SILDENAFIL (VIAGRA)


SILDENAFIL (VIAGRA) AND THE HEART

Hassan Chamsi-Pasha, FRCP, FACC, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia

أكدت الدراسات العلمية حدوث تحسن في العنانة عند حوالي 69% من المصابين بالعجز الجنسي، إذا ما أخذت حبة الفياجرا قبل ساعة من المعاشرة الزوجية، إلا أن ذلك يترافق مع بعض التأثيرات الجانبية، كالصداع الذي حدث بنسبة 16% ، والإحساس بتوهج الوجه عند 10% من المرضى، وعسر الهضم عند 7% من المرضى، واضطراب رؤية الألوان عند 3%، واحتقان الأنف عند 4%، وهبوط ضغط الدم في أقل من 2%.

ولابد من تقييم حالة القلب قبل استخدام هذا الدواء خاصة عند المرضى المصابين بنقص التروية القلبية أو جلطة القلب. ولا يجوز استخدامه عند المصابين بجلطة حديثة في القلب. ولا يجوز تناول حبوب الفياجرا عند المرضى الذين يتناولون مركبات النترات (مثل الأيزوزوربايد) أو حبوب النيتروجلسرين تحت اللسان. وقد يكون استعمال حبوب الفياجرا محفوفاً بالمخاطر عند : (أ) المصابين بنقص حاد في تروية القلب (ب) المصابين بفشل القلب الاحتقاني (ج) المرضى ذوي الضغط المنخفض (د) المرضى الذين يستخدمون عدة أدوية لعلاج ارتفاع ضغط الدم (هـ) الذين يتناولون أدوية يمكن أن تؤثر على استقلاب الفياجرا.

الكلمات المرجعية:الفياجرا، العجز الجنسي، تروية القلب.  

Sildenafil (Viagra) is the most effective oral therapy currently available for erectile dysfunction. Patients should be given clear instructions regarding the use of sildenafil. The most common side effects include flushing, headaches, dyspepsia, and transient visual changes. In combination with nitrates, it can and has caused fatal hypotension. It should not be prescribed to patients on nitrates. Additionally, nitrates should not be administered to anyone who has recently ingested sildenafil. Synergetic blood pressure lowering has not been observed when sildenafil was used with other classes of antihypertensives. Sildenafil is not offered to patients with low cardiac output states, those on intensive regimens to prevent heart failure or those with acute coronary ischemia.

Key Words: Sildenafil, erectile dysfunction, heart failure.


 

Impotence – the preferred term is now erectile dysfunction is a common problem affecting between 10 to 30 million men in the United States.1 Worldwide, more than 100 million men are estimated to have some degree of erectile dysfunction.2,3 The introduction of sildenafil (Viagra) has been a valuable contribution to many patients


 

Correspondence to:

Dr. Hassan Chamsi-Pasha, Consultant Cardiologist and Chief of Noninvasive Cardiology, King Fahd Armed Forces Hospital, P.O. Box 9862, Jeddah 21159, Saudi Arabia


 

suffering from erectile dysfunction, and the drug, has now been approved by the Ministry of Health in Saudi Arabia. There have been 20 million prescriptions written for sildenafil. A total of 69 death has been reported to the FDA as of August 26, 1998, in patients who have used sildenafil.4 Recently, the American College of Cardiology/American Heart Association (ACC/AHA) published their “Expert Consensus Document” on the use of sildenafil in patients with cardiovascular disease.4 This article is based primarily on the recommendations made in that “document”.

                Sildenafil acts as a selective inhibitor of cycle GMP-specific phosphodiesterase type 5, resulting in smooth muscle relaxation, vasodilation, and enhanced penile erection. The vasodilating action of sildenafil affects both the arteries and the veins.5

                Reported side effects in the normal healthy population are usually associated with vasodilation. These include headaches (16%), flushing (10%), rhinitis (4%), dizziness (2%), hypotension (<2%), and postural hypotension (<2%). Other side effects include dyspepsia (7%), blue-green color-tinged vision and blurred vision (3%), and an unexplained myalgia.3,4

                Although their incidence is small, serious cardiovascular events including significant hypotension can occur in certain population at risk. Most at risk are individuals who are concurrently taking organic nitrates.4

                Sexual dysfunction in men after the diagnosis of coronary artery disease or a myocardial infarction is common.7 Most is due to the fear that the exertion of sexual activity will precipitate another myocardial infarction, but 10 to 15% of erectile dysfunction is due to organic causes.8 In USA, approximately 5.5 million men take nitrates on a regular basis for angina pectoris,9 and another half million will experience a heart attack annually and are potential candidates for nitrate therapy.  Sildenafil is potentially contraindicated in these 6 million patients. All patients taking either sildenafil or nitrates must be warned of the contraindications and potential consequences of taking sildenafil within 24-hour interval after taking a nitrate preparation, including sublingual nitroglycerin.

                Sildenafil is predominantly metabolized by both the P 450 2C9 and the P450 3A4 pathways. Thus, potent inhibitors of the P450 3A4 pathway may increase the plasma concentrations of sildenafil and its pharmacological effects. Cimetidine and erythromycin are commonly prescribed drugs that inhibit the P450 3A4 pathway. The simultaneous administration of either of these agents significantly increases the plasma concentration of sildenafil; a lower initial dose (25 mg) rather than the recommended 50 mg should be considered in the coadministration of sildenafil to patients receiving either of these agents.4

                Many drugs are metabolized by the P450 3A4 pathway but are not inhibitors of the pathway. The coadministration of one of these drugs may lead to competitive inhibition of the metabolism of sildenafil. Physicians should be aware of the potential interaction of such agents. This list of commonly prescribed drugs metabolized via the P450 3A4 pathway includes: amiodarone, digoxin, diltiazem, losartan, nifedipine, atorvastatin, cerivastatin, lovastatin, simvastatin, and cisapride.4 Patients with severe renal impairment (creatinine clearance <30 ml/min) have a reduced clearance of sildenafil. Thus, the duration of the effect of sildenafil in these patients will be prolonged and particular care should be taken in the administration of concomitant medications that may lower blood pressure.

                Plasma concentrations of sildenafil and of its metabolites may be significantly increased in patients with hepatic dysfunction. Thus, the duration of activity of sildenafil may be prolonged and the extent of its effect enhanced. As in patients with renal dysfunction, the initiation of therapy at 25 mg rather than 50 mg may be appropriate in patients with hepatic dysfunction. Because the effects of sildenafil have not been evaluated in patients with bleeding disorders or in patients taking non-aspirin antiplatelet agents (e.g. ticlopidine, clopidogrel or dipyridamole), caution should be exercised when the drug is administered in these clinical settings.4

                What are the current recommendations for prescribing sildenafil to patients at risks? Sildenafil is absolutely contraindicated in patients taking any long-acting nitrates or using short-acting nitrates because of the risk of developing potentially life-threatening hypotension. All patients taking organic nitrates, even if they have not asked for Viagra, should be informed about the nitrate-sildenafil hypotensive interaction. Similarly, patients must be warned of the contraindication of taking sildenafil in the 24-hour time interval after taking a nitrate preparation, including sublingual nitroglycerin.

