Approach to acute abdominal pain

Signs and symptoms of serious illness in adults with acute abdominal pain presenting to ambulatory care: a systematic review

BACKGROUND

Acute abdominal pain is a common complaint, caused by a variety of conditions, ranging from acutely life-threatening to benign and self-limiting, with symptom overlap complicating diagnosis. Signs and symptoms may be valuable when assessing a patient to guide clinical work.

AIM

Summarising evidence on the accuracy of signs and symptoms for diagnosing serious illness in adults with acute abdominal pain in an ambulatory care setting.

DESIGN & SETTING

We performed a systematic review, searching for prospective diagnostic accuracy studies that included adults presenting with acute abdominal pain to an ambulatory care setting.

METHOD

Six databases and guideline registers were searched, using a comprehensive search strategy. We assessed the risk of bias, and calculated descriptive statistics and measures of diagnostic accuracy. Results were pooled when at least four studies were available.

RESULTS

Out of 18 923 unique studies, 16 studies with moderate to high-risk bias were included. Fourteen clinical features met our criteria, including systolic blood pressure <100 mmHg (positive likelihood ratio [LR+]7.01), shock index >0.85, uterine cervical motion tenderness (LR+5.62 and negative likelihood ratio [LR-]8.60), and a self-assessment questionnaire score >70 (LR+12.20) or <25 (LR-0.19). Clinical diagnosis made by the clinician had the best rule-in ability (LR+24.6).

CONCLUSIONS

We identified 14 signs and symptoms that can influence the likelihood of a serious illness, including pain characteristics, systemic signs, gynaecological signs, and clinician's overall assessment. The risk of bias was moderate to high, leading to uncertainty and preventing us from making firm conclusions. This highlights the need for better research in this setting.

Clinical and Epidemiological Profile of Patients Presenting With Acute Abdomen to the Emergency Department of a Tertiary Care Hospital

BACKGROUND

 Acute abdomen is a common and urgent clinical condition requiring prompt diagnosis and treatment. This study determines the clinical and epidemiological profile of patients presenting with acute abdomen at a tertiary care hospital.

OBJECTIVE

To describe the demographic characteristics, provisional diagnoses, treatment modalities, and pain management effectiveness in patients with acute abdomen.

METHODS

 This prospective observational study was conducted in the Emergency Medicine department at Dr. D. Y. Patil Medical College, Hospital & Research Center, Pimpri, Pune, over a specified period. The study included patients presenting with acute abdomen, aged above 14 years, excluding those with traumatic acute abdomen and pregnant patients. A sample size of 146 was calculated based on the proportion of ureteric colic cases, with a 95% confidence interval and a 6% margin of error; however, a total of 176 patients were included in the study. Data collection involved recording demographic details, clinical features, provisional diagnoses, and pain scores, as well as performing required blood investigations and ultrasonography. Pain scores were assessed before and after treatment. Patients will be given non-steroidal anti-inflammatory drugs (NSAIDs) or opioid analgesia, depending on the clinical severity. Emergency medicine residents, in consultation with the on-call consultant, determined the disposition of patients, deciding if they required surgical or conservative management.

RESULTS

The study found that the majority of patients, n = 130 (73.86%), were aged 26-50 years, with cases n = 103 (58.52%) being males and cases n = 73 (41.48%) females. Acute appendicitis was the most common diagnosis, n = 41 (24.43%), followed by urolithiasis n = 33 (18.75%). Surgical interventions were required for n = 78 (45.08%) of patients, highlighting the urgent nature of these conditions. Pain management was effective, with significant reductions in pain scores post-treatment (mean visual analog score (VAS) decreased from 6.22 to 2.33, and mean numerical rating score (NRS) from 6.05 to 2.10; p < 0.001).

CONCLUSION

 The study underscores the high prevalence of gastrointestinal and renal conditions in patients with acute abdomen, particularly in middle-aged adults. The high rate of surgical interventions reflects the urgent nature of these conditions. Significant reductions in pain scores demonstrated effective pain management. Comprehensive care strategies are essential for optimizing patient outcomes. Future research with larger sample sizes and multi-center participation is recommended to validate these findings and enhance management protocols for acute abdomen.

Abdominal Ultrasonography Used for Abdominal Pain in the Rural Outpatient Setting of South Texas: Impact on Patient Outcomes

