Journal of the Royal Society of Medicine Volume 85 July 1992

379

Abdominal pain: parietal or visceral?

The acute abdomen has been defined as any situation in which abdominal symptoms suggest the possibility of a life threatening disease'. Not infrequently the picture of the acute -abdomen is dominated by the presence of abdominal pain. However, despite their often dramatic presentation, over 40% of patients with acute abdominal pain return home without a diagnosis2; some having had an unnecessary operation. Many of these undiagnosed patients are said to suffer from non-specific abdominal pain (NSAP)3, a 'condition' which, at least in the early stages, may mimic acute appendicitis; the similarity between the two and also the difficulty of distinguishing either from gynaecological diseases have resulted in the removal of a normal appendix in up to 30% of patients4. To improve the management ofthose cases where clear signs of local or general peritonitis are absent two approaches have been suggested. The first, and simplest, is to observe and examine the patient at intervals; if the patient's condition subsequently improves then operation is rendered unnecessary. Secondly, investigation by ultaound5 or laparoscopy6 may be used, since both, have been shown to reduce the negative appendicectomy rate. While applying the first of these tactics and before resorting to the second, the surgeon should consider the abdominal wall as a possible source of symptoms. The suspicion that pain is arising from the abdominal parietes may be aroused by features in the history: for instance, the onset of symptoms may be related to physical exertion, while coughing, turning over in bed or the lifting of heavy weights may all aggravate the discomfort. Confirmation that the parietes are at fault is obtained by applying Carnett's test7. With the patient supine the abdomen is palpated in the usual way to elicit any area of tenderness. If such an area is found the patient is asked to contract his abdominal muscles by raising his head from the couch. Once the muscles are tensed, pressure is reapplied and the patient asked if the pain has altered. If the cause of the pain is intra-abdominal, the tensed muscles should now protect the viscera and the tenderness should diminish. On the other hand, if the abdominal wall is to blame the pain will be at least as severe and even increased. If further confirmation is required, local anaesthetic will be found to abolish the pAin following its injection into the tender spot. Quite how frequently abdominal wall pain occurs is difficult to judge. Thompson and Francis8 recorded it in 24 of 120 patients presenting with acute abdominal pain and in all but one of these no pathological diagno was found. In the one -exception, an inflamed appendix was adherent to the abdominal wall. In another prospective study, Gray et aL9 found abdominal wall tenderness to be present in 24 of 158 patients admitted with abdominal pain. However, in five of these the final diagnosis was appendicitis. These studies suggest that 10-20% of patients present with acute abdominal pain which is parietal in origin. As demonstrated in both the above series, false positive results can undoubtedly occur with Carnett's test; the clinician must therefore interpret his findings with due regard to the overall clinical picture.

With the exception of external hernias the precise cause of abdominal wall pain is of less importance than its identification. In this issue two cases of rectus. sheath haematoma'0 are presented in which computerized tomography was required for diagnosis. In both instances, however, there were features in the history which might have suggested an abdominal wall problem, namely, preceding muscular effort and localized abdominal tenderness. The early application of Carnett's test in these circumstances would almost certainly have implicated the abdominal wall and rendered further investigation unnecessary. Sir Zachary Cope"1 emphasized the need for a thorough physical examination in every case of the acute abdomen. This dictum is as true today as it was in 1926. However, there is a danger that the importance of the physical examination in the acute abdomen will become submerged beneath a proliferating array of investigations. If the examination is to survive, each aspect of its contribution to the management of the patient must be critically evaluated. The recent demonstration that rebound tenderness is not a good indicator of peritonitis'2 is an example of this critical approach. By contrast, prospective evaluation of Carnett's test has shown it to be of value in the management of the acute abdomen.
N Gallegos M Hobsley
Department of Surgery University College and Middlesex School of Medicine The Rayne Institute University Street, London WCIE 6JJ

References 1 Hobsley M. Pathways in surgical management. London: Edward Arnold, 1986:293 2 Wilson DH, Wilson RG, Walmsley RG, Horrocks JC, DeDombal FT. Diagnosis of acute abdominal pain in the accident and emergency department. Br J Surg 1977; 64:250-4 3 Jones PF. Acute abdominal pain in childhood, with special reference to cases not due to appendicitis. BMJ 1969;i:284-6 4 Hoffman J, Rasmussen 00. Aids in the diagnosis of acute appendicitis. Br J Surg 1989;76:774-9 5 Puylaert JBCM, Rutgers PH, Lalisang RI, et al. A prospective study of ultrasonography in the diagnosis of appendicitis. N Engi J Med 1987;317:666-9 6 Leape LL, Ramenoky ML Lapacopy for questionable appendicitis: can it reduce the negative appendicectomy rate? Ann Surg 1980;191:410-13 7 Carnett JB. Intercostal neuralgia as a cause of abdominal pain and tenderness. Surg Gynecol Obstet 1926;42:625-32 8 Thomson H, Francis DMA. Abdominal wall tenderness: a useful sign in the acute abdomen. Lancet 1977; ii:1053-4 9 Gray DWR, Seabrook G, Dixon JM, Collin J. Is abdominal wall tenderness a useful sign in the diagnosis of non-specific abdominal pain. Ann R Coll Surg Engl 1988;70:233-4 10 Siddiqui MN, Abid Q, Qaseem T, Hameed S, Ahmed M. 'Spontaneous' rectus sheath haematoma a rare cause of abdominal pain. J R Soc Med 1992;85:420-1 11 Cope Z. The early diagnosis of the acute abdomen. London: Oxford University Press, 1926:7 12 Liddington MI, Thomson WHF. Rebound tenderness test. Br J Surg 1991;78:795-6

0141-0768/92/ 070379-01/$02.00/0 1992 The Royal Society of Medicine