My patient with jaundice complains of abdominal fullness. How useful is the history or physical exam when assessing for ascites?

Even in the age of ultrasound, history and physical exam can be useful in assessing for ascites.

History is a good place to start. Of all the questions we often ask when we suspect ascites (eg, increasing abdominal girth, weight gain and ankle swelling), lack of report of ankle swelling is probably the most helpful in excluding ascites (negative likelihood ratio [LR-], 0.1 in a study involving men), followed by no increase in abdominal girth (LR-, 0.17). Conversely, patient reported ankle swelling or increasing abdominal girth may be helpful in suspecting ascites (LR+ 4.12 and 2.8, respectively). 1

Of the various physical signs and maneuvers, absence of peripheral edema is highly associated with the lack of ascites, followed by lack of shifting dullness or fluid wave (LR-, 0.2, 0.3, 0.4, respectively). The presence of a fluid wave may be the most helpful in suspecting ascites, followed by peripheral edema, and shifting dullness (LR+ 6.0, 3.8, 2.7, respectively). 1  Relatively high sensitivities have been reported for shifting dullness (83-88%), while relatively high specificities have been reported for the fluid wave test (82-90%).2,3 An elevated INR may also improve the positive predictive value of shifting dullness and fluid waves.4

So if you don’t get a history of ankle edema and find no evidence of peripheral edema or shifting dullness on exam, the likelihood of ascites is pretty low. On the other hand, if you find a positive fluid wave, you can be pretty sure that the patient has ascites.

Of course, the actual likelihood of detecting ascites also depends on several other factors, including your pre-test probability and the volume of the ascites in the abdominal cavity, with at least ~500 ml of ascites necessary before it can be detected on exam (vs ~100 ml for ultrasound). 2,5

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References

  1. Williams JW, Simetl DL. Does this patient have ascites? How to divine fluid in the abdomen. JAMA 1992;267: 2645-48. https://jamanetwork.com/journals/jama/fullarticle/397285
  2. Cattau EL, Benjamin SB, Knuff TE, et al The accuracy of the physical examination in the diagnosis of suspected ascites. JAMA 1982;247:1164-66. https://www.ncbi.nlm.nih.gov/pubmed/7057606
  3. Cummings S, Papadakis M, Melnick J, et al. The predictive value of physical examinations for ascites. West J Med 1985;142:633-36. https://www.ncbi.nlm.nih.gov/pubmed/3892916
  4. Fitzgerald FT. Physical diagnosis versus modern technology. A review. West J Med 1990;152:377-82. https://www.ncbi.nlm.nih.gov/pubmed/2190412
  5. CDC. Assessment for ascites. https://www.cdc.gov/dengue/training/cme/ccm/Assess%20for%20Ascites_F.pdf. Accessed November 13, 2019.
My patient with jaundice complains of abdominal fullness. How useful is the history or physical exam when assessing for ascites?

My patient with low back pain was just diagnosed with a lumbar spinal epidural abscess. Should I order an MRI of the rest of the spine?

First, look closely for any signs or symptoms which may suggest cord involvement due to spinal epidural abscess (SEA) at other levels of the spine (in this case cervical or thoracic) which would necessitate an urgent MRI. Be particularly on the lookout for new pain (particularly radicular) or paresthesias involving the abdomen, chest or upper extremities (with or without weakness)1.

Otherwise, whether an MRI of the entire spine should be routinely obtained after a diagnosis of SEA in the absence of any suggestive signs or symptoms is less clear, in part related to lack of properly designed studies.1-4

Nevertheless, a retrospective study involving 233 patients with SEA may shed some light on the subject. Based on 22 cases of noncontiguous SEA (9.4% of total), the following independent risk factors were identified3:

  • Delay in presentation (≥1 week of symptoms)
  • Concomitant area of infection outside the spine and paraspinal region
  • ESR > 95 mm/h at presentation

Probability of non-contiguous SEA based on the number of risk factors was as follows:

  • 3 risk factors: 73%
  • 2 risk factors: 13%
  • 1 risk factor: 2%
  • Zero risk factor: 0%

Despite several shortcomings and the need to confirm its findings2,3, this study helps raise awareness of the potential for concurrent but asymptomatic SEA elsewhere in the spine whenever SEA is diagnosed.

