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Abdominal Pain: Laboratory Test Pearls and Pitfalls

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Title: Abdominal Pain: Laboratory Test Pearls and Pitfalls


1
Abdominal Pain Laboratory Test Pearls and
Pitfalls
  • Joe Lex, MD, FAAEM
  • Temple University Hospital
  • Philadelphia, PA USA
  • Education Chair, American Academy of Emergency
    Medicine

2
Abdominal Pain
  • 10 of Emergency Department visits
  • 40 diagnosed as nonspecific
  • 50 of those admitted discharged with change in
    diagnosis

3
Differential Includes…
  • Diabetic ketoacidosis
  • Alcoholic ketoacidosis
  • Uremia
  • Sickle cell disease
  • Porphyria
  • Systemic lupus
  • Vasculitis
  • Glaucoma
  • Hypertension
  • Scorpion sting
  • Methanol poisoning
  • Black widow spider bite

4
Differential Includes…
  • Heavy metal toxicity
  • Acute coronary syndrome
  • Pneumonia
  • Pulmonary embolism
  • Testicular torsion
  • Herniated thoracic disc
  • Streptococcal pharyngitis
  • Rocky Mountain spotted fever
  • Mononucleosis
  • Etc.

5
Differential Includes…
  • …and those are just the extraabdominal causes of
    abdominal pain
  • Id be happy with a test that could tell me that
    the source of pain was really the abdomen.

6
Literature Suggests We Get…
  • White blood cells
  • Electrolytes
  • Glucose
  • Renal functions
  • Liver functions
  • Amylase / lipase
  • Pregnancy test
  • Urinalysis
  • C-reactive protein
  • Procalcitonin
  • Lactate
  • Phosphorus
  • Leukocyte elastase
  • Others??

LABS
7
Literature Suggests We Get…
LABS
8
First and Foremost…
  • Female ovaries pregnancy
  • When patients said…
  • My last period was on time.
  • I dont think Im pregnant.
  • I cant possibly be pregnant.
  • …10 were pregnant.

PREGNANCY
Ramoska EA, et al. Ann Emerg Med. 1989
Jan18(1)48-50.
9
Abdominal Pain
10
Right Upper Quadrant
11
Gall Bladder
G B
12
Gall Stones / Colic
  • No pathognomonic study
  • Lab studies should all be normal
  • ? ALT / AST think hepatitis
  • ? alkaline phosphatase / bilirubin think common
    bile duct obstruction
  • ? amylase / lipase think pancreatitis

G B
13
Common Duct Stones
  • ? serum bilirubin in 32
  • ? aminotransferases in 34
  • ? alkaline phosphatase in 22
  • Common duct stones in 17.4
  • Best predictive value for duct stone ? alkaline
    phosphatase (46)

G B
Jarvinen H. Ann Clin Res. 1978 Dec10(6)323-7.
14
Common Duct Stones
  • ? bilirubin and alkaline phosphatase associated
    with common duct stones
  • Combination of bilirubin level gt 3.0 and alkaline
    phosphatase gt250 gt75 chance of common duct
    stone
  • ? serum or urine amylase little, if any, value

G B
Saltzstein EC, et al. Surg Gynecol Obstet. 1982
Mar154(3)381-4.
15
Cholecystitis
  • 40 patients pathologically confirmed acute
    cholecystitis
  • Fever at presentation 10
  • Leukocytosis at presentation 60
  • No single / combination of clinical / laboratory
    findings at time of presentation identified all
    patients

G B
Singer AJ, et al. Ann Emerg Med. 1996
Sep28(3)267-72.
16
Cholecystitis
  • Acute cholecystitis nongangrene
  • 71 lack fever
  • 32 lack leukocytosis
  • 28 lack fever and leukocytosis
  • Acute cholecystitis gangrene
  • 59 lack fever
  • 27 lack leukocytosis
  • 6 lack fever and leukocytosis

