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Three Part Question

In [elderly patients presenting to an Emergency Department with abdominal pain and suspected AAA] does [Clinical examination] accurately [rule in or out the diagnosis]?

Clinical Scenario

A 78 years old man presents to the Emergency Department with central abdominal and back pain for 2 hours. He is smoker, overweight, hypertensive and is on bisoprolol and amlodepine 5 mg each daily. Clinical examination reveals tenderness and pulsation in the epigastrium and around the umbilicus his pulse is 78 beat per minute and systolic blood pressure is 85mm Hg.
You wonder if you can rely on your examination to rule out a leaking AAA.

Search Strategy

Medline,CINAHL search using EBSCO and EMBASE search using OVID interface (1950- September 2013) Using ((((("Abdominal Pain"[Mesh] or ((abdominal and (pain or discomfort or acute)))) AND "Aortic Aneurysm, Abdominal/diagnosis"[Mesh]) AND (((elderly[ti] or geriatric[ti]) OR ("Aged"[Mesh] or "Aged, 80 and over"[Mesh] or "Frail Elderly"[Mesh])))) AND ((emergency or urgent or emergent or ED or "a and e" or "a & e" or ER or casualty))) AND "Physical Examination"[Mesh]
We also searched Google scholar and Cochrane library.

Search Outcome

30 papers were found 4 of which were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Fink HA,et al 2000 USA	200 Subjects 99 with AAA, 101 without diagnosed already by ultrasound scan. Patients were then examined by 2 internist who were blinded to the scan findings and to each other diagnosis.	Prospective observational study	The sensitivity of abdominal examination is 68% (95% confidence interval [CI], 60%-76%); specificity, 75% (95% CI, 68%-82%); the interobserver agreement Kappa 0.53 was fair. Sensitivity increased with the diameter and decreased by abdominal girth.	Abdominal palpation has moderate sensitivity for detecting AAA.	This study was done on patients who were not acutely presenting of had any disruption of their aneurysm. There is introduced bias as the examining internists were focusing on detecting aneurysm
Lederle FA et al, 1999 USA	Patients not previously known to have AAA.	Systematic review of literature (15 studies) comparing abdominal palpation and ultrasound	The sensitivity of abdominal palpation increases significantly with the increase of AAA diameter (P<.001), ranging from 29% for AAAs of 3.0 to 3.9 cm to 50% for AAAs of 4.0 to 4.9 cm and 76% for AAAs of 5.0 cm or greater. Positive and negative likelihood ratios with 95% confidence intervals (CIs) using a cutoff point for AAAs of 3.0 cm or greater are 12.0 (95% CI, 7.4-19.5) and 0.72 (95% CI, 0.65-0.81), respectively, and for AAAs of 4.0 cm or greater are 15.6 (95% CI, 8.6-28.5) and 0.51 (95% CI, 0.38-0.67)	Abdominal palpation specifically directed at measuring aortic width has moderate sensitivity for detecting an AAA that would be large enough to be referred for surgery but cannot be relied on to exclude AAA, especially if rupture is a possibility	Pooled effect of screening studies
Beede SD 1990 USA	116 patients with suspected AAA on examination underwent US Scan examination.	Retrospective data analysis	17 patients had a 3.5-cm or greater AAA by ultrasound examination (PPV = 14.7%). The probability of AAA by ultrasound examination (PPV = 14.7%). The probability of AAA documentation by ultrasound examination given clinical suspicion of an AAA was associated with higher body mass index, older age,and presence of other macro vascular disease. In 17 patients aged 70 years or younger, without other macro vascular disease and with body mass index of 24 or less, only 1 had an AAA of 3.5 cm or greater (PPV = 6%), while 10 of 20 patients aged 70 years or older, with macro vascular disease, and with body mass index greater than 24 had an AAA of 3.5 cm or greater (PPV = 50%)	poor PPV of the clinical assessment for AAAs indicate that abdominal palpation aimed at detecting AAAs as part of a periodic health examination may lead to a much higher rate of false-positive results than indicated by previous referral-based data	Population-based data as part of investigation of screening effectiveness. Retrospective study.
Lynch RM 2004 UK		Review article	sensitivity of PE in the diagnosis of AAA ranges from 33% to 100%, the specificity from 75% to 100%, and the positive predictive value from 14% to 100%.	Detection rates increase with increasing aortic diameter, increasing age, male sex, presence of recognisable risk factors, examination by an experienced clinician, PE directed specifically towards the detection of AAA	Using the ultrasound scan as the gold standard

Comment(s)

The clinical examination although essential is not on its own reliable in such serious pathology with high mortality rates. No study has assessed the accuracy of abdominal examination in emergency situation. Current available evidence suggest that abdominal examination has only moderate sensitivity which increases with the increase in the diameter of the aneurysm and is reduced with the increase in the abdominal girth.

References

1. Fink HA, Lederle FA, Roth CS, Bowles CA, Nelson DB, Haas MA. The accuracy of physical examination to detect abdominal aortic aneurysm Arch Intern Med 2000 Mar 27; 160(6):833-6
2. Lederle FA, Simel DL. The rational clinical examination. Does this patient have abdominal aortic aneurysm? JAMA 1999 Jan 6; 281(1):77-82
3. Beede SD, Ballard DJ, James EM, Ilstrup DM, Hallet JW Jr. Positive predictive value of clinical suspicion of abdominal aortic aneurysm. Implications for efficient use of abdominal ultrasonography. Arch Intern Med. 1990 Mar; 150(3):549-51.
4. Lynch RM Accuracy of abdominal examination in the diagnosis of non-ruptured abdominal aortic aneurysm. . Accid Emerg Nurs 2004 Apr;12(2):99-107.