                Other patients in whom the use of sildenafil is potentially hazardous include those with active coronary ischemia, those with congestive heart failure and borderline low blood volume and low blood pressure status; those with complicated, multidrug, antihypertensive therapy regimens; and those taking medications that may effect the metabolic clearance of sildenafil. If patients are taking a combination of antihypertensive medications, they should be cautioned about the possibility of sildenafil-induced hypotension. Although firm data are lacking, pre-Viagra treadmill test to assess for the presence of stress-induced ischemia can be helpful. If the patient can achieve 5 to 6 during coitus without the added stress of a heavy meal or alchohol ingestion, is probably low.4

                In patients with recurring mild angina after sildenafil use, other nonnitrate antianginal agents, such as b-blockers, should be considered. Patients taking sildenafil who have an acute myocardial infarction should be treated in the usual manner including, where appropriate, primary angioplasty or thrombolysis. The only difference is that nitrates are contraindicated for these patients.

                In patients with unstable angina, therapy should include only non-nitrate antianginal medications. To date, there is no evidence of significant interactions between sildenafil and heparin, b-blockers, calcium channel blockers, narcotics or aspirin. These drugs can be used as appropriate. After 24 hours, nitrates may be administered if close monitoring is provided. In patients who inadvertently received nitrates while taking sildenafil and who manifest a severe hypotensive response, it is essential to have the capability to support the patient with fluid resuscitation and alpha-adrenergic agonists.4

                A number of unresolved issues remain to be answered. One of such issues is assessing the risks of sildenafil use in patients with heart failure, patients with myocardial infarction or stroke within 6 months, or patients with uncontrolled hypertension. Such patients were not included in the published studies. Thus, there are possible problems in the use of Viagra in these patients. Other unresolved issues include central nervous system, effects of sildenafil, hypotensive effects with sildenafil alone in high-risk cardiac patients (severe heart failure) and its musculo-skeletal effects.

                Finally, whether the promise of sildenafil will be realized after many more men have been treated and the drug has been taken repeatedly for prolonged period of time remains to be seen.

REFERENCES

1.     Cohan P, Korenamn SG. Erectile dysfunction. J Clin Endocrinol Metab 2001;86:2391-4.

2.     Jackson G. Viagra: a three-year sexual revolution and the need to recognize its role within the NHS. Int J Clin Pract 2001;55:75-6.

3.     Goldstein I, Lue TF, Padua-Nathan H, Rosen RC, Steers WD, Wicker PA. Oral sildenafil in the treatment of erectile dysfunction. N Engl J Med 1998; 338:1397-404.

4.     Cheitlin MD, Hutter Jr AM, Brindis RG, et al. The ACC/AHA “Expert Consensus Department”. Use of sildenafil (Viagra) in patients with cardiovascular disease. J Am Coll Cardiol 1999; 33: 273-82.

5.     Utiger RD. A pill for impotence (editorial). N Engl J Med 1998; 338:1458-9.

6.     Riley AJ, Athanasiadis L. Impotence and its non-surgical management. Br J Clin Pract 1997; 51:99-105.

7.     Muller JE, Mittleman A, Maclure M, Sherwood JB, Toffler GH. Triggering myocardial infarction by sexual activity. JAMA 1996; 275:1405-9.

8.     Tardif GS. Sexual activity after a myocardial infarction. Arch Phys Med Rehab 1989; 70:763-6.

9.     Mitka M. Viagra leads as rivals are moving up. JAMA 1998; 280:119-20


-0001-11-30

THE INTERNET


THE IN TERNET AND THE WORLD WIDE WEB: APPLICATIONS FOR FAMILY PHYSICIANS IN SAUDI ARABIA

Abdulaziz M. Sebiany,FFCM (KFU), Department of Family and Community Medicine, College of Medicine, King Faisal University, Dammam, Saudi Arabia

أحدث انتشار شبكة المعلومات العالمية تطورا سريعا في استخدامات الحاسب الآلي و الإنترنت. فقد سهلت الشبكة طرق الحصول على المعلومات و جعلتها أقل كلفة و أكثر مرونة في الاتصال بالمرضى أو بالآخرين من ذوي المهن المتقاربة.

يهتم تخصص طب الأسرة أو الممارسة العامة بالفرد لشخحصه أو كجزء من الأسرة بدون أية حدود عمرية، جنسية أو حتى نوع المشاكل الصحية التي تعتري الشخص أو أسرته. و لتقديم خدمة طبية عالية الجودة من خلال هذا التخصص تبلورت صفات طبيب الأسرة بإلمامه المتميز بمهارات الاتصال بالآخرين، و بالتفكير النقدي، و بإدارة الموارد و المعلومات،   و بالتعلم الذاتي المستمرمدى الحياة، و بتقديم الرعاية الطبية السريرية و النصح للمجتمع.  و لتقديم مثل هذا النوع من الرعاية الرفيعة المستوى كان من الضروري أن يعتمد تخصص طب الأسرة على المعلومات و تقنياتها. و من ناحية أخرى فإن التوسع الكبير و الانتشار السريع للمعلومات الإليكترونية من خلال الإنترنت و شبكة المعلومات العالمية يشكل تحديا حقيقيا لأطباء الأسرة. لذا كان لزاما على أطباء الأسرة بالمملكة العربية السعودية أن تكون لديهم المعلومات و المهارات الخاصة التي تساعدهم على الحصول على المعلومات الموثوق بها علميا عن طريق الشبكة العالمية و استرجاعها عند الحاجة إليها بكل سهولة لكي يحققوا التطوير المهني لأنفسهم و من ثم الخدمة الطبية المتميزة لمرضاهم. تلقي هذه المقالة الضوء على أهم استخدامات الشبكة العالمية للمعلومات، مع بعض الأمثلة لأهم المواقع المفيدة بالشبكة و التي تهم أطباء الأسرة بالمملكة العربية السعودية.  

الكلمات المرجعية:الإنترنت، شبكة المعلومات العالمية، طب الأسرة/الممارسة العامة، المملكة العربية السعودية.

The introduction of the World Wide Web has revolutionized the applications of the computer and the Internet in the medical field.  The Web provides an easy and cost-effective way of retrieving medical information and a more flexible way of communicating with patients and colleagues. Family practice is a specialty in which care is given to persons as individuals and members of families regardless of their age, gender or specific problems. To provide quality family practice, a family physician should be a good communicator, a critical thinker, a resource and information manager, a life-long learner, a care giver and a community advocate. Providing such high quality care requires that family practice be an information-sensitive specialty. However, the expansion of the new electronic resources on the Internet and the Web poses a real challenge to the family physician. Family physician in Saudi Arabia need to have basic skills and knowledge for easily retrieving and finding reliable Internet information for his professional development and the care of his patients. This article addresses the Web applications for family physicians in Saudi Arabia, giving examples of the most important Websites.

