Carnett's sign

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Carnett's sign
Specialty Gastroenterology
Differential diagnosis Abdominal wall pain

In medicine, Carnett's sign is a finding on clinical examination in which (acute) abdominal pain remains unchanged or increases when the muscles of the abdominal wall are tensed. [1] [2] For this part of the abdominal examination, the patient can be asked to lift the head and shoulders from the examination table to tense the abdominal muscles. An alternative is to ask the patient to raise both legs with straight knees.

Contents

A positive test indicates the increased likelihood that the abdominal wall and not the abdominal cavity is the source of the pain (for example, due to rectus sheath hematoma instead of appendicitis). [3] [4] A negative Carnett's sign is said to occur when the abdominal pain decreases when the patient is asked to lift the head; this points to an intra-abdominal cause of the pain. [1]

History

This test was first described by John B. Carnett in 1926. [5] The first clear description of anterior abdominal wall pain arising from structures other than the underlying viscera was Edgar Ferdinand Cyriax in 1919. [6] Cyriax considered that pain could be mimicked by lesions that arose from the vertebra, ribs or other associated structure or that they were the result of direct irritation of intercostal nerves. By identifying conditions such as alterations in the normal vertebral curves, minor subluxation of vertebral bodies and pressure on the peripheral portions of the intercostal nerves, he was able to employ various mechanical treatments to correct the abnormalities and relieve his patients’ symptoms. Despite this paper little attention was paid to this problem until Carnett developed his simple clinical test. Carnett thought that lower abdominal pain was commonly caused by the lower six thoracic nerves and wanted to be able to distinguish this origin from that arising from the viscera.

Differential diagnosis

The differential diagnosis of a positive Carnett's test includes hernias, nerve entrapment syndrome, irritation of intercostal nerve roots, thoracic disk herniations, [7] anterior cutaneous nerve entrapment, slipping rib syndrome, myofascial pain, trigger points and rectus sheath hematomas.

All abdominal wall hernias may be associated with pain and Carnett's test may be useful in their evaluation. The hernias of the anterior abdominal wall include: epigastric hernias, umbilical hernias, spigelian hernias and incisional hernias. Those of the groin include: direct inguinal hernia, indirect inguinal hernia, femoral hernia and sports hernia. Those of the pelvic wall include: sciatic hernia, obturator hernia and perineal hernia. The support hernias include: vault prolapse, enterocele, cystocele, rectocele and uterine decensus. Although most hernias can be detected clinically with the presence of a lump with an expansile cough impulse some may be difficult to detect either because they are small or because the patient is obese. In cases where the diagnosis is suspected but clinically unconfirmed, additional investigation using radiography or ultrasonography may be helpful. Herniography, in which contrast medium is introduced into the peritoneal cavity, has been successfully used to reveal previously unsuspected inguinal hernias in patients with groin pain of uncertain origin and to detect impalpable interparietal lesions such as Spigelian hernias.

Slipping rib syndrome is characterized by pain along the costal margin and is caused by laxity of the eighth, ninth and tenth ribs at the interchondral junctions. These ribs do not articulate with the sternum but instead are bound to each other by a thin band of fibrous tissue. If this fibrous attachment becomes dislocated, the rib(s) may ride up and irritate the intercostal nerve(s), causing pain. Clinically the patient may be aware of a popping or clicking sensation as the ribs move relative to one another. The symptoms can be reproduced by the "hooking maneuver", in which the examiner will hook their fingers under the costal margin and pull upwards. [8] [9]

Spontaneous rectus sheath hematoma arises from rupture of the epigastric vessels. The patient usually presents with a sudden well-localized abdominal pain associated with a tender nonpulsatile abdominal mass, usually in the lower abdomen. There is frequently a plausible precipitating factor such as local trauma, a bout of coughing or anticoagulant therapy. The diagnosis can be confirmed on ultrasound examination and a conservative approach to treatment can be adopted provided that the hematoma does not enlarge. Carnett's test may be diagnostic in this setting.

Related Research Articles

<span class="mw-page-title-main">Hernia</span> Abnormal exit of tissues or organs from the cavity they usually reside in

A hernia is the abnormal exit of tissue or an organ, such as the bowel, through the wall of the cavity in which it normally resides. The term is also used for the normal development of the intestinal tract, referring to the retraction of the intestine from the extra-embryonal navel coelom into the abdomen in the healthy embryo at about 7½ weeks.

