Imaging in Acute Abdominal Pain

The use of imaging techniques (US and CT) in case of acute abdominal pain no doubts gives help but with high costs, without thinking to radiation exposure caused by CT. Through a Dutch multicentric and prospective trial, 1021 adults with abdominal pain of a duration between 2 hours and 5 days have been studied to determine the optimal diagnostic strategy. Everyone underwent clinical examination, blood tests and standard X-ray. After diagnosis was given in this way, everyone underwent US and CT, with a new record for diagnosis (the radiologist performing X-ray wasn’t able to see ultrasonography and vice versa). Every diagnosis was then compared with final diagnosis, given after 6 months, when the episode had ended. In a retrospective way, urgency conditions have been identified in 65% of patients. The use of US or CT reduced the number of false urgent diagnoses and CT showed to be more sensitive than ultrasonography, even if the greatest sensitiveness was obtained with the performance of ultrasonography to all patients followed by CT in case of negative or non-conclusive US (94% of sensitiveness, with only 6% of false negatives). This technique allowed to limit radiation exposure only for 49% of patients. Diagnostic strategies based on pain localization, age, BMI have shown a lower sensitiveness than the above mentioned strategy.

The trial confirms the greater sensitiveness of CT than ultrasonography, but given the high number of ionizing radiations to which the patient is exposed, the best strategy seems to be to perform a US followed by a CT in case of doubts or negative US.

Bleedings of the Upper Gastrointestinal Tract not Due to Varices

Patients presenting bleedings of the upper gastrointestinal tract not due to esophageal varices are treated according to international guidelines, which have been recently updated according to the available scientific evidence. The fundamental points are the following: - Use a standardized prognostic evaluation to establish the risk of relapsing bleeding and of death. - Make blood transfusions when the Hb level is under 7 mg/dl. - Do not delay endoscopy to correct bleeding disorders or to administer PPIs. - Discharge, in short times, patients with a low risk after an endoscopy. - Perform an early endoscopy (within 24 hours) in most patients. - PPI therapy must be performed in patients presenting a high bleeding risk after endoscopy, and these patients should be hospitalized for at least 72 hours. - At discharge, prescribe a PPI. - If endoscopic treatment fails, consider percutaneous embolization as an alternative to surgery. - In patients with peptic ulcer, perform a HP test and treat the patient if positive. - Repeat HP test if the result is negative in an acute phase. - If necessary, use NSAIDs, associate a PPI or a COX-2 inhibitor. - Aspirin at a cardiovascular dosage must be taken again as soon as the benefit overpasses the bleeding risk: clopidogrel gives a higher risk than aspirin associated with a PPI.

 The consensus document is much detailed and it gives certainly useful indications, most of which, however, are not surprising, since they already belong to usual protocols.

Dyspepsia caused by Protonic Pump Inhibitor Interruption

In a randomized trial performed in 2009, some asymptomatic volunteers have developed dyspeptic symptoms after being treated for 8 weeks with esomeprazole. Now, some Swedish researchers have examined the rebound phenomenon after the interruption of a therapy based on protonic pump inhibitors. 48 healthy and asymptomatic volunteers have been randomized to receive 40 mg of pantoprazole or placebo daily for 4 weeks; then, they have been followed for 6 further weeks. A week after the end of the treatment, subjects treated with the PPI presented dyspeptic symptoms more frequently than subjects treated with placebo (44% vs. 9%) and the average score on an evaluation scale for dyspepsia was significantly higher with pantoprazole (5.7 vs. 0.7). The differences between the two groups have gradually decreased during the second week and they have disappeared during the third week after assumption.

Other trials have documented the onset of dyspepsia after the interruption of a therapy based on PPIs, probably because of some gastrin-mediated phenomena, with rebound hyperacidity. The conclusion is easy: protonic pump inhibitors are very powerful drugs and they must be taken only if there is a real need, warning patients that at their interruption there can be short-duration dyspeptic symptoms.