Contribution of Imaging to the Management of Surgical Emergencies in the General Surgery Department of the Ignace Deen National Hospital

The aim of this work was to eassess the contribution of imaging in the management of non-traumatic abdominal surgical emergencies at the General Surgery Department of the Ignace Deen National Hospital. Material and methods: This was a prospective, descriptive study that included for 6 months all patients admitted and operated for a non-traumatic abdominal surgical emergency and having performed at least one imaging test. Results: During our study period, Non-traumatic abdominal surgical emergencies accounted for 25.27% of admissions. The average age was37.58 years old with a male predominance (65.3%) and a sex ratio of 1.88. The mean consultation time was 66.92h±40.15. PSA was the most performed imaging test (86.44%) followed by abdominal ultrasound (8.47%). The main non-traumatic abdominal surgical emergencies observed were acute generalized peritonitis (45.8%), followed by acute intestinal obstruction (44.1%). The agreement between imaging and operative diagnosis was 93.46% on PSA, 92.86% on abdominal ultrasound and 100% on abdominal CT. Conclusion: Non-traumatic abdominal surgical emergencies are frequent, imaging examinations (ASP, ultrasound) allow a good appreciation of all non-traumatic abdominal emergencies when they are judiciously used. In addition, CT, although essential, remains inaccessible due to its cost, thus limiting its emergency use.


Introduction
Non-traumatic abdominal surgical emergencies include all abdominal conditions of non-traumatic origin, of recent occurrence, having in common the therapeutic emergency [1].
They constitute one of the most frequent reasons for consultation in emergency reception services [2,3]. The aetiological diagnosis of an acute abdomen, based on clinical data and laboratory results alone, is often difficult [1,[2][3][4][5] and a source of error in the absence of recourse to the imagery. The proportion of diagnostic errors is estimated between 25 and 50% in the absence of imaging [1]. Close collaboration between the responsible clinician and the radiologist is therefore required [6].
In developed countries, an abdominal surgical emergency is managed promptly and adequately, thus providing a better prognosis for patients [7].
Developing countries suffer from the lack of means allowing judicious management of patients, most often admitted in a precarious clinical state [7].
The aim of this study was to report the contribution of imaging in the management of non-traumatic abdominal surgical emergencies in the general surgery department of the Ignace Deen National Hospital.

Methodology
This was a prospective descriptive study that took place over a 6-month period from September 1, 2017 to February 28, 2018.
We included in our study all patients admitted and operated on for a non-traumatic abdominal surgical emergency and having performed at least one imaging test with informed consent.
The parameters studied were: age, sex, origin, level of education; profession, consultation time, reasons for consultation, main etiologies, imaging examinations performed, concordance between imaging diagnoses and operative diagnoses.

Results
During our series, 467 surgical pathologies were admitted to the department, non-traumatic abdominal surgical emergencies represented 118 cases, or 25.27%. All of these 118 cases of non-traumatic abdominal surgical emergencies underwent at least one imaging test. Both sexes were involved with a male predominance in 65.3% (77 cases); the sex ratio was 1.88. The 21-30 age group was the most represented (22.9%); The average age of our patients was 37.58 years with extremes of 5 years and 90 years. In 104 cases the patients resided in Conakry and came from the interior of the country in 14 cases. Workers were the most represented socio-professional layer with 38 cases (32.2%), followed by housewives 25 cases (21.2%), pupils / students 23 cases (19.5%), and traders 15 cases (12.7%). The mean consultation time from the onset of the disease was 40.18 h with extremes of 8 h and 168 h ( Table 1). Generalized acute peritonitis was the most common pathology with 54 cases, ie 45.8% ( Table 2).
The most common imaging test was an unprepared x-ray of the abdomen. It was the only imaging test in 102 cases, associated with abdominal ultrasound in 04 cases and CT in 01 cases. Abdominal ultrasound alone was sufficient in 10 cases, CT alone was performed in 01 cases. The x-ray of the abdomen without preparation was contributory in 100 cases out of 117 cases, i.e. a positivity rate of 93.46%, abdominal ultrasound in 13 out of 14 cases, or a positivity rate of 92, 86% and CT in 02 out of 02 cases, i.e. 100% positivity. X-ray of the abdomen without preparation, abdominal ultrasound and CT resulted in various pathologies and signs (Tables 3 and 4). We reported the concordance and correlation between imaging diagnosis and operative lesions (Tables 5 and 6).    28-year-old patient admitted for abdominal-pelvic pain, metrorrhagia.
Ultrasound: Demonstration of the presence of an extrauterine gestational sac containing an embryo. Cranio-caudal length=12 mm. Gestational age=7SA Conclusion: Extrauterine Pregnancy    During our study period, 118 patients consulted for a non-traumatic abdominal surgical emergency out of a total of 467 patients admitted to the department, ie a hospital frequency of 25.27%. This frequency was lower than that ofKassegne I et al. [3] in Togo which reported 95.6% and that of Harouna Y et al. [4] in Niger who reported 90.11% emergency abdominal non-traumatic surgery. On the other hand, it is higher than that ofDembele Y (10%) [8] in Mali. These figures can be explained respectively by the fact that the sample size and the duration of the studies are not the same.