<span class="mw-page-title-main">Tietze syndrome</span> Inflammation, tenderness, and pain of the chest wall with swelling present

Tietze syndrome is a benign inflammation of one or more of the costal cartilages. It was first described in 1921 by German surgeon Alexander Tietze and was subsequently named after him. The condition is characterized by tenderness and painful swelling of the anterior (front) chest wall at the costochondral, sternocostal, or sternoclavicular junctions. Tietze syndrome affects the true ribs and has a predilection for the 2nd and 3rd ribs, commonly affecting only a single joint.

<span class="mw-page-title-main">Abdominal pain</span> Stomach aches

Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given that, approaching the examination of a person and planning of a differential diagnosis is extremely important.

<span class="mw-page-title-main">Inguinal hernia</span> Protrusion of abdominal contents through the inguinal canal in the pelvis

An inguinal hernia or groin hernia is a hernia (protrusion) of abdominal cavity contents through the inguinal canal. Symptoms, which may include pain or discomfort especially with or following coughing, exercise, or bowel movements, are absent in about a third of patients. Symptoms often get worse throughout the day and improve when lying down. A bulging area may occur that becomes larger when bearing down. Inguinal hernias occur more often on the right than left side. The main concern is strangulation, where the blood supply to part of the intestine is blocked. This usually produces severe pain and tenderness of the area.

<span class="mw-page-title-main">Rectus abdominis muscle</span> Paired straight muscle

The rectus abdominis muscle, also known as the "abdominal muscle" or simply the "abs", is a pair of segmented skeletal muscle on the ventral aspect of a person's abdomen. The paired muscle is separated at the midline by a band of dense connective tissue called the linea alba, and the connective tissue defining each lateral margin of the rectus abdominus is the linea semilunaris. The muscle extends from the pubic symphysis, pubic crest and pubic tubercle inferiorly, to the xiphoid process and costal cartilages of the 5th–7th ribs superiorly.

<span class="mw-page-title-main">Transverse abdominal muscle</span> Muscle of the abdominal area

The transverse abdominal muscle (TVA), also known as the transverse abdominis, transversalis muscle and transversus abdominis muscle, is a muscle layer of the anterior and lateral abdominal wall, deep to the internal oblique muscle. It is thought by most fitness instructors to be a significant component of the core.

<span class="mw-page-title-main">Abdominal internal oblique muscle</span> Muscle in the abdominal wall

The abdominal internal oblique muscle, also internal oblique muscle or interior oblique, is an abdominal muscle in the abdominal wall that lies below the external oblique muscle and just above the transverse abdominal muscle.

Meralgia paresthetica or meralgia paraesthetica is pain or abnormal sensations in the outer thigh not caused by injury to the thigh, but by injury to a nerve which provides sensation to the lateral thigh.

Athletic pubalgia, also called sports hernia, core injury, hockey hernia, hockey groin, Gilmore's groin, or groin disruption, is a medical condition of the pubic joint affecting athletes.

<span class="mw-page-title-main">Abdomen</span> Part of the body between the chest and pelvis

The abdomen is the front part of the torso between the thorax (chest) and pelvis in humans and in other vertebrates. The area occupied by the abdomen is called the abdominal cavity. In arthropods, it is the posterior tagma of the body; it follows the thorax or cephalothorax.

<span class="mw-page-title-main">Inferior epigastric artery</span> Blood vessel

In human anatomy, the inferior epigastric artery is an artery that arises from the external iliac artery. It is accompanied by the inferior epigastric vein; inferiorly, these two inferior epigastric vessels together travel within the lateral umbilical fold The inferior epigastric artery then traverses the arcuate line of rectus sheath to enter the rectus sheath, then anastomoses with the superior epigastric artery within the rectus sheath.

<span class="mw-page-title-main">Femoral nerve</span> Long nerve down the thigh and inner leg

The femoral nerve is a nerve in the thigh that supplies skin on the upper thigh and inner leg, and the muscles that extend the knee. It is the largest branch of the lumbar plexus.

<span class="mw-page-title-main">Conjoint tendon</span> Medial part of the posterior wall of the inguinal canal

The conjoint tendon is a sheath of connective tissue formed from the lower part of the common aponeurosis of the abdominal internal oblique muscle and the transversus abdominis muscle, joining the muscle to the pelvis. It forms the medial part of the posterior wall of the inguinal canal.

<span class="mw-page-title-main">Spigelian hernia</span> Surgical condition

A Spigelian is the type of ventral hernia where aponeurotic fascia pushes through a hole in the junction of the linea semilunaris and the arcuate line, creating a bulge. It appears in the lower quadrant of the abdomen between an area of dense fibrous tissue and abdominal wall muscles causing a.

Postcholecystectomy syndrome (PCS) describes the presence of abdominal symptoms after a cholecystectomy.