Key Words: Internet, World Wide Web, Family Practice/Medicine, Saudi Arabia

Correspondence to:

Dr. Abdulaziz M. Sebiany, P.O. Box 40208, Al-Khobar 31952, Saudi Arabia


 

INTRODUCTION

The uses of medical technology for information management, diagnostic and therapeutic purposes enable family physicians to enhance family practice and improve patient outcome.1 The recent advances in medical technology and the rapid growth in computing and the Internet have already changed medical practice significantly and the means by which many physicians educate themselves and communicate with each other and with their patients. The introduction of the World Wide Web ( WWWor the Web) has revolutionized the application of the computer and the Internet. The Internet characteristics have been well reviewed in medical literature.2-9  The Web provides an easy and a cost-effective way of retrieving medical information and a more flexible way of communication with patients and colleagues. It has also the advantage of enhancing education through the collection of texts, pictures, sounds and video clips. The Web can be a very rich source by which the efficiency of patient care as well as medical research irrespective of investigators’ locations can be improved.10

                Family practice is an evolving specialty ideally placed to achieve quality, cost effective, and equity in health care. The core values of family practice require a wide range of knowledge, skills and attitudes to provide personal “continuing and comprehensive medical care, health maintenance and preventive services to each member of the family regardless of sex, age or type of problem, be it biological, behavioral, or social”.11 In addition, family practice is patient-centered,12 family-focused, community-oriented, and evidence-based.13 To provide proper family practice, a family physician is supposed to be a good communicator, critical thinker, resource and information manager, life-long learner, care giver, decision maker, health team manager, and community advocate.

                Providing such high quality care requires that family practice be a specialty that is  information sensitive as well as information demanding. This in turn requires essential information about the best and most cost-efficient ways to anticipate, diagnose and manage the common health problems encountered in family practice. However, a busy family physician who encounters explosive free medical information is under increased pressure to find an up-to-date reliable information for his professional development and the care of his patients. All over the world, patients and their families nowadays can access any kind of health information on their own computers. Therefore, it is essential that the family physician be competent in the effective management of medical information to meet day-to-day patient needs as well as improve the educational and research developments in family medicine. 

                Saudi Arabiahas experienced rapid changes in social life, patterns of diseases, education, economic growth, and more recently the introduction of the Internet. The new developments require better utilization and incorporation of the recent advances including the Internet in medical technology.

                Family physicians in Saudi Arabiaface many challenges. Besides the shortage of family physicians, the term “family physician” is unfamiliar to many people including health professionals, administrators, medical students and the general public.14

                In a recent survey of all locally trained family physicians in Saudi Arabia, it was found that only 231 family physicians, which is only (0.8%) of all physicians (n = 30,281) and (4%) of all Saudi physicians (n = 5,699) working in the Ministry of Health and all other governmental health services as well as in the private sector.14,15 The survey also showed that both graduates and residents reported that information management and computer skills were important to their practice. Their mean scores of agreement out of five were (4.49 ± 0.57 and 4.32 ± 0.74, respectively). However, both groups thought that preparation during training for information management and computer skills was poor. The mean scores of agreement were low (2.75 ± 1.02 and 2.30 ± 1.04, respectively).

                Other problems facing family physicians in Saudi Arabiaare poor professional communication system, demanding work conditions and obsolete local medical Web sites. Family practice in Saudi Arabia, and consequently health care, can benefit much through the availability of well-designed and medically reliable national Web sites together with the proper training for the Internet use.

                The explosion of medical information and the rapid growth of Web sites available for family physicians and their patients form a significant problem for family physicians.  Every family physician should possess basic computer and Internet skills as support for the provision of high quality health care.One way to better introduce the unique values and principles of family medicine and to effectively face the current and future challenges is to have Web-based input from family physicians in Saudi Arabia. High quality, reliable and easily accessible family practice related Web sites should be available for medical students, family practice residents, family physicians, patients and their families.

                This article is an attempt to help family physicians in Saudi Arabiabecome familiar with the Internet and available medical information relevant to their practice. A brief description of the Web is given as well as a searching for information on a variety of sites for continuing medical education (CME) and professional development and patient education. In this article, the term family physician is used to denote general practitioner as well as  primary health physician.

                It is worth mentioning that the Web is a rapidly changing medium and although the addresses mentioned in this article were accurate at the time of submission, consultation of search engines for the most up-to-date address is necessary. Time and space constrained us to exclude many excellent Web sites that could have been mentioned.

QUALITY OF HEALTH RESOURCES ON THE INTERNET

Health information available on the Internet is a great resource of improving health.16,17 However, this information can be inaccurate, biased and even harmful to users.18,19  The criteria for evaluating the appropriateness or quality of health related Internet sites have been addressed in literature.20-23 Although currently there is no consensus for evaluating Web-based health information, there should be minimum criteria evaluating acceptable information. This should include authorship with the proper affiliations and credentials, disclosure, evidence of the source and how current information is.20,21  Additional criteria include site quality, reliability, accuracy, scope, depth, design, and ease of use.

                Six Senses Review Program (http://www. sixsenses.com/) evaluates health and medical Web sites based on six criteria: content, aesthetics, innovation, interactivity, freshness, and character. Other helpful sites for evaluating the strengths and weaknesses of Web pages can be found at the Information Quality Tool (http://hitiweb. mitretek.org/iq/default.asp), Discern (http:// discern.org.uk) or Health On the Net Foundation (http://www.hon.ch/honcode/ condut.html).

COMPUTER AND THE WEB

Access to the Web requires a computer, a modem, the appropriate software and an account with an Internet Service Provider (ISP) which connects the user to the Web in the same way a local phone company connects their users to the phone system. In Saudi Arabia, there are many companies providing Internet access. King Faisal Specialist Hospitaland Research Center(http://www.kfshrc.edu.sa/) provides a free Internet access to all physicians in Saudi Arabia. ISP provides a user name and password for use in accessing the Internet, an e-mail box and instruction for computer configuration.

                Most computers on the Saudi market purchased within the last three years come equipped with the necessary hardware and software for the Internet use. Software programs needed to access and use the Internet efficiently include: a word processor, a program for presentation, WinZip, an antivirus program, and program for Portable Document Format (DPF) viewing.

                All computers on the Internet exchange information through the same set ofprotocols called Transmission Control Protocol/Internet Protocol (TCP/IP). Recent versions of Windows include or accept a program called a Web browser (Microsoft Internet Explorer or Netscape Navigator), which makes the Internet more fun and user-friendly. The Web has the advantage of using the Hypertext Markup Language (HTML), which enhances text documents with graphics and links to other sites. To reach a particular Web page you need to type (the street address) the Uniform Resource Locator (URL) into the address space. The URLs have the format (protocol://address of the host computer/ directory/file name). For example, the Saudi Society of Family and Community Medicine (SSFCM) can be accessed by typing into the Web browser the URL: (http://www.ssfcm.com/english/english.htm). It has a hypertext transfer (http://), a host computer (www.ssfcm.com), a directory (English/), and document (english.htm). Educational host names ending in ".edu" are often universities, sites with ".org" are nonprofit organizations, ".com" indicates a commercial or company sites “.net” for networking organization and “.mil” for military host.  

                A link is a unique feature of the Web that enables users to "surf" the Web from page to page to find the required information. Internet tutorials are a useful source for family physicians. A useful site to start with can be found at (http://www.faughnan.com/ fp/net/index.html/).

SEARCHING FOR INFORMATION

Information on the Internet and its Web is vast and overwhelming and requires efficiency in locating the appropriate information. Web sites can easily be searched for any word or phrase, subject, country, educational institution, organization or company. There are two commonly used approaches: search engines, for narrower and specific searches, and directories, for broader and categorized topics.

