Role of fine catheter peritoneal cytology and laparoscopy in the management of acute abdominal pain

Abstract

Laparoscopy and fine catheter peritoneal cytology (FCPC) have been advocated as aids in the assessment of acute abdominal pain. In all, 411 patients admitted to a district general hospital during a 10-month period were managed using a standard protocol incorporating these techniques. After initial assessment by a surgical registrar, 151 patients were excluded from further progress through the protocol (age less than 16 years, definite diagnosis made or contraindication to FCPC. The remaining 260 patients were placed in one of four management groups: (A) urgent operation (23 patients); (B) 'look and see' (40 patients); (C) 'wait and see' (59 patients); (D) urgent operation not indicated (138 patients). Eighty-eight of 99 patients (88 per cent) in groups B and C, where the need for operation was uncertain, underwent successful FCPC and 39 patients (39 per cent) underwent laparoscopy. In these patients the initial registrar management decision proved to be incorrect in 33 cases (33 per cent), but by following the protocol the number of management errors actually made was reduced to 13 (13 per cent, P less than 0.001). This would have been reduced to 8 per cent if the protocol had not been violated in five patients. This study demonstrates the effectiveness of a protocol using FCPC and laparoscopy to improve the management of patients with acute abdominal pain.

Macroscopic assessment of the appendix at diagnostic laparoscopy is reliable

“…A multitude of studies have addressed this issue, and various techniques and technologies have been assessed, including structured history-taking and examination [48,57,59,89,95], algorithms and scores [5,8,57,134], biochemical investigations [1,37,39], peritoneal lavage [54], computer-aided diagnosis [32], radiological investigations [20], and ultrasound [57,59,60,61,104]. Laparoscopy was initially introduced as a promising and powerful additional diagnostic tool.…”

Effect of CO₂ Pneumoperitoneum on Bacteremia in Experimental Peritonitis

“…Laparoscopic surgery is being increasingly used in patients with localized peritonitis such as appendicitis, perforated peptic ulcer, cholecystitis, and intestinal obstruction [1,2]. In the future, laparoscopic surgery will proba bly be used in cases with generalized peritoni tis.…”

“…with localized peritonitis such as acute chole cystitis, acute appendicitis, gastroduodenal ulcer perforation and intestinal obstruction [1,2], Previously, peritonitis was generally considered a relative contraindication for lap aroscopic surgery, but this has changed re cently as the surgeons' experience and selfconfidence have increased [3]. It is generally necessary to induce pneumoperitoneum and to increase intra-abdominal pressure to 14-15 mm Hg during laparoscopic procedures.…”

Strategies for reducing inappropriate laparotomy rate in the acute abdomen.

“…The risk ofperforating underlying viscera seems to be small when a cannula of this size is used.5' An increase in the proportion of polymorphonuclear cells (>50%) has been shown to predict reliably the presence of acute intra-abdominal inflammatory conditions (fig 3).5' This technique has now been used to improve clinical decision making in difficult cases of acute abdominal pain5 and, when performed on every patient with acute abdominal pain, BMJ VOLUME 303 2 NOVEMBER 1991 History and examination by using structured data sheets (with or without computer aided diagnosis) Emergency investigations (including ultrasonography when possible) Diagnosis established t Treat as appropnate significantly reduces the number of inappropriate management decisions.52 Acute inflammatory conditions requiring surgery and those which do not cannot be differentiated by peritoneal cytology, although it does identify patients without an inflammatory focus. Thus fine catheter aspiration is of most value as an investigation before laparoscopy, with negative results preventing unnecessary laparoscopy and patients with positive results proceeding to laparotomy or laparoscopy depending on the clinical picture.53 54 Peritoneal lavage, although usually used to investigate blunt abdominal trauma," has also been used to assess the acute (non-traumatic) abdomen. 56 As in trauma examination of lavage fluid for leucocytes, red cells, bile, amylase, and bacteria provides valuable information about the underlying condition and the need for surgery.…”