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Diagnosis of pneumoperitoneum on supine abdominal radiographs
Abstracts
IN YOUNG SUBJECTS. Velasco AL, Delgado-Paredes C. Templeton J, Steigman C, Templeton JM. J Pediatr Surg. 1991;26:4-8 In this preliminary study to evaluate the efficacy of intraosseous (IO) infusion in resuscitating subjects with severe hemorrhagic shock, 39 puppies were progressively exsanguinated until their mean arterial pressure (MAP) was 20% or less of their baseline MAP for 5 min. One group of 13 puppies, the control group, received no treatment. A second group of 13 was treated with specially designed canine military antishock trousers (MAST) inflated to 50 to 55 torr. In the third group of 13, an 18-gauge intraosseous needle was inserted into the tibia1 bone marrow, and lactated Ringer’s solution was infused at 300 torr pressure until a volume 3 times the blood loss had been administered. The average needle insertion time was 16 seconds. The rate of infusion varied from 4.5 to 25.7 mL/min, with a mean of 10.6 mL/ min. At one hour after the onset of shock, the control group mortality was 54%, the MAST group mortality was 23%, and the IO group mortality was 0%. At 2 hours after shock, the control group mortality was 85%. the MAST group mortality was 69%, and the IO group mortality was still 0%. Recovery of MAP, urine output, and lactate clearance were also significantly better in the IO group when compared with the other two groups. Lung sections from each of the dogs in the IO group were examined histologically. In 4 of the 13 dogs, this examination revealed small (5 700 X 200 km) bone marrow emboli localized to medium and small peripheral vessels. The authors conclude that IO infusion in hemorrhagic shock is safe, effective, and superior to MAST, which, in turn, is superior to no treatment. They do point out the need for close monitoring of IO infusions, noting that one of the preliminary test dogs had an immediate cardiac arrest secondary to air embolism when the IO fluid bag emptied and 50 cc of air infused into the marrow. [Michael A. Kohn, MD] Editor’s Note: It’s difficult to justify bleeding dogs to death, when in fact IO is a well-accepted method of volume resuscitation.
0 DIAGNOSIS OF ECTOPIC PREGNANCY BY VAGINAL ULTRASONOGRAPHY IN COMBINATION WITH A DISCRIMINATORY SERUM HCG LEVEL OF 1000 H/L (IRP). Cacciatore B, Stenman U, Ylostalo P. Brit J Ob Gyn. 1990;97:904-8. The investigators of this prospective study, involving 200 pregnant women suspected of having an ectopic pregnancy, have developed a sensitive and specific means to make this diagnosis. Detection of an adnexal mass separate from the ovaries was diagnostic of ectopic pregnancy with a sensitivity of 93% and specificity of 99%; both positive predicitive value and negative predictive value were greater than 96%. A diagnostic dilemma arises if neither an intrauterine sac nor an adnexal mass can be visualized on vaginal ultrasonography. Using an admission quantitative serum hCG of greater than 1000 iu/L, sensitivity of diagnosis of ectopic pregnancy in all patients increases to 97%, with a specificity of 99%, and both positive predictive and negative predictive values of 98%. This study supports the value of using quantitative hCG in conjunction with vaginal ultrasonography to aid in the sometimes difficult diagnosis of ectopic pregnancy. [Scott Parazynski, MD]
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0 DIAGNOSIS OF PNEUMOPERITONEUM ON SUPINE ABDOMINAL RADIOGRAPHS. Levine MS, Scheiner JD, Rubesin SE, et al. Am J Roent. 1991;156:731-5. Upright or left lateral decubitus films of the abdomen are accepted as valuable in the diagnosis of pneumoperitoneum. A blinded retrospective study was performed to determine the value of supine abdominal radiographs in diagnosing pneumoperitoneum, as most often used in acutely ill patients who only tolerate supine films. Supine films from 44 cases of pneumoperitoneum diagnosed by left lateral decubitus or upright films were randomly interspersed among films from 87 control cases and reviewed by a gastrointestinal radiologist. The films were evaluated for presence or absence of Rigler’s sign (gas on both sides of bowel wall), the falciform ligament sign (gas outlining the ligament), the football sign (gas outlining the peritoneal cavity), inverted-V sign (gas outlining medial unbilical folds), and right upper quadrant (RUQ) gas sign. One or more of these signs were present in 59% of cases. Most reliable was the RUQ sign, seen in 41% of cases, and Rigler’s sign, seen in 32%. There was a total of 11 false positive cases (13%), observed when RUQ gas lacked an inferolateral-to-superomedial orientation or a concave superolateral border, or with Rigler’s sign when the bowel wall was less than 1 mm thick. Other supine signs of pneumoperitoneum were observed in less than 3% of cases. [Merle Miller, MD]