                Search engines (tools or services) which have their own Web pages are programs created to search the Internet. None of these engines contains the whole information in the Web. Therefore, different results will be obtained from different search tools. Most widely used search engines are AltaVista (http://altavista.digital.com/), Lycos (http:// www.lycos.com/), Infoseek (http://www. infoseek.com/), Excite (http://www.excite. com/), Google (http://www.google.com/), and WebCrawler (http://webcrawler.com/). Using meta-search services such as Ixquick (http://www.ixquick.com/) or MetaCrawler
(http://www.metacrawler.com/) one can search multiple search engines at the same time.

                To have the best results, search in two or three search services and be familiar with their characteristics. Try multiple queries using synonyms and other variations taking into consideration the differences between the British and American spelling. On gathering the appropriate results, simply save them for later analysis. Resist any attempts to follow irrelevant but attractive links.

                Directories often have built-in search features beside their main categorization.  Yahoo Directory (http://www.yahoo.com), classifies sites into categories (in the form of a tree) such as health, business, arts, education, society and culture subjects, etc.

                Achoo (http://www.achoo.com/) is organized similarly but lists only medical topics. It includes sections on diseases, medical organizations and medically related businesses. Health and medical directories are created and maintained by human experts (Physicians, informatics specialists and librarians). They may provide a ranking system for each resource, peer reviewed and dedicated to a specific mission. 

                There are two types of health directories: general for multi-subjects and specific single-subject like family practice or disease specific.  The American Academyof Family Physicians (AAFP) maintains a set of very high quality links to clinical resources on the web (http://www.aafp.org/sites/longlist. html). Primary Care Internet Guide (http:// www.uib.no/isf/guide/guide.htm) provides a comprehensive list of primary care related resources. Other useful Internet resources for the family physicians can be found at (http://www.lotusnet.org/it/reperio/eng/familymd.htm) or primary care-related Internet resources (http://views.vcu.edu/dimlist/). Other important sites for family physicians can be found at the World Health Organization (http://www.who.ch/), World Organization of Family Doctors (http:// www.wonca.org/), Centers for Disease Control and Prevention (http://www.cdc. gov/cdc.html) and National Institutes of Health (http://www.nih.gov/).

                Some tips are useful if better results in handling retrieved information in the computer are to be obtained. A suitable filing system should be developed and arranged for easy retrieval of information when most needed. Similarly, a favorite folder should be organized to include the most needed sites. A practical way is to have headings and subheadings suitable for site retrieval. The main headings including national and international sites can be subdivided into several subheadings. First, sites for family physicians include educational, clinical, research, and practice management resources. Second, sites for patients and their families include educational materials, support groups and social resources. Third, sites for subjects of interest include one’s own areas of interest and expertise. Finally, there are the computer-related sites which include the essential hardware and software needed to utilize computer and the Internet effectively.

MEDLINE
Searching for medical literature or references is an integral part of family medicine, especially in the era of evidence-based medicine.  Medline is produced by the United States National Library of Medicine which is considered the most useful resource for searching the medical literature. A number of suppliers offer Medline access.  Some Medline service providers offer free access to titles and abstracts but full text articles can be purchased on-line.

                PubMed (http://www.ncbi.nlm.nih.gov/ pubmed) which is located at the US National Institutes of Health is a very good Medline searching tool for accessing citations and links to full-text journals.  Tutorials on this Web site are a good source of help in carrying out a search on a particular subject in an easily and efficiently. Other sites that offer links to Medline include Dr. Felix's Free Medline Page (http://www.docnet.org.uk/drfelix/), Healthgate (http://www.healthgate.com/) and (http://www.healthy.net/). The availability of Full text articles for health professionals enhances clinical practice as well as medical research needed to develop the educational institutions and health services in Saudi Arabia.

PROFESSIONAL DEVELOPMENT AND CONTINUING MEDICAL EDUCATION

Using well-selected Web sites for professional development and CME can keep family physicians up to date with their professional obligations and save them time and money. In addition, such Web sites provide suitable educational materials which could be both effective and entertaining.   Furthermore, these Web sites are not limited by specific organizations, time or geographical location. Therefore, the Web is a convenient means of professional development and CME especially for those serving in remote areas. Other advantages of the Web are the provision of interactive CME courses, case studies and full text medical books. Academic institutions are the best sources for high-quality content. There is an urgent need for our academic centers to develop relevant educational materials for health professionals.

                AAFP Website (http://www.aafp.org/) has practical information useful for family physicians and other physicians. The site includes review articles, CME materials, policy and practice management guidelines, and other useful links. Other valuable sites are the Society of Teachers of Family Medicine (http://stfm.org/), (www. familypractice.com), Canadian College of Family Physicians (http://www.cfpc.ca/ index.htm), Royal College of General Practitioners (http://www.rcgp.org.uk/) and Royal Australian College of General Practitioners (http://www.racgp.org.au/).

                Medscape (http://www.medscape.com/ home/cmecenter/cmecenter.html) offers thousands of free CME online by specialty and topic. It also provides on line listings of medical conferences with summaries of many medical meetings. Other online CME sites  also available free of charge are at (http://www.cmecourses.com/), (http:// www.cmegateway.com/), (http://www.cmeweb.com/), (http://www.mdconsult. com/), and (http://www.medcases.com/).

                Interactive clinical case presentation is a growing trend on the Web. Text supported by graphics, video clips and feedback heightens the learning process. Interactive patient sites can be accessed at Medconnect  (http://www.medconnect.com/finalhtm/intacedu.htm) or Marshall University School of Medicine (http://medicus.marshall.edu/ mainmenu.htm).

                Family physicians in Saudi Arabiaare now able to link on to many online medical journals. Many publishers offer free full text versions, while others need subscriptions or offer limited full text. Family physicians could potentially find useful information in family medicine journals as well as in general journals (e.g. the British Medical Journal, JAMA, Lancet and New EnglandJournal of Medicine, etc). Some of family medicine/practice journals available online are listed in Table 1.

                Free journal abstracts via e-mail, a very useful way of keeping up with the growing volume of important medical literature of interest are provided by many medical journals. A useful site that categorizes journal collections by specialty can be located at (http://www.medjet.net/).

               


 

Table 1: Family Medicine Journals available on the Web

Journal

URL address*

Comments

American Family Physician

http://www.aafp.org/afp

From May 1996, includes tables of contents, searchable abstracts and full text. It is free.

Archives of Family Medicine

http://archfami.ama-assn.org/

From January 1999, includes tables of contents, searchable abstracts and full text, requires free online registration. Ceased publication November-December 2000

Australian Family Physician

http://www.racgp.org.au/publications/index.htm

From May 1999: Tables of contents, abstracts, and some full text.

Canadian Family Physician

http://www.cfpc.ca/

From 1997: Tables of contents and abstracts. Access to full text is available free to CFPC members.

Evidence-Based Medicine

http://www.acponline.org/journals/ebm/ebmmenu.htm

Includes summaries of Evidence-Based articles with commentaries by clinical experts.

Family Medical Practice Online

http://www.priory.com/fam.htm

An on line international peer-reviewed journal of family medicine. Includes tables of contents, full text.

