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A prospective study to define the role of diagnostic laparoscopy in evaluating right lower quadrant pain.

INTRODUCTION

Diagnostic laparoscopy is of tremendous help in a patient with uncertain abdominal pathology. The appropriate implementation of diagnostic laparoscopy often helps to avoid expensive diagnostic studies and more importantly unnecessary laparotomy.

It is indicated if neither laboratory findings nor modern imaging techniques provide a clear diagnosis or if the use of imaging techniques is impossible because of logistic reasons or if the necessary time is not available.

Right lower quadrant pain in abdomen is the most common type of acute abdominal pain (1) and often presents a diagnostic challenge to the surgeon. Patients with right lower quadrant pain often come to medical attention during off hours and hence require an efficient and goal-directed diagnostic assessment to receive the necessary treatment as early as possible. The assessment must often be carried out at times when the availability of ancillary testing is limited.

There are numerous differential diagnoses for this symptom, which can present in various ways (2). Acute appendicitis and diseases of female genital tract are the most frequent causes implicated. The systematic use of laparoscopy especially in cases of diagnostic dilemmas is a very valuable tool to arrive at the proper diagnosis as well to plan the treatment.

AIMS AND OBJECTIVES

This study was conducted in semi urban Government Medical College Hospital during the period of September 2013 to November 2015.

Study group comprised of patients who had undergone Diagnostic Laparoscopy for right lower abdominal pain and none of the patients were advised contrast-enhanced CT (CECT).

The Aims of this Prospective Study are

* To define the role of diagnostic laparoscopy in evaluating right lower abdominal pain.

* To study the incidence of different conditions causing right lower quadrant pain using diagnostic laparoscopy.

Right Lower Quadrant Pain

Diagnosing RLQ pain can be quite difficult in the sense that myriad of reasons are associated with such pain. (3)

The diagnostic evaluation of RLQ pain is challenging not just because of wide variety of causes, but also because the leading differential diagnoses are very much different depending on age and sex of the patient. The most frequent conditions encountered are acute appendicitis or female genital diseases. (4)

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Diagnostic Laparoscopy IN RLQ Pain

Diagnostic laparoscopy is an effective way of evaluating right lower abdominal pain. Though, imaging modalities such as ultrasonography exist to aid in the detection of acute appendicitis, they have low sensitivity and specificity. (6) Diagnostic laparoscopy though invasive is superior to transabdominal or transvaginal ultrasonography in the assessment of female adnexal organs when the diagnosis is in doubt. (7)

As compared to preoperative radiological investigation or a watch and wait policy, laparoscopy yields an accurate diagnosis in more patients. It also provides greater visualisation of other intra-abdominal organs and can also be used for therapeutic purposes.

Although, laparoscopy is not a substitute for good clinical judgment, early laparoscopy reduces the incidence of negative laparotomy, serious complications, and need for expensive preoperative investigations. Also, it offers the advantages of enabling a rapid and accurate assessment and providing a high degree of certainty for any subsequent treatment decisions.

If surgeons with appropriate training and skills are available, therapeutic laparoscopy can then be used to manage the condition with the added benefits of reduced pain, less wound morbidity, and a shorter recovery time.

Although, many patients with acute appendicitis can be diagnosed based on history, physical examination, laboratory studies, and imaging, there are significant number of patients in whom diagnosis remains elusive. Diagnostic laparoscopy will provide a direct examination of the appendix and a survey of the abdominal cavity for the other possible causes of pain. Other important advantage of doing a diagnostic laparoscopy is that it can be extended to a therapeutic procedure in which the appendicectomy can be done laparoscopically.

It is of prime use in women of childbearing age in whom preoperative pelvic ultrasound or CT fails to give a diagnosis and a concern about the possible adverse effects of a missed perforation and peritonitis prompts earlier intervention in this patient population.