Introduction Abdominal ultrasonography is a key diagnostic tool used in complaints of abdominal pain. The rationale for this study is to examine abdominal ultrasonography's impact on the conclusion of care of abdominal pain in a predominantly Hispanic/Latino patient population. Materials and methods A chart review of 350 patients with a new diagnosis of abdominal pain from a rural family practice clinic in Texas was performed. These patients' charts were reviewed for a new diagnosis of abdominal pain, medications prescribed for abdominal pain, whether abdominal ultrasonography was completed, and the number of visits regarding their complaint. The last visit for their abdominal pain was denoted as the conclusion of care of abdominal pain within the clinic. The primary analyses were logistic regressions with conclusion of pain care or number of visits as the outcome and abdominal ultrasound completion as the primary predictor. Results The sample size was 216 of the 350. Patients were excluded due to age under 18 and if the patient's pain was not coded as epigastric, generalized, or right upper quadrant pain. The patient age range was 18-88 years, and they were all of Hispanic/Latino origin. Abdominal ultrasound was completed on 59 of the patients, and 65 patients experienced conclusion of primary care for abdominal pain. Regarding the number of visits for abdominal pain, 69% had one visit, 25% had two visits, and 6% had three or more visits. Patients who had abdominal ultrasounds were more likely to have multiple visits (typically just two visits) but had markedly higher conclusions of care for abdominal pain. These relationships remained when adjusting for demographic and medical covariates such as age, abdominal pain (all types), and medical treatments used. Conclusion In the outpatient rural care of Hispanic/Latino patients residing in the Rio Grande Valley, patients who had a new complaint of abdominal pain were more likely to have conclusion of primary care for abdominal pain, with only a slight increase in primary care healthcare consumption, if abdominal ultrasonography was completed for abdominal pain.

A Primary Care Approach to Abdominal Pain in Adults

Abdominal pain is a common presenting problem with multiple aetiologies that often pose diagnostic and therapeutic dilemmas for primary care practitioners. The vague symptomatology and difficult correlation to specific organ pathology obscures clinical findings leading to incorrect diagnoses. Although most presentations of abdominal pain are benign, a significant number of patients have life-threatening conditions that require a meticulous approach to management in order to prevent morbidity and mortality. The skill in assessing patients presenting with abdominal pain is fundamental for all primary care doctors. This review will discuss an approach to the assessment and diagnosis of abdominal pain in the primary care setting.

The volume of general surgery emergency cases in a government hospital during the COVID-19 pandemic and two other periods: a comparative, retrospective study

Background

During March and April 2020, reductions in non-COVID-19 hospital admissions were observed around the world. Elective surgeries, visits with general practitioners, and diagnoses of medical emergencies were consequently delayed.

Objective

To compare the characteristics of patients admitted to a northern Israeli hospital with common surgical complaints during three periods: the lockdown due to the COVID-19 outbreak, the Second Lebanon War in 2006, and a regular period.

Methods

Demographic, medical, laboratory, imaging, intraoperative, and pathological data were collected from electronic medical files of patients who received emergency treatment at the surgery department of a single hospital in northern Israel. We retrospectively compared the characteristics of patients who were admitted with various conditions during three periods.

Results

Patients’ mean age and most of the clinical parameters assessed were similar between the periods. However, pain was reportedly higher during the COVID-19 than the control period (8.7 vs. 6.4 on a 10-point visual analog scale, P < 0.0001). During the COVID-19 outbreak, the Second Lebanon War, and the regular period, the mean numbers of patients admitted daily were 1.4, 4.4, and 3.0, respectively. The respective mean times from the onset of symptoms until admission were 3, 1, and 1.5 days, P < 0.001. The respective proportions of surgical interventions for appendiceal disease were 95%, 96%, and 69%; P = 0.03.

Conclusions

Compared to a routine period, patients during the COVID-19 outbreak waited longer before turning to hospitalization, and reported more pain at arrival. Patients during both emergency periods were more often treated surgically than non-operatively.

Identifying return visits to the Emergency Department: A multi-centre study

BACKGROUND

Patients who return to the Emergency Department (ED) for the same complaint are known to be at risk of adverse events. Monitoring of return visits is considered a way to measure the quality of care provided in the ED, although the most commonly used benchmark of 48h lacks evidence. This study aimed to describe the incidence, characteristics and outcomes of patients with unplanned return visits. The study also aimed to determine the capture rate of the 48-h benchmark using an all-inclusive method of return visit identification.

METHODS

A retrospective cross-sectional study was conducted across three EDs in Sydney, New South Wales from July 1st, 2017 to June 30th, 2018. Visits that occurred within 28 days with the same or similar presenting complaint following discharge from the ED were classified as a return visit. Data were grouped by index and return visit. Descriptive statistics were used to summarise incidence, patient characteristics and outcomes for all presentations. Categorical data were analysed using Chi square tests. Continuous data were analysed using Mann-Whitney when data were not normally distributed and t-tests when normally distributed.

RESULTS

Of all ED presentations (n=164,598), 5860 (3.6%) were identified as a return visit. Return patients were younger than non-return patients, but those that required admission were older (43 vs 33 years, p=<0.01). Abdominal problems were the most common reason for return followed by urological and mental health. The median time to return was 64:51h (IQR 20:35-226:37). Only 43% of return visits occurred within 48h. Return visits to a different ED accounted for 13.2% of return visits.

CONCLUSION

More than half of ED return visits are missed when the existing benchmark of 48h is used. Current policy makers should consider increasing the 48-h benchmark to more accurately reflect the incidence of return visits. Further investigation into the causal factors for return visits is warranted, particularly in patients with abdominal, urological or mental health complaints.