0 SERUM ESTRADIOL AS AN AID IN THE DIAGNOSIS OF ECTOPIC PREGNANCY. Guillaume J, Benjamin F, Sicuranza B, Deutsch S, Seltzes V, Tores W. Obstet Gynecol. 1990;76: 1126-9. This study was conducted to determine whether a serum E, assay would be useful in the evaluation of ectopic pregnancy. This study was prompted by a previous study in which the authors found significantly lower levels of serum E,, progesterone, and B-hCG in women with ectopic pregnancies. They studied 100 consecutive patients with proven ectopic pregnancy, 69 with normal pregnancy, and 36 with threatened abortion. In each instance, pelvic sonography was done and blood was drawn for assays of E,, progesterone, and B-hCG. Their data suggests that a progesterone level above 23 ng/mL and or an E, level above 650 ng/mL would indicate a normal intrauterine pregnancy and therefore rule out an ectopic pregnancy or an abnormal intrauterine pregnancy with a specificity of 98.5% and a sensitivity of 99%. For a patient in whom an ectopic pregnancy is suspected, a definitive diagnosis often cannot be made by culdocentesis, ultrasonography , and serial B-hCG measurements. Their data show that the use of E, determinations may be as helpful or even more useful than progesterone levels alone, having a higher sensitivity and specificity. Newer E, assays can now be performed in less than one hour. The addition of these two rapid tests to the early, noninvasive diagnostic armamentarium may lead to better, and earlier diagnosis. Earlier intervention in ectopic pregnancies, less interference with normal pregnancies, and a decrease in the use of invasive procedures are possible. [William Sandusky, MD] Editor’s Note: Obtaining serum estradiol and progesterone levels may play an important role in assessing for the presence of ectopic pregnancy, especially when ultrasound may not be readily available.
IN YOUNG SUBJECTS. Velasco AL, Delgado-Paredes C. Templeton J, Steigman C, Templeton JM. J Pediatr Surg. 1991;26:4-8 In this preliminary study to evaluate the efficacy of intraosseous (IO) infusion in resuscitating subjects with severe hemorrhagic shock, 39 puppies were progressively exsanguinated until their mean arterial pressure (MAP) was 20% or less of their baseline MAP for 5 min. One group of 13 puppies, the control group, received no treatment. A second group of 13 was treated with specially designed canine military antishock trousers (MAST) inflated to 50 to 55 torr. In the third group of 13, an 18-gauge intraosseous needle was inserted into the tibia1 bone marrow, and lactated Ringer’s solution was infused at 300 torr pressure until a volume 3 times the blood loss had been administered. The average needle insertion time was 16 seconds. The rate of infusion varied from 4.5 to 25.7 mL/min, with a mean of 10.6 mL/ min. At one hour after the onset of shock, the control group mortality was 54%, the MAST group mortality was 23%, and the IO group mortality was 0%. At 2 hours after shock, the control group mortality was 85%. the MAST group mortality was 69%, and the IO group mortality was still 0%. Recovery of MAP, urine output, and lactate clearance were also significantly better in the IO group when compared with the other two groups. Lung sections from each of the dogs in the IO group were examined histologically. In 4 of the 13 dogs, this examination revealed small (5 700 X 200 km) bone marrow emboli localized to medium and small peripheral vessels. The authors conclude that IO infusion in hemorrhagic shock is safe, effective, and superior to MAST, which, in turn, is superior to no treatment. They do point out the need for close monitoring of IO infusions, noting that one of the preliminary test dogs had an immediate cardiac arrest secondary to air embolism when the IO fluid bag emptied and 50 cc of air infused into the marrow. [Michael A. Kohn, MD] Editor’s Note: It’s difficult to justify bleeding dogs to death, when in fact IO is a well-accepted method of volume resuscitation.