Whenever, the clinical findings lead to no clear diagnosis and particularly in young women who maybe suffering either from appendicitis or from adnexitis, (8) laparoscopy is a good option that should be considered if the patient wishes to avoid the radiation exposure associated with CT. In these patients with appendix being found normal in laparoscopy, about 75 percent of them were found to have an underlying gynaecological pathology. (9)

Imaging studies cannot precisely identify the intraabdominal adhesion. Hence, diagnostic laparoscopy becomes the ideal investigation to diagnose it. Also, as adhesions are more common over scar sites, open adhesiolysis may result in recurrence.

The enlarged grossly visible mesenteric nodes seen in diagnostic laparoscopy in a patient presenting with acute RLQ pain is usually due to acute mesenteric lymphadenitis. Laparoscopy is often needed to diagnose and to prevent missed appendicitis. We should also be aware that the multiple enlarged lymph nodes maybe due secondaries from a GI malignancy. (10) It is always better to take a biopsy of lymph node and send it for histopathological examination and act accordingly.

It is a very useful investigation for abdominal tuberculosis in that it aids in direct visualisation of peritoneal cavity to collect ascitic fluid for analysis even when there is minimal fluid and to take biopsy of suspected lesions.

Acute peritoneal tuberculosis (11) though rare can present with acute RLQ pain, which mimics an acute abdomen. Laparoscopy reveals straw-coloured fluid with tubercles in the peritoneum and bowel wall.

MATERIALS AND METHODS

Data was collected prospectively from September 2013 to November 2015 in patients with right lower abdominal pain admitted to the Department of General Surgery, Chengalpattu Medical College, Chengalpattu, and undergone diagnostic laparoscopy were evaluated.

DATA ANALYSIS AND RESULTS

In this prospective study, the role of diagnostic laparoscopy was analysed in 72 patients with RLQ pain in government hospital from September 2013 to November 2015.

In the study period, 342 patients were admitted with acute RLQ pain. 75 patients were considered for diagnostic laparoscopy since their investigations (Laboratory and ultrasonogram) were inconclusive.

Among these 75 patients, 3 of them were not willing for diagnostic laparoscopy, which is an invasive diagnostic procedure. The remaining 72 patients gave consent for diagnostic laparoscopy and were included in the study.

The data from these patients were analysed and results studied.

Age and Sex Distribution

The age and sex distribution of these 72 patients are shown in the table.
Age          No. of Patients    Total

            Male     Female

18-25        15        26        41
26-35         8        10        18
36-45         3         5         8
46-55         2         2         4
56-65         0         1         1
Total        28        44        72


The 72 patients who came under our inclusion criteria were subjected to diagnostic laparoscopy by open Hasson method. Following findings were noted.
Findings                                  No. of Cases

Appendicitis                                   45
Adhesions                                      5
Appendicitis+Adhesions                         5
Normal Study                                   5
Appendicitis+Adnexitis                         3
Mesenteric Lymphadenitis                       2
Appendicitis+Mesenteric Lymphadenitis          1
Right Adnexal Cyst+Adhesions                   1
Adnexitis                                      1
Hydrosalpinx                                   1
Mesenteric Panniculitis+Adhesions              1
Meckel's Diverticulitis                        1
Abdominal TB                                   1
Total                                          72


RESULTS

In this observational study, "diagnostic laparoscopy in the evaluation of right lower abdominal pain" 72 patients were analysed.

There were 28 males and 44 females. Lowest and highest age of the patients included was 18 and 63 years respectively.

Operative findings of these patients were compared with the clinical diagnosis and any discrepancies noted including the resultant change in management secondary to diagnostic laparoscopy.

The laparoscopic finding of appendicitis was found in 55 patients among which 84% of patients had appendicitis alone. The rest 16% of patients had other coexisting findings like adhesions, adnexitis, and mesenteric lymphadenitis.

Out of patients with inflamed appendix, 32 were females. Among these 32 females, 24 patients were in the age group of 18 to 25.

12 patients had adhesions involving mesentery and bowel. 6 out of these 12 patients had associated findings like appendicitis, mesenteric panniculitis, and adnexal cyst. From the data analysed, it is clear that females were commonly affected by bowel adhesions.

Mesenteric lymphadenitis was present in 3 patients with one of them having associated appendicitis.

