuracy of spiral CT scan compared to that of abdominal ultrasound and plain radiography. 

Methods: We assessed the data of 91 consecutive patients, including 45 males and 46 females, ranging in age from 8 to 84 years (mean age 52.38 years) presenting to the emergency department of Sina Hospital, Tehran, Iran, with acute non-traumatic abdominal pain during the years 2003-2005. All patients underwent spiral CT scanning in addition, sonography and plain radiography were performed for 66 and 64 of the patients, respectively. The sensitivity, specificity and accuracy were calculated and compared, based on the final diagnosis, which was established with surgical, pathologic, and clinical follow-up. The data was analyzed by SPSS 13.0 software.

Results: Among the 91 patients examined, CT scan was reported to be normal in 15 patients (16.5%). The most common CT findings were aortic aneurysm (12.1%), pancreatitis (9.9%), ovarian cyst (7.7%), intestinal distension (7.7%), and hepatic cyst (7.7%). The overall sensitivity, specificity, and accuracy of unenhanced spiral CT were 92.2%, 92.86%, and 92.3%, respectively, whereas those of plain radiography were 13.2%, 72.7%, and 23.4%, respectively, and ultrasound 73.2%, 90%, and 75.7%, respectively.

Conclusions: This study suggests that plain radiography is an insensitive technique in the evaluation of nontraumatic acute abdominal pain presenting in the emergency department. Unenhanced spiral CT is accurate for adult patients with nontraumatic acute abdominal pain and should be considered as an alternative to radiography as the initial imaging modality.

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Background: Management of acute abdomen usually does not necessitate accurate pre-operative diagnosis but the surgeon should make a decision about the need for emergent laparotomy. This fact is somehow different for localized peritonitis (e.g. acute appendicitis) in which the clinical presentation directs straightly to the diagnosis. However, acute appendicitis has lots of differential diagnoses, finding the normal appendix during laparotomy is just a start point to look for other diagnoses. Omental torsion is a rare cause for acute abdomen that is usually missed. Knowing about this rare condition and its frequently encountered presentation at the operating room (sero-sanguinous fluid coming out of peritoneal cavity) may prevent missing the diagnosis and doing a malpractice.
Case report: Report a 9 year- old boy presented with acute abdomen which turned out to be an omental torsion after the operation.
Conclusion: Knowledge about this rare condition "omental torsion" and its clinical and intra operative presentations may prevent missing the diagnosis and a malpractice.

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Background: Tubal sterilization is the permanent and effective contraception method. This can be performed at any time, but at least half are performed in conjunction with cesarean or vaginal delivery and are termed puerperal. The most complication after tubal ligation is ectopic pregnancy. Ectopic pregnancy is the leading cause of maternal death in first trimester.
Case presentation: We present a 33 years old woman gravida5, para4, all normal vaginal delivery, presented with complaints of delayed menstrual period, pelvic pain and spotting. She underwent tubal ligation for two times. For the first time she had puerperal Pomeroy tubal sterilization after third child delivery. Intra uterine pregnancy occurred three years later. One day after vaginal delivery of fourth child, she underwent post partum tubal ligation with the Parkland method. Tubal pregnancy occurred nine months later. Physical examination identified acute abdomen. Pelvic ultrasound showed no gestational sac in uterine cavity. The sac with fetal pole was in right adnexa. Beta-HCG was 2840mIU/ml. She underwent laparotomy. Surgical management included salpingectomy with cornual resection in both sides. The surgery identified Ectopic pregnancy.
Conclusion: Any symptoms of pregnancy in a woman after tubal ligation must be investigated an ectopic pregnancy should be excluded. Ectopic pregnancy must be considered, in any woman with lower abdominal pain, missed period and vaginal bleed-ing. Conception after tubal sterilization can be explained by fistula formation and re-canalization of fallopian tube.

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