Cope's Acute Abdomen: Old-School Wisdom or Obsolete Guidelines?

[JediZero]

So with boards and ERAS out of the way, I finally got around to starting on Cope's Early Diagnosis of the Acute Abdomen, which my surgery attending recommended to me ages ago.

Obviously, it's a very old-school treatise: heavy focus on history and physical, a lot of weight given to special maneuvers, and a strong distaste for diagnostic testing, especially CT scanning. The author strongly supports the notion that an experienced clinician should be able to diagnose an acute abdomen through a good H&P, without needing to scan someone to confirm it.

However, that seems to have almost no bearing on the way EM is practiced today. Pretty much anyone with a significant abdominal pain, especially if they're over thirty, gets a CT without much debate. Further, while the author spends a lot of time discussing ways to distinguish between various serious ailments, he doesn't seem to worry about distinguishing the serious from the benign, which seems to be > 95% of the people that come in to the ED (seriously, I see at least five people with belly pain a day, and I can think of two that went to surgery, one for an abdominal abscess and one for an infected kidney stone).

So my question is this: does this type of thinking have a place in modern Emergency Medicine? Or is it a relic from a time before we had the technology to accurately diagnose people, and as such it should be treated as a collection of nice concepts that have little bearing on our management? Like most things, I suspect it's somewhere in the middle, but I'd like to hear some opinions on this from people who have been around a little longer.

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[TooMuchResearch]

So with boards and ERAS out of the way, I finally got around to starting on Cope's Early Diagnosis of the Acute Abdomen, which my surgery attending recommended to me ages ago.

Obviously, it's a very old-school treatise: heavy focus on history and physical, a lot of weight given to special maneuvers, and a strong distaste for diagnostic testing, especially CT scanning. The author strongly supports the notion that an experienced clinician should be able to diagnose an acute abdomen through a good H&P, without needing to scan someone to confirm it.

However, that seems to have almost no bearing on the way EM is practiced today. Pretty much anyone with a significant abdominal pain, especially if they're over thirty, gets a CT without much debate. Further, while the author spends a lot of time discussing ways to distinguish between various serious ailments, he doesn't seem to worry about distinguishing the serious from the benign, which seems to be > 95% of the people that come in to the ED (seriously, I see at least five people with belly pain a day, and I can think of two that went to surgery, one for an abdominal abscess and one for an infected kidney stone).

So my question is this: does this type of thinking have a place in modern Emergency Medicine? Or is it a relic from a time before we had the technology to accurately diagnose people, and as such it should be treated as a collection of nice concepts that have little bearing on our management? Like most things, I suspect it's somewhere in the middle, but I'd like to hear some opinions on this from people who have been around a little longer.

Good book or not, the surgery attending that told us to read it also stated that abdominal pain patients are not to receive pain meds until after a surgeon completes his assessment.

 

[DeadCactus]

Pretty sure Copes explicitly voices against that nonsense, so maybe he should read it.

I think Copes does a great job of helping you interpret physical exam and history findings and translate them into an underlying physiologic process. The value of that will depend on your practice style.

 

[gman33]

Not sure what I really think about most of the physical exam.
I'd like to be better at certain parts.
You have to be able to use physical exam like any other type of test.
Know the sensitivity/specificity etc.

Problem is that even if I was good enough to just go on PE, most surgeons are going to want a CT Scan anyway.

 

[deleted547339]

Two things: the surgeons always say that they "need a CT to plan the surgery" even when the I am 100% sure of the diagnosis, e.g. Nonreducible, painful hernia vomiting feces. I think "plan the surgery" means "I don't trust you" lol.

The other thing is that an abdominal CT is a relatively benign exam (assuming it doesn't significantly delay definitive therapy). Personally, is rather do everything possible to avoid someone getting cut if they don't 100% need it.

 

[Hamhock]

Do you use egophony?

HH

 

[Arcan57]

Do you use egophony?

HH

Only if whispered petriquiloly (sp?) is equivocal.

The bottom line is that you need to be able to identify an acute abdomen as the cause for a patient's instability and you need to be confident enough in your physical exam to limit CT scanning in an evaluatable population. If reading Cope's helps with that, then go for it. I enjoyed it, but can't say it was practice changing.

 

[JediZero]

Good book or not, the surgery attending that told us to read it also stated that abdominal pain patients are not to receive pain meds until after a surgeon completes his assessment.

Pretty sure Copes explicitly voices against that nonsense, so maybe he should read it.

Exactly. All the pain medication in the world isn't going to make an inflamed appendix not hurt when you're applying pressure directly on it...

Two things: the surgeons always say that they "need a CT to plan the surgery" even when the I am 100% sure of the diagnosis, e.g. Nonreducible, painful hernia vomiting feces. I think "plan the surgery" means "I don't trust you" lol.

The other thing is that an abdominal CT is a relatively benign exam (assuming it doesn't significantly delay definitive therapy). Personally, is rather do everything possible to avoid someone getting cut if they don't 100% need it.

Pretty much. Not like they're going to make a different incision if the hernia is distal small bowel and not proximal...

 

[JediZero]

Only if whispered petriquiloly (sp?) is equivocal.