 

References

  1. Bond A, Manian FA. Spinal epidural abscess: a review with special emphasis on earlier diagnosis. BioMed Res International 2016;Volume 2016, Article ID 1614328. https://www.hindawi.com/journals/bmri/2016/1614328/
  2. Schoenfeld AJ, Hayward RA. Predicting modeling for epidural abscess: what we can, can’t, and should do about it. Spine J 2015;15:102-104. http://www.sciencedirect.com/science/article/pii/S152994301401554X
  3. Ju KL, Kim SD, Melikian R, et al. Predicting patients with concurrent noncontiguous spinal epidural abscess lesions. Spine J 2015;15:95-101. https://www.ncbi.nlm.nih.gov/pubmed/24953159
  4. Pfister HW, vonRosen F, Yousry T. MRI detection of epidural spinal abscesses at noncontiguous sites. J Neurol 1996;243:315-7. https://www.ncbi.nlm.nih.gov/pubmed/8965103
My patient with low back pain was just diagnosed with a lumbar spinal epidural abscess. Should I order an MRI of the rest of the spine?

“In my patient with abdominal pain, what physical exam finding can help differentiate abdominal wall from intra-abdominal sources of pain?”

Carnett’s sign (described by a surgeon, J.B. Carnett, in 1926) is a physical exam finding that helps differentiate abdominal wall or psychogenic pain from intra-abdominal sources of pain.

The test is considered positive when, upon locating the tender abdominal spot, the patient’s pain worsens on tensing of the abdominal wall muscles by lifting the head and shoulders from the bed or by raising both legs with straight knees. Conversely, if the pain decreases with this maneuver, an intra-abdominal source is more likely1,2. Sensitivity of ~80%, specificity of ~90%, positive likelihood ratio of 2.6 and negative likelihood ratio of 0.2 have been reported in various studies. 3,4,5

A positive Carnett’s sign should broaden the differential of abdominal pain to include: hernias, irritation of intercostal nerve roots, rectus sheath hematomas, myofascial pain, anterior cutaneous nerve entrapment or ACNES (also see another P4P pearl 6) and psychogenic pain. In the appropriate clinical setting,  local corticosteroids or anesthetic injections, or the application of hot or cold packs may be therapeutic. 2,7

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 References

  1. Carnett JB. Intercostal neuralgia as a cause of abdominal pain and tenderness. J Surg Gynecol Obstet 1926; 42:625-632.
  2. Bundrick JB, Litin SC. Clinical pearls in general internal medicine.  Mayo Clin Proceedings 2011;86: 70–74.  https://mayoclinic.pure.elsevier.com/en/publications/clinical-pearls-in-general-internal-medicine-2.
  3. Takada T, Ikusaka M, Ohira Y, et al. Diagnostic usefulness of Carnett’s test in psychogenic abdominal pain. Intern Med 2011;50:213-17. https://www.jstage.jst.go.jp/article/internalmedicine/50/3/50_3_213/_article
  4. Kamboj Ak, Hoverten P, Oxentenko AS. Chronic abdominal wall pain: a common yet overlooked etiology of chronic abdominal pain. Mayo Clin Proc 2019;94:139-44. https://www.mayoclinicproceedings.org/article/S0025-6196(18)30852-8/pdf
  5. Sweetser S. Abdominal wall pain: a common clinical problem. Mayo Clin Proc 2019;94:347-335.https://www.mayoclinicproceedings.org/article/S0025-6196(18)30671-2/fulltext  
  6. https://pearls4peers.com/2015/11/18/whats-acnes-anterior-cutaneous-nerve-entrapment-syndrome/
  7. Suleiman S , Johnston DE.  The abdominal wall: an overlooked source of pain. Am Fam Physician 2001; 64: 431-8. https://www.ncbi.nlm.nih.gov/pubmed/11515832

Contributed in part by Brad Lander MD, Mass General Hospital, Boston, MA.

 

“In my patient with abdominal pain, what physical exam finding can help differentiate abdominal wall from intra-abdominal sources of pain?”

Are GI symptoms such as nausea, vomiting, and diarrhea common in patients with influenza?