<span class="mw-page-title-main">Rectus sheath hematoma</span> Accumulation of blood in the sheath of the rectus abdominis muscle

A rectus sheath hematoma is an accumulation of blood in the sheath of the rectus abdominis muscle. It causes abdominal pain with or without a mass.

Amyand's hernia is a rare form of an inguinal hernia which occurs when the appendix is included in the hernial sac and becomes incarcerated. The condition is an eponymous disease named after a French surgeon, Claudius Amyand (1660–1740), who performed the first successful appendectomy in 1735.

<span class="mw-page-title-main">Anterior cutaneous nerve entrapment syndrome</span> Chronic abdominal pain due to ingrowth of thoracic nerves into abdominal muscles

Anterior cutaneous nerve entrapment syndrome (ACNES) is a nerve entrapment condition that causes chronic pain of the abdominal wall. It occurs when nerve endings of the lower thoracic intercostal nerves (7–12) are 'entrapped' in abdominal muscles, causing a severe localized nerve (neuropathic) pain that is usually experienced at the front of the abdomen.

<span class="mw-page-title-main">Slipping rib syndrome</span> Pain in the false ribs due to the partial dislocation of the costal cartilage

Slipping rib syndrome (SRS) is a condition in which the interchondral ligaments are weakened or disrupted and have increased laxity, causing the costal cartilage tips to subluxate. This results in pain or discomfort due to pinched or irritated intercostal nerves, straining of the intercostal muscles, and inflammation. The condition affects the 8th, 9th, and 10th ribs, referred to as the false ribs, with the 10th rib most commonly affected.

<span class="mw-page-title-main">Twelfth rib syndrome</span> Medical condition caused by mobile floating ribs

Twelfth rib syndrome, also known as rib tip syndrome, is a painful condition that occurs as a result of highly mobile floating ribs. It commonly presents as pain that may be felt in the lower back or lower abdominal region as a result of the 11th or 12th mobile rib irritating the surrounding tissues and nervous systems. Diagnosis is often made by a physical examination after other conditions are ruled out. The condition is often labelled as slipping rib syndrome due to the unclear definitions of the conditions, with twelfth rib syndrome sometimes being referred to as a subtype of slipping rib syndrome.

References

  1. 1 2 Suleiman S, Johnston DE (August 2001). "The abdominal wall: an overlooked source of pain". Am Fam Physician. 64 (3): 431–8. PMID   11515832.
  2. ↑ Cartwright SL, Knudson MP (April 2008). "Evaluation of acute abdominal pain in adults". Am Fam Physician. 77 (7): 971–8. PMID   18441863.
  3. ↑ Gray DW, Dixon JM, Seabrook G, Collin J (July 1988). "Is abdominal wall tenderness a useful sign in the diagnosis of non-specific abdominal pain?". Ann R Coll Surg Engl. 70 (4): 233–4. PMC   2498809 . PMID   2970820.
  4. ↑ Thomson H, Francis DM (November 1977). "Abdominal-wall tenderness: A useful sign in the acute abdomen". Lancet. 2 (8047): 1053–4. doi:10.1016/S0140-6736(77)91885-2. PMID   72957. S2CID   1292751.
  5. ↑ Carnett JB (1926) Intercostal neuralgia as a cause of abdominal pain and tenderness. J. Surg. Gynecol. Obstet. 42:625-632
  6. ↑ Cyriax EF (1919) On various conditions that may stimulate the referred pains of visceral disease, and a consideration of these from the point of view of cause and effect. Practitioner 102:314-322
  7. ↑ Chronic Abdominal Syndrome Due to Nervous Compression. Study of 100 Cases and Proposed Diagnostic-Therapeutic Algorithm Francisco Javier Pérez Lara, nJ. Quintero Quesada, J. A. Moreno Ramiro, R. Bustamante Toledo, A. Del Rey Moreno, and H. Oliva Muñoz J Gastrointest Surg. 2015; 19(6): 1059–1071. PMID   25801595
  8. ↑ Beltsios, ET; Adamou, A; Kontou, M; Panagiotopoulos, N (April 2021). "Surgical Management of the Slipping Rib Syndrome". SN Comprehensive Clinical Medicine. 3 (6): 1404–1411. doi:10.1007/s42399-021-00886-4. ISSN   2523-8973. S2CID   233247861.
  9. ↑ Obourn, PJ; Benoit, J; Brady, G; Campbell, E; Rizzone, K (March 2021). "Sports Medicine-Related Breast and Chest Conditions—Update of Current Literature". Current Sports Medicine Reports. 20 (3): 140–149. doi: 10.1249/JSR.0000000000000824 . ISSN   1537-8918. PMID   33655995. S2CID   232103016.
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