Other rare laparoscopic findings shown by diagnostic laparoscopy include abdominal tuberculosis, mesenteric panniculitis, and Meckel's diverticulitis, which together constituted less than 5% of the total cases.

Certain gynaecological findings were noted in diagnostic laparoscopy. It includes adnexitis, hydrosalpinx, and right adnexal cyst. 44 females in the study, 3 females were postmenopausal.

Among the females with an abnormal study, only 15% were due to gynaecological pathologies. Majority of them had non-gynaecological causes like appendicitis and adhesions.

There were 6 patients in whom diagnostic laparoscopy revealed normal study of the visualised organs.

In the study, it was noticed that 63 (87.5%) patients had an advantage of undergoing extended definitive therapeutic or ancillary procedure.

Diagnostic laparoscopy is an effective way of evaluating RLQP. Though imaging modalities such as USG exist to aid in the detection of acute appendicitis, they have low sensitivity and specificity. Compared to preoperative radiological investigations or wait and watch policy, laparoscopy yields an accurate diagnosis and visualisation of intra-abdominal organs and can be used for therapeutic purpose. (12)

DISCUSSION

Diagnostic laparoscopy though invasive is superior to transvaginal or transabdominal USG in female adnexal lesions when diagnosis in doubt as reported by Lim GH et al in Singapore Medical Journal (Diagnostic laparoscopy one year audit 2000;June 49(6)451-3).

There were 28 males and 44 females, lowest and highest age of patients included were 18 and 65 respectively.

The most common age group affected was 18 to 25 years. (13) This peak can be attributed to prevalence of appendicitis in this age group, which is the leading cause of right lower quadrant abdominal pain.

The commonest symptom associated with right lower quadrant pain was vomiting, which was found in 38 percent of patients. This is mainly because appendicitis is the most frequent finding noticed and it is usually associated with vomiting. The abnormal findings that were shown by laparoscopy include appendicitis, adhesions, adnexitis, mesenteric panniculitis, mesenteric lymphadenitis, Meckel's diverticulitis, hydrosalpinx, and right adnexal cyst. The laparoscopic finding of appendicitis was found in 55 patients, appendicitis in 84% of the patients.

The single predominant finding noted in laparoscopy, which contributed to 75 percent of total findings is appendicitis. (14) Interestingly, among patients with appendicitis, 16 percent had other concomitant pathologies found on laparoscopy, which included mainly adhesions and gynaecological causes like inflamed fallopian tubes. These are possibly due to surrounding inflammation caused by appendicitis. 12 persons had adhesions involving mesentery and bowel, 6 of this 12 patients had associated finding like appendicitis, adnexal pathology. Females are commonly affected by adhesions. (14) This may be due to the fact that females commonly undergo lower abdominal surgeries like caesarean section and sterilisation. Rare laparoscopy finding include mesenteric panniculitis and Meckel's diverticulitis.

Females with RLQ pain were found to have more number of non-gynaecological findings (85 percent) than gynaecological ones. (15)

About 10 percent of the patients showed normal study of the visualised organs.

About 85 percent of the patients with RLQ pain had a benefit of undergoing extended therapeutic and ancillary procedures. The most common procedure done was laparoscopic appendicectomy. (16) Other procedures include laparoscopic adhesiolysis and biopsy for mesenteric lymphadenitis and ileocaecal tuberculosis. In this study, 63 (87.5) had an advantage of definitive therapeutic procedure.

CONCLUSION

In this observational study, we have tried to understand the essentials of laparoscopy and its role in the evaluation of right lower abdominal pain over a period of one year and two months in 72 patients whose other routine investigations like laboratory tests and ultrasonogram abdomen were inconclusive and CECT is not used in any of this patients.

* Laparoscopy provided its diagnostic benefit in ninety one percent of patients who presented with right lower abdominal pain.

* Laparoscopy yielded its maximum diagnostic gain in women of childbearing age group. In these patients, the exposure to radiation by subjecting them to unnecessary radiological investigation is minimised. It had therapeutic role in eighty percent of the patients with RLQ pain.