Family Medicine

http://stfm.org/fmhub/fmhub.html

From January 1997. It is the official journal of Society of Teachers of Family Medicine. Free full texts are available from 1998 & abstracts are available only for 1997.

Family Practice

http://www.oup.co.uk/jnls/list/famprj/hdb

Oxford University Press' family practice journal. Includes table of contents, a searchable index and abstracts. Full text is available on prescription. Begins in January 1996.

Family Practice Management

http://www.aafp.org/fmp

From April 1996, includes searchable index of tables of contents and full text. It is free.

Journal of Family Medicine Online

http://www.medical-library.org/j_fammed.htm

An online peer-reviewed journal of family medicine. Includes tables of contents and full text.

Journal of Family Practice (JFP) POEMS collection

http://www.jfponline.com

From December 1999: free, Full text of Patient Oriented Evidence that Matters (POEMs), Complete text of all JFP Journal Club (POEM) reviews.

Journal of Family & Community Medicine

http://www.ssfcm.com

From 1997, contains compressed files of tables of contents and abstracts but limited full text. It is free.

Journal of the American Board of Family Practice

http://www.abfp.org/journ al.htm

From 1998, contains full text at Family Practice.com. From 1997, full text is available at Medscape which requires free registration.

The Journal of Family Practice

http://www.phypc.med.wa yne.edu/jfp/jfp.htm

Includes table of contents and full text. Contains reviews and critical appraisals of JFP Journal Club as well as recommendations for clinical practice. It also contains useful links for family physicians.

*URL: the Uniform Resource Locator


 

There are Websites designed to give collections of medical journal instructions to authors for the submission of manuscripts. This service is offered at (http://www. mco.edu/lib/instr/libinsta.html). Arab Doctor's Net (http://www.arabdoctors net. net/newjournal.htm) provides names and addresses of a variety of medical journals published in the Arab world.

                A range of medical calculators is accessible on the Internet to help health professionals in their day-to-day practice. A variety of medical calculators on a wide range of topics such as epidemiology, body mass index, pregnancy, diabetes/insulin, and breast cancer risk is available at (http://www.medic8.com/medicaltools.htm).

MEDICAL EDUCATION

The use of the Internet is a potential source to support for the improvement of  medical education. The work of medical schools is to strive to produce competent physicians capable of being life-long learners, educator-communicators, clinicians, researchers and managers.24  Medical informatics is an important support for the diverse roles of physicians25  and should be given an adequate place on the medical school curriculum. A medical student who has basic medical informatics skills can access his college curriculum, syllabus, educational materials, timetable and other available resources to help his education. Many medical with varying levels of accessibility are now on the web, offering a diversity of content.  

                It is essential for family practice residents to acquire the essential medical informatics skills for their day-to-day practice. AAFP recommend curriculum guidelines in medical informatics and computer applications at (http://www.aafp.org/edu/ guide/rep288.html).26 The guidelines outline the essential knowledge, skills and attitudes to be mastered by the residents  and the way they can be utilized. It is important that every medical school and family practice residency should teach its medical students and residents medical informatics competencies including the Internet tools for accessing, and how to appraise and manage medical information critically.

                Many Web sites today offer a variety of information through different residency programs or vocational schemes. Information about family practice residencies/general practice scheme programs and departments of family medicine/general practice and primary health care can be accessed through any search engine or directly through relevant organizations such as AAFP.

EVIDENCE-BASED MEDICINE

Since the application of Evidence-Based Medicine (EBM) is a necessary component of modern family practice, the Web with its huge medical database is a potential source of facilitating that practice. By adapting Patient-Oriented Evidence that Matters (POEMs) in reviewing articles on common primary care problems, family physicians would effectively change their practice.27,28

                Best Web sites for EBM can be accessed through the Journal Club of American College of Physicians (http://www. acponline.org/journals/acpjc/jcmenu.htm) and EBM of the United Kingdom Centerfor Evidence-Based Medicine (http://cebm.jr2. ox.ac.uk). Two other important Web sites for EBM are the Journal of Family Practice POEMs (http://www.jfponline.com/) and the Cochrane Collaboration Library (http:// www.medlib.com) or (http://cochrane.hcn. net.au/).

                These sites contain peer-reviewed abstracts from biomedical journals scrutinized for the research quality and level of evidence. The abstracts also include summaries of evidence-based articles with commentaries by clinical experts. Principles of EBM are used in the abstracts to support the evidence by reporting important findings such as number needed to treat, number needed to harm, relative and absolute risk reduction, odds ratio and confidence interval.

PATIENT INFORMATION

Although there are substantial numbers of patient education materials on the Web sites, there is a dearth of Arabic materials. The provision of health care by family physicians in Saudi Arabiais mostly to patients whose primary language is Arabic. There is therefore a need to have reliable patient education materials in Arabic. Family physicians are ideally placed to develop, maintain and update suitable Web-based information materials for their patients and their families. Some drug companies, health magazines and health-related Arabic Web sites provide a variety of patient information materials. Data on the reliability of the health information posted on these sites are unfortunately not available.

                Since family physicians have to provide personal care to a culturally diverse group of patients, education materials should also be available in the languages that are commonly encountered in family practices in Saudi Arabia. Several Web sites provide multilingual patient education resources. Multilingual information about immunization and vaccination can be found at (http://www.immunize.org/). Information at this site is reviewed for reliability and accuracy by the Centers for Disease Control. Other Web sites that offer multilingual patient information materials are located at (http://www.familydoctor. org/) as well as (http://www.drpen.com/).

                Some of the online health resources useful for patients are accessed at the AAFP's Health Information for Patients (http://familydoctor.org/), Medical Matrix: Patient Education (http://www.medmatrix. org/_SPages/Patient_Education.asp), MEDLINEplus (www.nlm.nih.gov/ medlineplus), the Internet Drug Index (http://www.rxlist.com/), HealthAnswers (http://www.healthanswers.com/), and Hardin Meta Directory of Internet Health Sources (http://www.arcade.uiowa.edu/ hardin-www/md.html).

                Another valuable service that the Internet offers is the provision of suitable social resources to help family physicians in assisting their patients and their families to solve social problems that are encountered. For example, charitable or volunteer organizations can offer a wide range of resources for low-income patients at their Web sites.   An example of Web sites providing access to low cost or free medications in United Statesis offered by (http://www.needymeds.com/).

CONCLUSION

Family Medicine is a specialty that deals with the care of a wide spectrum of individuals and members of families regardless of their age, gender or specific problems. A wide range of technology is needed to support the role of family physicians as caring, trusted and competent clinicians.

                Besides the challenge posed by the expansion of the new electronic resources on the Internet and the Web, the paucity of local Internet resources and the inadequacy of their numbers are some of the current problems facing family physicians in Saudi Arabia.

                The Internet creates a valuable opportunity of raising the standard of family practice through increased access of family physicians’ and the community to information to an international standard of care. Thus, there is a need to encourage family physicians in Saudi Arabiato be in the front of effort to create, develop and


 


 

maintain quality Web sites based on the values of their discipline. It is equally important to provide training in medical informatics to family physicians to enable them to critically appraise the validity and reliability of medical information to their practice. In addition, family physicians in Saudi Arabiashould participate in integrating the best available evidence for primary care practice and make this evidence easily and rapidly accessible at the point of care.