Typically, GI symptoms are more prominent in children with influenza than adults but during the H1N1 epidemic in 2009 (which has subsequently become endemic), up to 26% of hospitalized adults with H1N1 infection had abdominal pain or vomiting and up to 25% had diarrhea (1).  In fact, H1N1 virus has been isolated from stool of adult hospitalized patients (2).

Interestingly, the mechanism involved in influenza-mediated intestinal injury may have less to do with direct invasion of the intestinal mucosa by the virus and more to do with immune mediated changes  related to alterations in the intestinal microbiota induced by influenza virus infection itself (3)!  Who would have thought?

 

References

  1. Writing Committee of the WHO Consultation on Clinical Aspects of Pandemic (H1N1) 2009 influenza. Clinical aspects of pandemic 2009 influenza A (H1N1) virus infection. N Engl J Med 2010;362:1708-19.
  2. Yoo SJ, Moon SJ, Kuak E-Y, et al. Frequent detection of pandemic (H1N1) 2009 virus in stools of hospitalized patients. J Clin Microbiol 2010; 48:2314-2315.
  3. Wang J, Li F, Wei H, et al. Respiratory influenza virus infection induces intestinal immune injury via microbiota mediated Th17 cell-dependent inflammation. J Exp Med 2014;211:2397-2410.
Are GI symptoms such as nausea, vomiting, and diarrhea common in patients with influenza?

What’s ACNES (anterior cutaneous nerve entrapment syndrome)?

 As the name implies, this is an abdominal pain syndrome thought to be due to the entrapment of cutaneous branches of an intercostal nerve at the level of the rectus abdominis muscle (1,2).   It may be acute or chronic.

Up to a third of patients with chronic abdominal pain may have ACNES with the source of pain attributed to the abdominal wall, not the viscera (1,3).  Unfortunately, a third of patients with ACNES experience pain for >1 year and about 10% for > 5 years before diagnosis of ACNES is made.

In about one-half of cases, ACNES begins spontaneously, with the remainder developing after abdominal surgery or pregnancy, or is associated with “sports”, “job” or “unusual activity” (4).   Females outnumber males by a 4:1 margin with an average age of 37  y (2).  Carnett’s sign on physical exam may be a clue (2,5) with a sensitivity of 78% and specificity of 88% for abdominal wall pain (6) .

Identification of abdominal wall trigger points and their infiltration with lidocaine may relieve the pain instantaneously and can serve as a diagnostic test.  Surgical neurectomy may be effective in those with only temporary or partial response to repeated lidocaine injections (1).

 

References

1. Boelens OBA, Scheltinga MR, Houterman S, et al. Randomized clinical trial of trigger point infiltration with lidocaine to diagnose anterior cutaneous nerve entrapment syndrome. Br J Surg 2013;100:217-221. https://www.ncbi.nlm.nih.gov/pubmed/23180371

2. van Assen T, Brouns JAGM, Scheltinga MR, et al. Incidence of abdominal pain due to anterior cutaneous nerve entrapment syndrome in an emergency department. Scand J Trauma Resusc Emerg Med 2015;23:19. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4327965  

3. van Assen T, de Jager-Kievit JW, Scheltinga MR, et al. Chronic abdominal wall pain misdiagnosed as functional abdominal pain. J Am Board Fam Med 2013;26:738-44. https://www.ncbi.nlm.nih.gov/pubmed/24204070

4. Boelens OB, Scheltinga MR, Houterman S, et al. Management of anterior cutaneous nerve entrapment syndrome in a cohort of 139 patients. Management of anterior cutaneous nerve entrapment syndrome in a cohort of 129 patients. Ann Surg 2011;254:1054-1058.  https://www.ncbi.nlm.nih.gov/pubmed/21881494

5. Pearls4Peers.  https://pearls4peers.com/2016/12/20/in-my-patient-with-abdominal-pain-what-physical-exam-finding-can-help-differentiate-abdominal-wall-from-intra-abdominal-sources-of-pain

6. Sweetser S. Abdominal wall pain: a common clinical problem. Mayo Clin Proc 2019;94:347-355. https://www.mayoclinicproceedings.org/article/S0025-6196(18)30671-2/fulltext

 

 

What’s ACNES (anterior cutaneous nerve entrapment syndrome)?