G B
Gruber PJ, et al. Ann Emerg Med. 1996
Sep28(3)273-7.
17
Hepatitis
Liver
18
Hepatitis
  • ALT usually gtAST
  • Both 10 100 times normal
  • ? prothrombin time first sign of complicated
    course
  • WBC / differential not helpful

Liver
19
Spot Urine Dipstick
  • 70 74 sensitive for serum bilirubin
  • 43 53 sensitive for other liver enzyme
    abnormalities
  • 77 87 specific for hepatitis

Liver
Kupka T, et al. Ann Emerg Med. 1987
Nov16(11)1231-5.
20
Spot Urine Dipstick
  • 83 86 positive predictive values for detecting
    at least one LFT abnormality
  • 85 negative predictive value for serum bilirubin
    elevations, but lower for other LFTs

Liver
Kupka T, et al. Ann Emerg Med. 1987
Nov16(11)1231-5.
21
Typical AST / ALT Values
Liver
Johnston DE. Am Fam Physician. 1999 Apr
1559(8)2223-30.
22
Abdominal Pain
23
Right Lower Quadrant
24
Appendix
25
White Cells and Appendicitis
  • Typical range 12,00018,000 / mm3
  • Leukocytosis in 75 80
  • Immature white cells in 75 80
  • Same as in gastroenteritis, pelvic inflammatory
    disease, ruptured ovarian cyst, ectopic
    pregnancy, etc.

RULE IN?
26
White Cells and Appendicitis
  • Progressive increase in white cell count over
    time unreliable
  • Elderly (gt60!) with appendicitis normal white
    cell count 45 of time

Scott JH 3rd, et al. J Urol. 1983
May129(5)1015.
RULE IN?
Thimsen DA, et al. Am Surg. 1989
Jul55(7)466-8.
Freund HR, et al. Am Surg. 1984
Oct50(10)573-6.
27
White Cells and Appendicitis
  • Proportion of patients with elevated white cell
    count and perforation equal to proportion
    perforated with normal white cell count

RULE IN?
Coleman C, et al. Am Surg. 1998
Oct64(10)983-5.
Young DV. Am J Surg. 1989 Apr157(4)428-30.
Graham JM, et al. Am J Surg. 1980
Feb139(2)247-50.
28
White Cells and Appendicitis
  • White cell count normal early in 80, eventually
    rises over 24 hours

Doraiswamy NV. Br J Surg. 1977 May64(5)342-4.
RULE IN?
Hoffmann J, et al. Br J Surg. 1989
Aug76(8)774-9.
  • White cell count does not effect surgeons
    decision to operate

English DC, et al. Am Surg. 1977
Jun43(6)399-402.
29
White Cells and Appendicitis
  • White cell count and differential normal in 4
    11 of patients with appendicitis

RULE IN?
Arnbjornsson E, et al. Acta Chir Scand.
1983149(8)789-91.
Sasso RD, et al. Am J Surg. 1970
Nov120(5)563-6.
Raftery AT. Br J Surg. 1976 Feb63(2)143-4.
30
Other Laboratory Studies
  • C-reactive protein and leukocyte elastase not
    consistently reliable to rule in or rule out
    appendicitis
  • BUT…

RULE IN?
Paajanen H, et al. J Am Coll Surg. 1997
Mar184(3)303-8.
Eriksson S, et al. Eur J Surg. 1995
Dec161(12)901-5.
31
Triple Test
  • …if white cell count lt9000 / mm3 AND
  • …if neutrophils lt75 of total white cells AND
  • …C-reactive protein lt0.6 mg/dL, THEN
  • Negative predictive value approaches 100

RULE OUT?
Dueholm S, et al. Dis Colon Rectum. 1989
Oct32(10)855-9.
32
Urine and Appendicitis
  • Proven appendicitis 20 30 have blood, white
    cells, or bacteria in urine
  • Retrocecal appendicitis abnormal urine in 50