Discussions
During our study period, both sexes were represented with a predominance of men. Our results are similar to those of Attipou K in Lomé (64.4%) [9] and ofDembele Ein Mali (61%) [10]. However, our result is different that of Dembele Y [8] in Mali which reported a female predominance. This male predominance in our study could be explained by the fact that men are more exposed to risk factors (regular use of NSAIDs, poor food hygiene, carrying heavy loads).
Our study population consisted mainly of adults. Our results are similar to those found in the literature [10,11] who report that abdominal surgical emergencies concern adults with an average age ranging from 40 to 50 years. However Bienyame [12] found 52.2% of acute abdominal surgical emergencies in children. This difference could be explained by the fact that his study was carried out in a pediatric center while ours took place in a general surgery department.
The majority of our patients were from urban areas. This could be explained by the fact that our study was carried out in a National Hospital located in the capital and which is a benchmark in the management of surgical pathologies.
In our study, the most represented socio-professional layer was the working class followed by housewives and schoolchildren. Our results are similar to those of Ouologuem MO [13] in Mali, which reported a high frequency of manual workers (46.05%) followed by schoolchildren (20.7%). This observation in our context could be explained by the low level of education concerning our population.
The majority of our patients consulted after 48 hours of onset of the first signs. Our result is close to that of Harissou A et al. [14] who reported that the majority of patients (57%) were admitted to the emergency room more than 48 hours after the onset of symptoms. The delay in consultation in our study could be explained by the fact that most patients favor traditional treatment on the one hand and on the other hand, by the financial difficulties affecting our population..
The most common non-traumatic abdominal surgical emergencies were acute generalized peritonitis followed by acute intestinal obstruction.
We did not encounter any acute appendicitis during our series; this could be explained by the fact that the diagnosis is made most often by the clinic on the one hand and on the other hand, by the fact that some patients often arrive at the hospital at an advanced stage. During our study, all of our selected patients performed at least one imaging test.
PSA was the most frequently performed imaging test followed by abdominal ultrasound. Dembele Y [8] andKassegne I and Coll. [15] also reported in their study that the ASP was the most performed examination.
However, according to Delabrousse E et al [16] CT has now become the gold standard for abdominal emergencies.
The availability and lower cost of PSA and ultrasound examinations explain this high frequency of their performance.
The main signs found at ASP were mostly hydro-aeric levels and gaseous crescents under diaphragmatic.
The rate of agreement between the results of the imaging examinations carried out and the operative diagnosis was 93.46% at the ASP; 92.86% on ultrasound and 100% on abdominal CT.
This justifies the indication of abdominal CT for the positive diagnosis of non-traumatic abdominal surgical emergencies according to the data in the literature [17].
In general, we observed that ASP made it possible to confirm a clinically suspected diagnosis without providing much additional information (causal mechanism). This finding is consistent with the data in the literature [2,18,19], considering PSA as a non-sensitive examination, but specific in occlusions and the search for signs of peritonitis.

Conclusion
Non-traumatic abdominal surgical emergencies are frequent, imaging examinations (ASP, ultrasound) allow a good appreciation of all non-traumatic abdominal emergencies when they are judiciously used. In addition, CT, although essential, remains inaccessible due to its cost, thus limiting its emergency use.