                In last three years, the Internet has grown rapidly in Saudi Arabia. The expansion of Internet services and the creation of web sites for Saudi universities, medical organizations, the accreditation body, and the SSFCM are great achievements. However, there is much to be done to improve quality educational and medical sites. 

                Family medicine organizations (in particular, the SSFCM) are expected to have more active role in creating relevant, reliable and easily accessible Web pages for family physicians and the population at large. Suggested improved site for the SSFCM is shown in figure 1. It is also important for health services, medical colleges and family practice residency programs to provide high quality and up-to-date medical Web sites to their consumers as well as the rest of the society.

ACKNOWLEDGEMENT

I would like to thank Dr. Sameeh M. Al-Almaie, Associate Professor and  Chairman of the Department of Family and Community Medicine, College of Medicine, King Faisal University, for his valuable comments and reviewing of the manuscript.

REFERENCES

1.     Ebell MH, Frame P. What can technology do to, and for, family medicine? Fam Med 2001;33(4):311-9.

2.     Lee N, Millman A. ABC of medical computing. The Internet.  BMJ 1995;311:1422-1424. 

3.     Pallen M. Guide to the Internet. The World Wide Web. BMJ 1995;311:1552-6.

4.  Pallen M. Guide to the Internet. Logging in, fetching files, reading news. BMJ 1995;311:1626-30.

5.     Kramer JM. Medical resources and the Internet. Arch Intern Med 1996;156:833-42. 

6.  Wang KK, Wong Kee Song LM. The physician and the Internet. Mayo Clin Proc 1997;72(1):66-71.

7.     Jenkins RD, Grey-Lloyd J, Hancock C. Medical resources on the Internet: searching and appraising. Hosp Med 1998;59(5):408-10.

8.     Rathe R. Finding what you need on the Internet. Fam Pract Management 1997;4:5-69.

9.     Sikorski R. Peters R. Medical literature made easy: querying databases on the Internet. JAMA 1997; 277:959-60.

10.   Peters R. Sikorski R. Navigating to knowledge: tools for finding information on the Internet. JAMA 1997;27:6505-6.

11.   American Academyof Family Physicians. AAFP official definitions of family practice, family physician, and family practice: content and responsibility for. Kansas City: AAFP; 1993. Reprint No.: 303.

12.   Steward M,  Brown JB, Donner A. Impact of patient-centered care on outcome. J Fam Pract 2000;49(9):796-804.

13.  Sackett DL, Richardson WS, Rosenberg W, Haynes RB, eds. Evidence-based medicine: how to practice and teach EBM. New York: Churchill-Livingston, 1997.

14.   Sebiany AM. Perceived competencies in family practice residency programs in Saudi Arabia[dissertation]. King Faisal University 2001.

15.  Annual health report. Ministry of Health, Kingdom of Saudi Arabia. Riyadh: 1998(1418-1419 H).

16.   Robinson TN, Patrick K, Eng TR, Gustafson D for the Science Panel on Interactive Communication and Health. An evidence-based approach to interactive health communication: a challenge to medicine in the Information Age. JAMA 1998;280:1264-9.

                                                                

17.   Eng TR, Maxfield A, Patrick K, Deering MJ, Ratzan S, Gustafson D. Access to health information and support: a public highway or a private road? JAMA 1998;280:1371-5.

18.  Bower H. Internet sees growth of unverified health claims. BMJ 1996;313:497.

19.   Weisbord SD, Soule JB, Kimmel PL. Poison on line—acute renal failure caused by oil of wormwood purchased through the internet. N Engl J Med 1997;337:825-7.

20.  Kim P, Eng TR, Deering M J, Maxfield A. Published criteria for evaluating health related web sites: review. BMJ 1999;318 (6):647-59.

21.   Silberg WM, Lundberg GD, Musacchio RA. Assessing, controlling, and assuring the quality of medical information on the internet. Caveant lector et viewor—let the reader and buyer beware. JAMA 1997;277:1244.5.

22.   Pealer LN, Dorman SM. Evaluating health-related web sites. J Sch Health 1997;67:232-5.

23.   Jadad AR, Gagliardi A. Rating health information on the internet. Navigating to knowledge or to Babel? JAMA 1998;279:611-4.

24.  The Information Panel and the population Health Perspective Panel. Contemporary issues in medicine--medical informatics and population health: report II of the Medical School Objectives Project. Acad Med. 1999;74(2):130-41.

25.   Greenes RA, Shortliffe EH. Medical informatics. An emerging academic discipline and institutional priority. JAMA 1990;263:1114-20.

26.   American Academyof Family Physicians. Recommended curriculum guidelines for family practice residents: Medical informatics and computer applications. Kansas City: AAFP;19967. Reprint No.: 288.

27.   Shaughnessy AF, Slawson DC, Bennett JH. Becoming an information master: a guidebook to the medical information jungle. J Fam Pract 1994; 39: 489-99.

28.  Slawson DC, Shaughnessy AF, Ebell MH, Barry HC. Mastering medical information and the role of POEMs: Patient-oriented Information that Matters. J Fam Pract 1997;45:195-6.


-0001-11-30

ABDOMINAL PAIN


ACUTE ABDOMINAL PAIN IN WOMEN OF CHILD-BEARING AGE REMAINS A DIAGNOSTIC DILEMMA

Maha S.A. Abdelhadi,FRCSI, Department of Surgery, King Fahd Hospital of the University, College of Medicine, King Faisal University, Dammam, Saudi Arabia

كثيراً ما تكون  آلام البطن الحادة موضع شك وصعوبة في التشخيص عند النساء ذوات السنوات الخصبة مقارنة بالرجال . وتكون  الصعوبة بدرجة أكبر أثناء فترة الحمل حيث من المعروف احتمال حدوث الآم البطن بسبب تغيرات الحمل . وهنا يوضع اللوم عادة على اضطربات الحمل . ولكن يؤدي ذلك أحياناً إلى تأخير التشخيص وتعرض المريضة والجنين إلى مضاعفات وخطورة .

وتهدف هذه الدراسة إلى وضع  خطة لمعاينة المريضات بصورة سريعة ودقيقة لتفادي المضاعفات .

أجريت هذه الدراسة بمستشفى الملك فهد الجامعي بالخبر، تم خلالها مراجعة الدراسات العالمية المماثلة على مدى عشرين عاماً . وقد ركز هذا البحث على الصعوبات في تشخيص الآم البطن  الحادة  ومحاولات إيجاد الحلول المناسبة .

وتم استخلاص أن الآم البطن الحادة لا تزال موضع تحدي للطبيب المعالج . فقد رصدت حالات الآم البطن الحادة وهي تعادل 5 % -10% من كل الحالات الطارئة مع اختلاف درجة الخطورة الناتجة عن نوع المرض . ولذاك وجب مراعاة بعض العوامل مثل الحرص ، المعاينة الدقيقة، التعاون المستمر بين قسم الجراحة وقسم النساء والولادة مع الاستعمال الحكيم لأدوات التشخيص الحديثة مجتمعة مما  يؤدي إلى نتائج مثمرة وإيجابية بإذن الله .

الكلمات المرجعية : الحمل، آلام البطن الحادة، التهاب الزائدة الدودية، انسداد الأمعاء.