REFERENCES

(1.) Paulson EK, Kalady MF, Pappas TN. Clinical practice. Suspected appendicitis. N Engl J Med 2003;348(3):23642.

(2.) De Dombal FT. Acute abdominal pain-an OMGE survey. Scand J Gastroenterol 1979;56:29-43.

(3.) Salky BA, Edye MB. The role of laparoscopy in the diagnosis and treatment of abdominal pain syndromes. Surg Endosc 1998;12(17):911-4.

(4.) Howell JM, Eddy OL, Lukens TW, et al. Clinical policy: critical issues in the evaluation and management of emergency department patients with suspected appendicitis. Ann Emerg Meg 2010;55(1):71-116.

(5.) Sarah L, Cartwright, Knudson MP. Wake Forest University School of Medicine, Winston-Salem, North Carolina. Am Fam Physician 2008;77(7):971-978.

(6.) Daily R, Danton G, Munera F. ER radiology evaluation of appendicitis and alternative diagnosis of right lower quadrant. Applied Radiology 2011.

(7.) Parker WH, Berek JS. Laparoscopic management of adnexal mass. Obstet Gynaecol Clin North Am 1994;21(1):79-92.

(8.) Daniilidis A, Hatzis P, Pratilas G, et al. Laparoscopy in gynaecology. InTech 2011. DOI:10.5772/20183.

(9.) Talat N, Afzal M, Razool N, et al. Role of diagnostic laparoscopy in evaluation and treatment of chronic abdominal pain in children: a five years data. J Ayub Medical College, Abbottabad 2016;28(1):35-8.

(10.) Mann GB, Conlon KC, LaQuaglia M, et al. Emerging role of laparoscopy in the diagnosis of lymphoma. J Clin Oncol 1998;16(5):1909-15.

(11.) Rai S, Thomas WM. Diagnosis of abdominal tuberculosis: the importance of laparoscopy. J R Soc Med 2003;96(12):586-588.

(12.) van den Broek WT, Bijnen AB, van Eerten PV, et al. Selective use of diagnostic laparoscopy in suspected appendicitis. Surg Endosc 2000;14(10):938-41.

(13.) Ghnnam WM. Early versus young patients with appendicitis 3 years' experience. Alexandra Journal of Medicine 2012;48(1):9-12.

(14.) Webster DP, Schneider CN, Cheche S, et al. Differentiating acute appendicitis from pelvic inflammatory disease in childbearing age. American Journal of Emergency Medicine 1993;11(6):569-72.

(15.) Rothrock SG, Green SM, Dobson M, et al. Misdiagnosis of appendicitis in non-pregnant women of childbearing age group. J Emergency Medicine 1995;13(1):1-8.

(16.) Kreesch AJ, Seifer DB, Sachs LB, et al. Laparoscopy in 100 women with chronic pelvic pain. Obstet Gynaecol 1984;64(5):672-4.

M. Ramula [1], P. S. Arun [2], A. Karthik [3], K. Ashwini [4], B. Palanisamy [5]

[1] Associate Professor, Department of Surgery, Chengalpattu Medical College Hospital.

[2] Assistant Professor, Department of Surgery, Chengalpattu Medical College Hospital.

[3] Assistant Professor, Department of Surgery, Chengalpattu Medical College Hospital.

[4] Junior Resident, Department of Surgery, Chengalpattu Medical College Hospital.

[5] Junior Resident, Department of Surgery, Chengalpattu Medical College Hospital.

Financial or Other, Competing Interest: None.

Submission 23-06-2016, Peer Review 18-07-2016, Acceptance 23-07-2016, Published 29-07-2016.

Corresponding Author:

Dr. M. Ramula, #A-14, Old G. S. T. Road, Alagesan Nagar, Chengalpattu-603001.

E-mail: ramuladurai@gmail.com

DOI: 10.14260/jemds/2016/968
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Title Annotation:Original Research Article
Author:Ramula, M.; Arun, P.S.; Karthik, A.; Ashwini, K.; Palanisamy, B.
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Aug 1, 2016
Words:2472
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