RULE OUT?
Arnbjornsson E. Am J Surg. 1988 Feb155(2)356-8.
Scott JH 3rd, et al. J Urol. 1983
May129(5)1015.
Jones WG, et al. J Urol. 1988 Jun139(6)1325-8.
Gardikis S, et al. Int Urol Nephrol.
200234(2)189-92.
33
Abdominal Pain
34
Epigastrium
35
Pancreas
36
Amylase Elevated in…
  • Pancreatitis
  • Exctopic pregnancy
  • Macroamylasemia
  • Parotitis
  • Renal failure
  • Bowel obstruction or infarct
  • Perforated ulcer
  • Acute peritonitis
  • Mesenteric ischemia
  • Other causes

AMYLASE
Vissers RJ, et al. J Emerg Med. 1999
Nov-Dec17(6)1027-37
37
Amylase Not Very Sensitive
  • Rises within 6 to 24 hours
  • Peaks in 48 hours
  • Normalizes in 5 to 7 days
  • Sensitivity decreases after first 24 to 48 hours

AMYLASE
Ranson JH. World J Surg. 1997 Feb21(2)136-42.
38
Amylase Not Very Specific
  • Amylase normal in 25 of patients with acute
    pancreatitis
  • Highly specific if elevated 5 times above upper
    limit of normal

AMYLASE
Vissers RJ, et al. J Emerg Med. 1999
Nov-Dec17(6)1027-37
39
Lipase Sensitivity / Specificity
  • Elevated in pancreatitis, bowel obstruction,
    perforated ulcer
  • Just as sensitive as amylase
  • Probably more specific than amylase (80 99)
  • At five times upper limit of normal 60
    sensitive, 100 specific

LIPASE
Vissers RJ, et al. J Emerg Med. 1999
Nov-Dec17(6)1027-37
40
Biliary Pancreatitis Labs
PANCREAS
Tenner S, et al. Am J Gastroenterol. 1994
Oct89(10)1863-6.
41
Other Possible Markers
  • Phospholipase A2
  • C-reactive protein
  • Interleukin-6
  • Interleukin-8
  • Trypsinogen
  • Trypsin activation peptide
  • Procarboxy-peptidase B activation peptide
  • Serum amyloid A
  • Procalcitonin
  • Leukocyte elastase

PANCREAS
Rau B, et al. Dig Dis. 200422(3)247-57.
42
Ulcer Disease
ULCER
43
Helicobacter pylori
ULCER
False negative in 5 15
44
Abdominal Pain
45
Diffuse
46
Diffuse
47
Small Bowel Obstruction
  • WBC not sensitive, not specific
  • Hemoglobin high if dry, low if bleeding
  • Amylase, lactate, creatine phosphokinase
    elevated late
  • Electrolytes, renal function if prolonged volume
    loss

S B O
48
Small Bowel Obstruction
  • History, physical, temperature, x-ray, white
    blood count, serum amylase cannot differentiate
    simple bowel obstruction from strangulated bowel

S B O
Deutsch AA, et al. Postgrad Med J. 1989
Jul65(765)463-7.
49
Small Bowel Ischemia
  • Leukocytosis common, nonspecific
  • Hemoconcentration, metabolic acidosis with base
    deficit, hyperamylasemia nonspecific, present in
    gt50
  • Lactate 100 sensitive, 42 87 specific

Ischemia
Ruotolo RA, et al. Clin Geriatr Med. 1999
Aug15(3)527-57.
50
Nonspecific Abdominal Pain
  • Most common in young
  • Low social class
  • Psychiatric disorders
  • BUT…
  • …If older than 50 years, 10 shown to have
    intra-abdominal cancer within next year

51
Other Causes Pain
  • Diverticulitis
  • Ruptured abdominal aortic aneurysm
  • Perforated viscus
  • Regional enteritis
  • Psoas abscess
  • Endometriosis
  • Mittelschmerz
  • Splenic rupture / infarct
  • Cecal volvulus
  • Gastric volvulus
  • Sigmoid volvulus
  • Rectus hematoma
  • Etc.

Others
52
No Magic Bullet
  • History and physical exam still most important
  • Lab studies helpful if interpreted properly
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