Abdominal pain is perhaps the most challenging of all the presenting complaints in the emergency department. It is estimated that it accounts for 5%-10% of all visits. Causes of abdominal pain range from the inconsequential to the life threatening.  In addition, it nearly always poses a greater degree of diagnostic uncertainty in women of child-bearing age as compared to males. Such difficulties become more pronounced in pregnant women where the unwritten policy seems to be: If she is pregnant blame the pregnancy. This policy is justified by the favorable clinical outcomes. However, in a small but significant number of patients, this policy has the potential of creating delays and increasing the risk of unwarranted complications.  Delays in management may lead to emotional trauma, loss to the society, and the potential for serious liability.

This review was undertaken at King Fahd hospital of the University, Eastern Province of Saudi Arabia, with a literature search covering a period of over twenty years. It mainly highlights the diagnostic difficulties in young women presenting with acute onset abdominal pain, and possible solutions.

It also suggests a policy which includes a careful clinical approach with liberal

Correspondence to:

Dr. Maha S.A. Abdelhadi, Assistant Professor and Consultant, Department of Surgery, King Fahd Hospital of the University, P.O. Box 2208, Al-Khobar 31952, Saudi Arabia

consults between the surgeon and the gynecologist reinforced by a judicious use of the available diagnostic aids leading to potentially favorable outcomes.

Key Words: Pregnancy, acute abdomen, acute appendicitis, intestinal obstruction

INTRODUCTION

Abdominal pain is one of the common causes of acute hospital admission.1 When­ever women of childbearing age present with an acute abdomen, diagnostic diffi­culties arise as to whether the emergency is surgical or gynecological. Due to the nature of the female pelvic anatomy, the under­lying etiology includes a wide range of differential diagnoses. Abdominal pain is an essentially a widespread experience in pregnancy; few women will fail to note, if not complain clinically of abdominal pain at some time during pregnancy.2 It has being reported that 1 in 500 pregnancies become complicated by a non-obstetric surgical problem with the high risk of peri-natal morbidity.3 The gravida is usually placed in jeopardy by the general reluctance toward early surgical intervention. The similarity and variations of the signs and symptoms of acute abdominal pain nearly always poses a challenge to the clinician.

                Acute appendicitis is the commonest non-traumatic, non-obstetric surgical malady. Its reported incidence complicating pregnancy is 1in 766 cases,4 with overall accuracy in diagnosing it being 60%,5 as compared to 80% in non-pregnant women. Perforated appendicitis especially during pregnancy leads to grave outcome with fetal loss rate of up to 35%, mandating prompt diagnosis and early surgical intervention.6 Reported fetal complications occurring due to appen­dectomy were spontaneous abortion (33%) in the first trimester, and (14%) in the second trimester. However, no complica­tions were observed  in the third trimester.4

                Intestinal obstruction is the second com­monest emergency with a reported inci­dence of 3%-5% in non-pregnant women, as compared to 0.02-0.04% in pregnant ones.7 Intestinal obstruction due to intussusception and adhesions secondary to intraperitoneal inflammation are rare events during preg­nancy. Their occurrence poses difficulties and delays in diagnosis. This is attributed to the overlapping symptoms in addition to the accomodative nature of the abdominal and pelvic cavities which contribute to the delayed presentation.

                Colonic cancer, on the other hand, occurs in 0.002% during pregnancy as compared to 3% in non-pregnant women. To date, only 32 cases of colonic cancer arising above the peritoneal reflection during pregnancy have been described in the literature.8 Late pregnancy hinders accurate clinical evalu­ation of intestinal obstruction and is commonly associated with shock leading to maternal and fetal mortality of 20%.7

                Both estrogen and progestrone predispose to the formation of lithogenic bile, whereas progestrone further inhibits gallbladder contractility, particularly in the second and third trimester.9 Cholelithasis, when symptomatic, is best treated with chole­cystec­tomy, yet the majority of gravid symptomatic patients respond to conserva­tive management. However, reported ma­ternal and fetal loss of 15% occurs with described complications.10

                The incidence of pancreatitis is equal in both pregnant and non-pregnant women, with reported series of 1 in 100011 and maternal and perinatal mortality up to 38%. The most common cause is secondary to gall bladder disease, followed by alcohol abuse, hyperlipidemia, and viral infection.10 The specificity of elevated levels of serum amylase is limited by the fact that cholecystitis, bowel obstruction, and ectopic pregnancy, among others, cause similar and potentially dramatic elevations in serum amylase. Conversely, serum amylase rises physiologically with pregnancy.

                Primary liver disease must also be con­sidered in the differential diagnosis. It becomes more pronounced during preg­nancy, and may complicate toxemia of pregnancy, commonly associated with dis­seminated intra-vascular coagulation (DIC), resulting in a mortality rate of 16%.12

                Acute fatty liver in pregnancy is a serious condition that occurs mainly in the third trimester; it should be suspected in patients presenting with jaundice, nausea, vomiting, abdominal pain and signs of fetal distress. These patients are in critical condition and should be treated in the intensive care unit.13 In 1982, Weinstein described a variant of this phenomenon which has being dubbed the “HELLP” syndrome, for Hemolysis, Elevated Liver enzymes, and Low Platelet count.14 It affects 10%-20% of the cases of severe preeclampsia, 70% of which occurs during pregnancy out of which 15% occurs as early as the second trimester.15 Failure to recognize this condition may result in both fetal and maternal death. Other causes of primary liver disease include intra-hepatic cholestasis and the more dramatic hepatic rupture, complicating toxemia of pregnancy. These patients present with clinical shock which results in extremely high maternal and fetal mortality. The other differential diagnosis of this hemorrhagic shock is rup­ture of the splenic artery aneurysm which can occur spontaneously during preg­nancy and may give a similar clinical picture.6

                Peptic ulcer disease and reflux esophagitis with their reported complications occur almost equally in both sexes. The incidence increases with stress, obesity, and increased intra-abdominal pressure. It has being reported that 40% of pregnancies are complicated by mild to moderate symptoms.17 Anti-acid therapy usually suf­fices as adequate therapy. However, if symp­­toms persist, investigations and treat­ment for peptic ulcer disease should be considered.

                Inguinal hernias diagnosed during preg­nancy rarely need surgical intervention. This is mainly due to the protective nature of the pregnant uterus against the hernial defect.18

                Urolithiasis is generally more prevalent in men, but it is noted that the incidence increases slightly during pregnancy. Contri­buting factors are urinary stasis due to ureteral dilatation and hypomotility, in con­sequence of ureteral compression by the en­larging uterus, and the relaxing effect of progestrone on smooth muscle, respec­tive­ly.19Renal resistive index is a sensitive and accurate test that can replace intravenous urography in the diagnosis of acute uni­lateral ureteral obstruction in pregnant women.20 Acute renal failure induced by bilateral ureteric obstruction during preg­nancy can be a reversible event.21 Patients are usually treated conservatively, since stones with a diameter of 7mm or less pass spontaneously. Surgical intervention is usually indicated in patients with recurrent pyelonephritis complicating nephrolithasis.

