The rapid development of modern science and technology, on the one hand, has promoted the progress of medical diagnosis and treatment technology, on the other hand, has also significantly increased the demand of the general public for medical consultation; doctors feel that patients often hang on the words: I have taken films, ultrasound, and even CT, why can’t I even find the cause of a stomachache? Therefore, in order to alleviate this confusion to a certain extent and to promote your understanding of the medical diagnosis process of acute stomach pain, I would like to talk to the majority of patients and friends about the diagnosis of acute abdominal disease in more common language as much as possible, and tell them how doctors diagnose and analyze acute abdominal disease. Zhang Jinxiang, Department of Emergency Medicine, Wuhan Union Medical College Hospital
Acute abdominal disease is commonly known as “stomach pain”, which is very common clinically and is defined as “a general term for a variety of diseases with acute abdominal pain as the main clinical manifestation”, with an incidence of about 25% or more of abdominal surgery patients. Compared with the general sense of plain patients, its distinctive features are: rapid onset, rapid changes, delayed diagnosis and treatment can bring about quite serious or even fatal consequences.
In medicine, we often divide acute abdominal diseases into various categories.
1. according to the cause: traumatic acute abdomen, non-traumatic acute abdomen.
2. by treatment method: surgical acute abdomen (mostly requiring surgical treatment), medical acute abdomen (surgery is prohibited).
3. by specialty: surgical acute abdomen, internal medicine acute abdomen, gynecological acute abdomen, pediatric acute abdomen, other specialty acute abdomen (such as neurology, dermatology, ophthalmology, etc.).
4. according to the etiology, they can be divided into: infectious/inflammatory, acute cavity organ perforation, hemorrhagic, cavity organ obstruction, vascular embolism, etc.
5. there are also rare acute abdominal conditions, such as severe abdominal pain produced by aneurysms of the entrapped abdominal aorta, which are both dangerous and difficult to classify as such.
It is clear that acute abdominal pain can be symptomatic of multiple medical disciplines and systemic diseases, which means that patients with acute “stomach pain” may have a condition that lies outside the “stomach”. Therefore, the diagnosis of acute abdominal disease requires comprehensive clinical knowledge and the full cooperation and understanding of the patient. In other words, if a doctor only understands the lesions in the abdominal cavity but does not have a comprehensive and in-depth grasp of the whole body system, he is likely to make mistakes in the diagnosis of acute abdominal pain. With the development of social progress and modern medical treatment technology, medical specialization has become more and more in-depth, although the diagnosis level of some diseases in acute abdominal disease such as pancreatitis and vascular embolism has been significantly improved and good results have been achieved; however, because acute abdominal disease covers many kinds of diseases and has a variety of clinical manifestations, often lacking specificity, and cannot completely rely on modern treatment equipment, misdiagnosis of acute abdominal disease is still common. I think this is more difficult for patients to understand: how can this still happen nowadays when medical technology is so advanced? Therefore, we will discuss the diagnosis and differential diagnosis of acute abdominal pain from a professional perspective as follows.
Doctors in the diagnosis of acute abdominal disease will first grasp the most central key issues.
1. first determine whether life-threatening conditions exist, such as acute myocardial infarction, diabetic hyperosmolar coma, hematopoietic crisis, ruptured abdominal aortic coarctation, etc. If these conditions exist, the underlying principle is to save life first, and the program implemented is to rescue and diagnose at the same time; if misdiagnosis occurs at this level, it will seriously endanger the patient’s life and even accidental death.
2. distinguishing between surgical acute abdomen and non-surgical acute abdomen.
3. in the case of surgical acute abdomen, the presence of an indication for emergency surgery (i.e., the need for immediate surgical treatment, despite the absence of a specific diagnosis).
The specific process by which physicians make the diagnosis and differential diagnosis of acute abdomen.
The diagnostic and differential diagnostic process for acute abdominal pain begins the moment the patient is seen and includes three bases and one analysis. Foundation 1: collection of a detailed and accurate medical history; Foundation 2: comprehensive and detailed physical examination; Foundation 3: reasonable and necessary laboratory and special tests. On top of this foundation, a “monogenic etiology” (by monogenic, we mean that all manifestations of this abdominal pain episode are caused by one cause) is analyzed and explained.
Since most of the diseases that lead to acute abdominal disease are common and frequent, such as acute appendicitis, acute intestinal obstruction, acute pancreatitis, acute cholecystitis, acute perforation of ulcer disease, etc., which are encountered every day in emergency surgery, the diagnosis and differential diagnosis of acute abdominal disease are made by the physician according to the three aspects of history, physical examination and ancillary examinations, i.e., the three basic tasks mentioned above are completed These are as follows.
