Acute Abdominal Pain

Efficacy of Alternative and Other Treatments According to GRADE* Ranking:

Strychnos Nux-Vomica (Maqianzi, Poison Nut) [1, 8, 9, 10]:

WARNING! This substance is HIGHLY POISONOUS. The seeds contain Strychnine, which may cause convulsions, breathing difficulties and death, even if as little as 5 milligrams is ingested

Recommendation: Strongly against (There is no evidence in the form of clinical trials which reports the effectiveness of Strychnos Nux-Vomica, because it is highly poisonous to humans, and is not recommended.)

Grade of Evidence: very low quality of evidence

Peppermint Oil [1, 2, 3, 4, 5, 6, 7]:

Please note, this management does NOT treat the condition itself. It may mildly help with some of the symptoms, and even then has insufficient evidence to back up this claim at present.

Recommendation: no recommendation (There is insufficient evidence to support claims that peppermint helps to treat acute abdominal pain)

Grade of Evidence: low of evidence

Red Pepper (Capsaicin):

Please note, this management does NOT treat the condition itself. It is proposed only as a weak supportive symptomatic support, and even then, has insufficient evidence to back up this claim at present.

Recommendation: weak (There is insufficient evidence to support claims that red peppers help to treat or acute abdominal pain)

Grade of Evidence: very low quality of evidence

Curanderismo:

Recommendation: weak (although there are reports from people that Curanderismo may help deal with pain, but there are no reliable studies done yet)

Grade of Evidence: very low quality of evidence

* www.gradeworkinggroup.org

Acute abdomen

The term acute abdomen refers to a sudden, severe abdominal pain that is less than 24 hours in duration. It is in many cases a medical emergency, requiring urgent and specific diagnosis. Several causes need surgical treatment.

Causes

The differential diagnosis of acute abdomen includes but is not limited to:

1. Acute appendicitis.
2. Acute peptic ulcer and its complications.
3. Acute cholecystitis.
4. Acute pancreatitis.
5. Acute intestinal ischemia (See Section Below.)
6. Diabetic Ketoacidosis.
7. Acute Diverticulitis.
8. Ectopic Pregnancy with tubal rupture.
9. Acute peritonitis.
10. Bowel perforation with free air or bowel contents in the abdominal cavity.
11. Acute ureteral colic.
12. Bowel volvulus.
13. Acute pyelonephritis.

Peritonitis

Acute abdomen is occasionally used synonymously with peritonitis. This is not entirely incorrect; however, peritonitis is the more specific term, referring to inflammation of the peritoneum. It is diagnosed on physical examination as rebound tenderness, or pain upon removal of pressure rather than application of pressure to the abdomen. Peritonitis may result from several of the above diseases, notably appendicitis and pancreatitis.

Ischemic Acute Abdomen

Vascular disorders are more likely to affect the small bowel than the large bowel. Arterial supply to the intestines is provided by the superior and inferior mesenteric arteries, (SMA and IMA respectively) both of which are direct branches of the aorta.

The Superior Mesenteric Artery supplies:

1. Small bowel.
2. Ascending and proximal 2/3 of the Transverse colon.

The Inferior Mesenteric Artery supplies:

1. Distal 1/3 of the Transverse colon.
2. Descending colon
3. Sigmoid colon.

Of note, the splenic flexure, or the junction between the transverse and descending colon, is supplied by the most distal portions of both the Inferior Mesenteric Artery and Superior Mesenteric Artery, and is thus referred to medically as a Watershed area, or an area especially vulnerable to ischemia during periods of systemic hypoperfusion, such as in shock.

Acute abdomen of the ischemic variety is usually due to:

1. A thromboembolism from the left side of the heart, such as may be generated during atrial fibrillation, occluding the SMA.
2. Nonocclusive ischemia, such as that seen in hypotension secondary to heart failure may also contribute, but usually results in a mucosal or mural infarct, as contrasted with the typically transmural infarct seen in thromboembolus of the SMA.
3. Primary mesenteric vein thromboses may also cause ischemic acute abdomen, usually precipitated by hypercoagulable states such as polycythemia vera.

Clinically, patients present with diffuse abdominal pain, bowel distention, and bloody diarrhea. On physical exam, bowel sounds will be absent. Laboratory tests reveal a neutrophilic leukocytosis, sometimes with a left shift, and increased serum amylase. Abdominal radiography will show many air-fluid levels, as well as widespread edema.

Acute ischemic abdomen is a surgical emergency. Typically, treatment involves removal of the region of the bowel that has undergone infarction, and subsequent anastomosis of the remaining healthy tissue.

Workup

Patients presenting to A&E or the ER with severe abdominal pain will almost always have an Abdominal x-ray and / or a CT scan. These tests can provide a differential diagnosis between simple and complex pathologies. It can also provide evidence to the doctor whether surgical intervention is necessary.

Patients will also most likely receive a complete blood count (or full blood count in the U.K.), looking for characteristic findings such as neutrophilia in appendicitis.

Traditionally, the use of opiates or other painkillers in patients with an acute abdomen has been discouraged before the clinical examination, because these would alter the examination. However, the scientific literature does not reveal any negative results from these alterations.

Summary References

Treatments:

1. Ades T, Alteri R, Gansler T, Yeargin P, "Complete Guide to Complimentary & Alternative Cancer Therapies", American Cancer Society, Atlanta USA, 2009

2. http://www.cancer.org/Treatment/TreatmentsandSideEffects/ComplementaryandAlternativeMedicine/HerbsVitaminsandMinerals/peppermint

3. http://www.ncbi.nlm.nih.gov/pubmed/17420159

4. http://www.ncbi.nlm.nih.gov/pubmed/19507027

5. http://www.medicine.ox.ac.uk/bandolier/booth/alternat/AT022.html

6. http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-peppermint.html

7. http://nccam.nih.gov/health/peppermintoil/index.htm

8. David Michael Wood et al. Case report: Survival after deliberate strychnine self-poisoning, with toxicokinetic data. Critical Care October 2002 Vol 6 No 5

9. Arnold, M.D., Harry L. (1968). Poisonous Plants of Hawaii. Tokyo, Japan: Charles E. Tuttle Co.. p. 20. ISBN 0804804745.

10. http://www.cancer.org/Treatment/TreatmentsandSideEffects/ComplementaryandAlternativeMedicine/HerbsVitaminsandMinerals/strychnos-nux-vomica

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