0 DIAGNOSIS OF ECTOPIC PREGNANCY BY VAGINAL ULTRASONOGRAPHY IN COMBINATION WITH A DISCRIMINATORY SERUM HCG LEVEL OF 1000 H/L (IRP). Cacciatore B, Stenman U, Ylostalo P. Brit J Ob Gyn. 1990;97:904-8. The investigators of this prospective study, involving 200 pregnant women suspected of having an ectopic pregnancy, have developed a sensitive and specific means to make this diagnosis. Detection of an adnexal mass separate from the ovaries was diagnostic of ectopic pregnancy with a sensitivity of 93% and specificity of 99%; both positive predicitive value and negative predictive value were greater than 96%. A diagnostic dilemma arises if neither an intrauterine sac nor an adnexal mass can be visualized on vaginal ultrasonography. Using an admission quantitative serum hCG of greater than 1000 iu/L, sensitivity of diagnosis of ectopic pregnancy in all patients increases to 97%, with a specificity of 99%, and both positive predictive and negative predictive values of 98%. This study supports the value of using quantitative hCG in conjunction with vaginal ultrasonography to aid in the sometimes difficult diagnosis of ectopic pregnancy. [Scott Parazynski, MD]
533
0 DIAGNOSIS OF PNEUMOPERITONEUM ON SUPINE ABDOMINAL RADIOGRAPHS. Levine MS, Scheiner JD, Rubesin SE, et al. Am J Roent. 1991;156:731-5. Upright or left lateral decubitus films of the abdomen are accepted as valuable in the diagnosis of pneumoperitoneum. A blinded retrospective study was performed to determine the value of supine abdominal radiographs in diagnosing pneumoperitoneum, as most often used in acutely ill patients who only tolerate supine films. Supine films from 44 cases of pneumoperitoneum diagnosed by left lateral decubitus or upright films were randomly interspersed among films from 87 control cases and reviewed by a gastrointestinal radiologist. The films were evaluated for presence or absence of Rigler’s sign (gas on both sides of bowel wall), the falciform ligament sign (gas outlining the ligament), the football sign (gas outlining the peritoneal cavity), inverted-V sign (gas outlining medial unbilical folds), and right upper quadrant (RUQ) gas sign. One or more of these signs were present in 59% of cases. Most reliable was the RUQ sign, seen in 41% of cases, and Rigler’s sign, seen in 32%. There was a total of 11 false positive cases (13%), observed when RUQ gas lacked an inferolateral-to-superomedial orientation or a concave superolateral border, or with Rigler’s sign when the bowel wall was less than 1 mm thick. Other supine signs of pneumoperitoneum were observed in less than 3% of cases. [Merle Miller, MD]
0 SERUM ESTRADIOL AS AN AID IN THE DIAGNOSIS OF ECTOPIC PREGNANCY. Guillaume J, Benjamin F, Sicuranza B, Deutsch S, Seltzes V, Tores W. Obstet Gynecol. 1990;76: 1126-9. This study was conducted to determine whether a serum E, assay would be useful in the evaluation of ectopic pregnancy. This study was prompted by a previous study in which the authors found significantly lower levels of serum E,, progesterone, and B-hCG in women with ectopic pregnancies. They studied 100 consecutive patients with proven ectopic pregnancy, 69 with normal pregnancy, and 36 with threatened abortion. In each instance, pelvic sonography was done and blood was drawn for assays of E,, progesterone, and B-hCG. Their data suggests that a progesterone level above 23 ng/mL and or an E, level above 650 ng/mL would indicate a normal intrauterine pregnancy and therefore rule out an ectopic pregnancy or an abnormal intrauterine pregnancy with a specificity of 98.5% and a sensitivity of 99%. For a patient in whom an ectopic pregnancy is suspected, a definitive diagnosis often cannot be made by culdocentesis, ultrasonography , and serial B-hCG measurements. Their data show that the use of E, determinations may be as helpful or even more useful than progesterone levels alone, having a higher sensitivity and specificity. Newer E, assays can now be performed in less than one hour. The addition of these two rapid tests to the early, noninvasive diagnostic armamentarium may lead to better, and earlier diagnosis. Earlier intervention in ectopic pregnancies, less interference with normal pregnancies, and a decrease in the use of invasive procedures are possible. [William Sandusky, MD] Editor’s Note: Obtaining serum estradiol and progesterone levels may play an important role in assessing for the presence of ectopic pregnancy, especially when ultrasound may not be readily available.