1. The physician will take a medical history.
We will patiently inquire about various aspects including current medical history (the development of this acute stomach pain), past medical history (previous disease conditions, including those related or unrelated to stomach pain), history of trauma, recent medication use, family history, etc. Female patients also include the need to inquire about menstrual history and marital history. For understandable reasons, we are alert to special circumstances such as young unmarried women concealing a history of sexual life and drug addicts concealing a history of substance abuse, and we pay attention to the mannerisms of the patient to detect clues and make sound judgments. When the past history suggests the presence of a highly dangerous underlying disease, the doctor will pay attention around this point, such as those with a history of hypertensive aortic coarctation, such patients should be included in a highly dangerous acute abdomen and be given focused attention in order to affirm or exclude them as soon as possible. Professor Xia Suisheng, a renowned surgical expert, has pointed out that “a complete medical history is half of the correct diagnosis of acute abdomen”.
The collection of current medical history should be centered on acute abdominal pain, paying attention to the differences in pain response/tolerance among people of different age levels, different occupational distributions, and different religious beliefs, from several aspects such as the trigger and urgency of pain onset, the location, degree, nature of abdominal pain, the presence or absence of radiation or metastasis, and the types of accompanying symptoms. Of course, from the patient’s point of view, it should be obligatory to take the initiative to provide a detailed and complete medical history, paying particular attention not to make judgments and draw conclusions on their own.
2. This will be followed by a careful physical examination.
The diagnosis of patients with acute abdomen often starts from the moment the patient is seen, and the physician begins to collect information about the patient’s gait, posture, appearance, body type, expression, speech, mental status and other aspects through “visualization” from this point on, and changes in this information can often reflect the criticality of the patient’s condition and is a very important clue. Further, vital signs need to be detected, including body temperature, blood pressure, pulse, respiration, and consciousness, pulse oximetry, etc. In the vast majority of cases, these simple physical examinations alone can determine whether a patient with acute abdomen is critical, whether resuscitation procedures should be started immediately, or whether the patient should be allowed to undergo an in-depth examination of routine procedures, thus avoiding the occurrence of respiratory and cardiac malignant events of respiratory and cardiac arrest or even accidental death during the examination of patients with acute abdomen.
When the patient undergoes a routine physical examination, the physician will emphasize the comprehensive collection of abdominal signs, examining the entire abdomen with full exposure of the entire abdomen and even expanding to the chest, pelvis, and low back, especially in cases where there may be intestinal obstruction due to a hernia in the groin or pelvic floor, or a hernia of the abdominal viscera into the chest cavity. The advantage will even be rectal examinations, and in female patients, double consultation will be performed to fully understand the cause of acute abdominal pain due to intrapelvic lesions.
Of course, we will pay attention to protect the privacy of the patient during the examination, and at the same time require the patient to cooperate with the physical examination to objectively respond to the true appearance of the lesion.
3. Then, we select various routine and targeted ancillary examinations.
The three routine (blood, urine and fecal) examinations are indispensable, and most of them also choose amylase tests, which have important significance when combined with medical history and physical examination. Further imaging means such as abdominal ultrasound, standing X-ray, or even CT/MRI scan, as well as endoscopic and laparoscopic techniques can be used. Invasive angiography, diagnostic laparotomy or lavage, and posterior vault aspiration will be used when difficulties still exist. For example, CTA (CT angiography) has a definite diagnostic value for intestinal ischemic lesions such as mesenteric vascular embolism and portal vein system thrombosis, which makes up for the deficiency of multispectral color vascular ultrasonography, and has the advantages of non-invasive, non-radiographic exposure and rapid examination that angiography does not have, which is beneficial to the early diagnosis and treatment of intestinal ischemia. The early diagnosis and treatment of acute abdominal disease and greatly reduces the mortality rate of this type of acute abdominal disease.
It is worth noting that, unlike the dependence of general specialty diseases on large comprehensive adjuvant examinations, taking a history and physical examination are the most important cornerstones in the diagnosis of acute abdominal disease, and an experienced physician will, in most cases, form a directional preliminary diagnosis after the collection of acute clinical data (history and physical examination) in patients with acute abdominal disease, and the value of selecting the appropriate adjuvant examinations is mostly in the verification of the already The preliminary diagnosis is formed, and it is important to keep in mind that all ancillary tests are for clinical reference only. These are still highly specialized statements, and it is important for patients to understand that the diagnostic process of acute stomach pain can be simple or complex.