                Abdominal pain of unclear etiology was reported in one study as 41.3% of all patients presenting to the emergency depart­ment.22 Symptoms may be nonspecific, especially in women in the reproductive age group. As long as no serious cause is identified, patients can be discharged with the diagnosis of non-specific abdominal pain rather than a diagnosis of convenience.

DIAGNOSTIC AIDS

Due to the large spectrum of differential diagnoses in acute abdominal pain in women, exhaustive studies are being undertaken to improve the accuracy of the preoperative diagnosis.

Haematological tests

Even though complete blood count, renal function tests, serum electrolytes, liver function test, serum amylase and lipase levels, pregnancy test, and blood glucose levels are nonspecific, they are considered to be the baseline investigations necessary in patients presenting with acute abdominal pain. In addition, urine analysis and urine culture may assist in identifying genito­urinary disease.23

Ultrasonography

Ultrasound has revolutionized the role of the radiologist in diagnosis of acute abdomen. It is the single most effective tool for exploring the abdomen without opening it.24 Ultrasound is simple, rapid, inexpensive, dynamic, and can be repeated as often as neces­sary without known harm to the pa­tient. It does, however, require dedication, skill, and experience. Unskilled use of the ultrasound may lead to medical disaster, and thereby, profound mistrust by the patient and referring clinicians. Performance of ultrasound has a definite impact on the clinical management of the acute abdomen. It prevents unnecessary delays, and mini­mizes the number of negative laparato­mies.25 Doppler ultrasound is used in determining the renal resistive index which is used to assess the degree of the ureteric obstruction in pregnant women. It is considered positive with a value of 0.70 or greater, and 0.04 or greater, respectively.20

CT-scan

With the recent advances in CT technology, this modality has become even more useful in determining the cause of an acute abdo­men. CT-guided interventional procedures can also give additional specific diagnostic information, or provide therapeutic options.  It is the second-line diagnostic modality in women of child-bearing age with reported sensitivity of 98%, specificity of 83%, and accuracy of 93%.26 The reported sensitivity of CT in diagnosing acute appendicitis is 98%,27 it is 93% in diverticulitis,28 90-94% in intestinal obstruction,29 and 56% in bowel ischemia.30 It may also play an important role in the diagnosis and management of acute cholecystitis, liver diseases, acute pan­creatitis, intra-abdominal collections, pelvic and retroperitoneal pathology. The reluc­tance to use this ionized radiation reduces its usefulness use during pregnancy.

Barium enema

This contrast study has limited use in the diagnosis of acute abdomen. It is rarely used when the above two modalities fail to accurately define the diagnosis. Differentia­tion from perforating carcinoma may be difficult to detect by CT-scan, and barium enema may be necessary in 10% of cases.31 Perforation from the procedure can occur ininflamedor ischemic bowel. Therefore, it is best reserved for cold cases.

Fine catheter peritoneal fluid analysis (FCPFA)

This diagnostic aid is reported to be safe and may help to avoid negative laparotomies.32 The fluid obtained can be sent for cytology and lactic acid levels.33 A neutrophil pro­portion of more than 50% indicates a positive cytology result. In addition, lactic acid levels are reported to be significantly higher in the peritoneal fluid than in the plasma of patients with hollow viscus per­foration, bowel gangrene, peritonitis, or intra-abdominal abscess.

Laparoscopy

With the advent of minimally invasive sur­gery, laparoscopy has become a popular tool as a diagnostic and therapeutic modality in abdominal and pelvic pathology. It allows full visualization of the abdominal cavity in its entirety and has shown to be accurate in the diagnosis and management of acute abdominal pain with the reduced incidence of complications as compared to negative laparatomies. However, it is invasive, and requires general anesthesia.34-36

CLINICAL APPROACH

A thorough clinical approach to patients presenting with acute abdominal pain can­not be overemphasized. The junior surgeon is usually the first person to handle patients with such a complaint and the decision to operate is based on the clinical judgment and available investigations. Accuracy in diagnosis is highest in young males, but is far lower in children and women of child-bearing age.37

                Over a period of ten years (1984-1994) at King Fahd Hospitalof the University, Al-Khobar, all women of child-bearing age referred to the surgical unit with question­able diagnosis were reviewed. The total number of patients was 162. In the majority of cases (137), an accurate diagnosis was reached and the patients were treated accordingly. However, 25 patients had equi­vocal signs and symptoms, which man­dated more tests for a definitive diagnosis. It should be noted that 8 out of the 25 patients were pregnant. There was an average delay of 6 hours to 3 days in both the investi­gations and treatment of these patients. The diagnosis in 4 patients was only made at laparotomy. Detailed history, careful clini­cal examination, liberal use of diagnostic aids and consultations between the surgeon and the gynecologist are necessary in order to achieve maximum accuracy in the diagnosis. Premature conclusions may lead to diagnostic inaccuracy and potential medi­cal disaster.38

                Some studies reported the lowest un­necessary laparatomy rates following a policy of active observation as an alternative management. However, this is frequently difficult to implement by the busy and stressed junior surgeons.39

CONCLUSION

Abdominal pain in women of child bearing age remains a diagnostic dilemma.  Causes range from the inconsequential to the life threatening. To avoid unnecessary laparoto­mies and improve the outcome, a clear-cut policy acceptable to both surgeons and gyne­colo­gists is to be outlined. This should include: (a) A careful combined clinical approach between the two disciplines; (b) Reinforcement by the judicious use of the available diagnostic aids; (c) Early surgical intervention as deemed necessary.

REFERENCES

1.     Hawthorn IE. Abdominal pain as a cause of acute admission to hospital. J R Coll Surg Edinb 1992; 37: 389-93.

2.     Setchell M. Abdominal pain in pregnancy. In: Studd J (ed): Progress in Obstetrics and Gyne­cology. Vol. 6. London: Churchill Living­stone; 1987. pp. 87-99.

3.     Griffen WO, Dilts PV, Roddick JW. Current Prolems in Surgery: Non-obestetric Surgery During Pregnancy. Chicago: Yearbook Medical Publishers; 1969.

4.     Andersen B, Nielsen TF. Appendicitis in preg­nancy: diagnosis, management and complications. Acta Obstet Gynecol Scand 1999; 9: 758-62.

5.     Weingold AB. Appendicitis in pregnancy. Clin Obstet Gynecol 1983; 26:801-9

6.     Kammerer WA. Non-obstetric surgery during pregnancy. Med Clin N Am 1979; 63: 1157-64.

7.     DavisMR, Bohon CJ. Intestinal obstruction in pregnancy. Clin Obstet Gynecol 1983; 26: 832-42.

8.     Balloni L, Pugliese P, Ferrari S, Danova M, Porta C. Colon cancer in pregnancy: report of a case and review of the literature. Tumori 2000;  86: 95-7. 

9.     Printen KJ, Ott RA. Cholecystectomy during pregnancy. Am Surg 1978; 44:432-4.

10.   Saunders P, MiltonPJD. Laparotomy during preg­nancy: An assessment of diagnostic accuracy and fetal wastage. BMJ 1973; 21:165-7.

11.   Jouppila P, Mokka R, Larmi TKI. Acute pan­creatitis in pregnancy. Surg Gynecol Obstet 1974; 139:879-82.

12.   Rolfes DB, Ishak KG. Liver disease in toxemia of pregnancy. Am J Gastroentol1986; 81:1138-44.

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