The bottom line is that you need to be able to identify an acute abdomen as the cause for a patient's instability and you need to be confident enough in your physical exam to limit CT scanning in an evaluatable population. If reading Cope's helps with that, then go for it. I enjoyed it, but can't say it was practice changing.

So Cope's observations can be used to develop the H&P into a high-sensitivity test, which you can then use to determine who is highly unlikely to have a surgical problem? Then scan the rest?

 

[deleted109597]

I've noticed disturbingly that many of my residents will not adequately diagnose acute abdomens in patients, especially pediatric patients. I blame it on the fact that everyone orders too many CTs now, so they gloss over the exam knowing they're going to use their xray vision anyway.

 

[Arcan57]

So Cope's observations can be used to develop the H&P into a high-sensitivity test, which you can then use to determine who is highly unlikely to have a surgical problem? Then scan the rest?

Not quite. Cope's will get you thinking about the acute abdomen which will make you pay more attention to your abdominal exams. It really has nothing to say about the non-acute abdomen. So you'll need to decide for yourself what the likelihood that the patients symptoms combined with whatever personal cut-off for calling a patient's abdomen tender warrants a CT. The value in Cope's is that when a pt is unstable and has an acute abdomen it may make you sound smarter when you are talking to the surgeon or make you question an erroneous radiology read because the H&P don't fit at all. There are few pts that can't be scanned for acute abdominal issues but it's helpful to know who to
call the surgeon on before they drink for
2 hrs and then crash

 

[MossPoh]

It is a quick read and it isn't like doing a good abdominal exam takes much longer than doing a bad one. People need to limit the CTs a bit. Just because it isn't immediate and obvious damage, doesn't mean there aren't consequences down the road.

 

[Hamhock]

Benign
Urgently acute (needs imaging in the ED)
Emergently acute (needs ED imaging now! and strong consideration of an early call to a surgeon)
----
Consider CT vs. UTS +/- upright CXR for free air (please spare me the discussion of KUB or such in adults...kids, well -- let's discuss)
----
If you take much more than this from an EM residency or Copes, you are practicing dangerously, in my opinion. Please don't think you can distinguish pancreatitis from biliary collic from cholecystitis from retrocecal appendicitis from subtle SBO from terminal illeitis for intra-abdominal abscess from vascular insufficiency/occulusion on exam. If you do this in these times, you should re-consider your understanding of the sensitivity/specificity of testing (which the PE certainly is) and your acceptance of pending litigation.

I don't mean to diminish the PE of the abdomen (one of the few important parts of the PE in the ED; unlike the lung exam), but please don't pretend you live in the Little House On The Prairie.

HH

 

[deleted109597]

Benign
Urgently acute (needs imaging in the ED)
Emergently acute (needs ED imaging now! and strong consideration of an early call to a surgeon)
----
Consider CT vs. UTS +/- upright CXR for free air (please spare me the discussion of KUB or such in adults...kids, well -- let's discuss)
----
If you take much more than this from an EM residency or Copes, you are practicing dangerously, in my opinion. Please don't think you can distinguish pancreatitis from biliary collic from cholecystitis from retrocecal appendicitis from subtle SBO from terminal illeitis for intra-abdominal abscess from vascular insufficiency/occulusion on exam. If you do this in these times, you should re-consider your understanding of the sensitivity/specificity of testing (which the PE certainly is) and your acceptance of pending litigation.

I don't mean to diminish the PE of the abdomen (one of the few important parts of the PE in the ED; unlike the lung exam), but please don't pretend you live in the Little House On The Prairie.

HH

Um, so what's your definition of benign?
It seems like you image anyone with pain, just the speed at which you do it changes. Sadly, that's the environment in some places.

 

[Hamhock]

Um, so what's your definition of benign?
It seems like you image anyone with pain, just the speed at which you do it changes. Sadly, that's the environment in some places.

Actually, I probably image fewer people than most ED docs.

I don't have a definition of benign. I think that was part of my point. The benign belly is something learned in residency and in at least the first few years after residency.

My other point is that the "modern" exam should identify those who require imaging (fewer than an untrained provider would determine) and what type of imaging is required and what degree of urgency is needed (which involves exam factors outside of the abdomen).

I think that continuing to palpate the acute abd so that you can pretend to determine cause of the acuity is a fun party trick that is actually remarkably inaccurate and consequently dangerous to patients.

HH

 

[deleted109597]

Actually, I probably image fewer people than most ED docs.

I don't have a definition of benign. I think that was part of my point. The benign belly is something learned in residency and in at least the first few years after residency.

My other point is that the "modern" exam should identify those who require imaging (fewer than an untrained provider would determine) and what type of imaging is required and what degree of urgency is needed (which involves exam factors outside of the abdomen).

I think that continuing to palpate the acute abd so that you can pretend to determine cause of the acuity is a fun party trick that is actually remarkably inaccurate and consequently dangerous to patients.

HH

I guess it was just how I was reading it. I work with people (and I bet most of you do as well) who really do image everyone with pain. Hence my off the cuff remark. I do have a couple surgeons who will operate based on peritonitis without imaging, but it is rare.