Establishment of the diagnosis of acute abdominal pain
The aforementioned is the collection of relevant data, the diagnosis of acute abdominal disease can only be established after the differential diagnosis is completed (i.e., the doctor fully analyzes and excludes various possibilities), a process that requires the doctor to concentrate on a comprehensive mastery of medical knowledge, with special emphasis on the need for a detailed understanding of the characteristics of common acute abdominal diseases, especially typical acute abdominal diseases, and the characteristics of their lesions, relevant pathophysiological changes, etc. when making the differential diagnosis. In order to fully analyze and comprehensively consider the case without missing important history and signs and meaningful clues, we generally follow the following procedures.
1. to clarify whether the abdominal pain is caused by diseases outside the abdominal cavity, i.e., the acute abdomen is merely an involved or radiating pain of other systemic diseases with primary lesions not in the abdominal cavity, such as pneumothorax/large lobe pneumonia, acute myocardial infarction, herpes zoster, etc.; or the manifestation of systemic diseases in the abdomen, such as systemic lupus erythematosus
2. whether it is a medical emergency abdomen, generally speaking, according to the “monism” viewpoint, acute abdominal pain that occurs gradually after fever first is mostly a medical emergency abdominal pain and does not require surgical treatment, but if the abdominal pain comes first and the fever comes later, it means that the fever is a concomitant manifestation of the abdominal pain, indicating that it is mostly a surgical emergency abdomen and often requires surgical treatment (b)
3. whether gynecological emergency abdomen, in female patients, note the presence of gynecological conditions such as ectopic pregnancy, corpus luteum rupture, ovarian cyst torsion, adnexitis, pelvic inflammatory disease, pregnancy uterine rupture
4. differentiation of pediatric acute abdominal diseases: the spectrum of acute abdominal pain diseases in pediatric patients is different from that in adults, paying attention to acute conditions such as intussusception, acute appendicitis, mesenteric lymphadenitis, and especially to misdiagnosis of abdominal purpura.
5. differentiation between surgical emergencies: about 30 kinds of surgical emergencies are generally encountered, the most common of which are acute appendicitis, acute intestinal obstruction, acute cholecystitis or choledocholithiasis, acute perforation of ulcer disease, acute pancreatitis, etc. in that order. These diseases account for almost 80% or more of all surgical acute abdominal diseases. Despite the wide variety of diseases, these surgical acute tummy aches can be broadly grouped into the following five major categories: (1) infection and inflammation; (2) acute perforation of cavernous organs (spontaneous/traumatic); (3) intra-abdominal hemorrhage (spontaneous/traumatic); (4) cavernous organ obstruction; and (5) organ ischemia. According to their respective characteristics, typical lesions are not difficult to identify, but difficult lesions mostly have atypical and inadequate manifestations and are difficult to diagnose, which require the physician’s attention to careful evidence-based analysis on the one hand, and the assistance of experienced physicians to give the necessary observation and symptomatic treatment and appropriate review (including additional follow-up history, re-examination, and repetition of certain laboratory tests or imaging examinations, etc.) on the other hand. On the other hand, we ask patients and their families to understand and cooperate, especially in the process of observation, do not easily interfere with the doctor’s diagnosis and treatment process, so that through the cooperation of both doctors and patients, the purpose of correct diagnosis and treatment is achieved.
Due to the development of science and technology and the overall level of medicine, there is a large group of patients who are seen for acute abdominal pain and are cured or relieved by non-surgical treatment, but a significant proportion of them are still undiagnosed. (non-spepcific acute abdominal pain, NSAP). From this point alone, it is clear that the accurate diagnosis of acute abdominal pain will remain a long-standing problem and a challenge for the medical community.
Finally, it should be noted that from the physician’s point of view, should all acute abdominal conditions be analyzed according to a “monistic” approach? This is especially true in the elderly population, who may have complex underlying disease states. Perhaps this acute abdominal pain is an abdominal manifestation of the underlying disease and does not require special treatment, but perhaps the opposite is true, and this episode is indeed a surgical emergency and induces an aggravation of the existing underlying disease, such as an acute perforation of a cavernous organ, which induces an acute cardiac accident (e.g., myocardial infarction) in the patient. even lead to the patient’s death. Therefore, in some unconventional cases, it is more important to consider the whole picture and to analyze it comprehensively, not to be satisfied with just a so-called correct diagnosis.
In summary, patients may have a certain understanding of the process of medical diagnosis of acute abdomen, and we hope that patients will understand this in the hope of obtaining their full cooperation and understanding throughout the diagnosis and treatment process, and thus emphasize the importance of the doctor’s patience in asking medical history, careful physical examination and concentration on the mastery of medical knowledge, so that through the joint efforts of both doctors and patients, patients will receive the correct treatment and recover as soon as possible.