Significance of Intra-abdominal Free Fluid Detected in Ultrasonography in the Clinical Assessment and Outcomes of Adult Patients Presenting to the Emergency Department Due to Abdominal Pain

Objective The aim of the study was to evaluate the diagnostic process and clinical course in adult patients who presented to the emergency department (ED) with acute abdominal pain (AAP) and were found to have intra-abdominal free fluid (FF) on ultrasonography (USG). Methods This prospective observational study was conducted in a training and research hospital adult emergency department between March 15, 2013, and April 15, 2013. The study included 252 patients aged above 18 years, who were admitted to the emergency room complaining of non-traumatic acute abdominal pain and provided consent for the study. Results The most common diagnoses were acute, nonspecific abdominal pain (37.3%), acute appendicitis (19%), and urinary tract pathology (15.9%). Intra-abdominal free fluid was detected with ultrasonography in 42.5% of patients. Patients with intra-abdominal free fluid were younger than the other patients. The emergency department length of stay was longer in patients with intra-abdominal free fluid (p=0.011). Of the 252 patients enrolled in the study, 32.9% were admitted to the hospital, 21.4% of whom underwent surgery and 11.5% received medical therapy. Most of the patients (64.5%) who were discharged home had no intra-abdominal free fluid in the ultrasonography (p<0.001). Conclusion The presence of intra-abdominal free fluid alone did not guide the clinical decision regarding the diagnostic evaluation of adult patients that presented to the emergency department complaining of non-traumatic acute abdominal pain.

Diagnostic imaging for acute abdominal pain in an Emergency Department in Italy

Imaging plays a key role in the diagnostic work-up of patients with non-traumatic acute abdominal pain (AAP) in emergency department (ED). We aimed to evaluate the use and diagnostic performance of imaging techniques in adult patients with AAP in an ED in Italy. Patients with non-traumatic AAP admitted at the ED of S. Orsola-Malpighi University Hospital of Bologna (Italy) from the 1st to the 30th November 2016 were included. Demographic and clinical data, data on radiological procedures and discharge diagnosis were collected. Sensitivity and specificity for detecting acute diseases were assessed using the discharge diagnosis from the ED as reference standard. Of the 578 patients (female 52.8%, mean age 51.3 years) admitted to the ED for AAP, 433 (74.9%) underwent abdominal imaging. The most frequent techniques used were abdominal plain radiography and ultrasonography (US), performed in 38.4% and 37.9% of patients, respectively, followed by computed tomography (CT) in 28% of patients. Plain radiography yielded a sensitivity of 28% and specificity of 91.1%; the sensitivity increased to 79.4% in patients with small bowel obstruction. Ultrasonography's sensitivity and specificity were 61.8% and 98.4%, respectively; the sensitivity of US reached 85.2% and 90% in patients with acute cholecystitis/biliary colic and urolithiasis, respectively. The sensitivity and specificity of CT were 87.8% and 92.9%, respectively. Plain radiography is still overused in the diagnostic work-up of AAP in ED in Italy, despite its unsatisfactory sensitivity. Ultrasonography and CT has a higher sensitivity and should be used as first-level imaging in most patients.

Utility of plain abdominal radiography in adult ED patients with suspected constipation

BACKGROUND

Abdominal radiographs are often obtained in ED patients with suspected constipation, although their utility in adults is not well understood. We sought to compare ED management when an abdominal radiograph is and is not obtained.

METHODS

We performed a retrospective chart review study of adult ED patients with a chief complaint of constipation from 2010 through 2016. Trained abstractors recorded radiologic tests ordered, treatments received, and final diagnosis. We determined the physician interpretation of the abdominal radiograph and its use in clinical decision making.

RESULTS

Of 1142 eligible patients, 481 (42%) patients underwent abdominal radiography. Stool burden rated moderate or large was observed in 271 patients (46%). Sixteen patients (3%) were diagnosed with small bowel obstruction; 15/16 of these patients had high risk features such as old age, complex surgical history, history of small bowel obstruction, abdominal malignancy, or presented with vomiting or inability to pass flatus. Of the 197 patients with no or mild stool burden or normal radiograph, 109 (55%) were diagnosed with constipation and 89 (45%) received constipation treatment in the ED. Conversely, of the 271 patients with moderate or greater stool burden, 114 (42%) received no treatment for constipation in the ED and 104 (38%) were prescribed no discharge medications for constipation; 77 of these 271 patients (28%) were diagnosed with something other than constipation.

CONCLUSION

Plain abdominal radiography did not appear to significantly affect the ED management of patients presenting with constipation; it was common for patients to receive treatment that was in direct opposition to radiographic findings. Though a small number of patients had concerning diagnoses identified on plain radiography, the history and physical examination should have sufficiently excluded simple constipation, prompting an alternate diagnostic approach. Fecal loading on radiography does not preclude a more serious diagnosis. In conclusion, abdominal radiography appears to have low value in patients with constipation.

Clinical protocols for adults with acute abdominal pain in Australian emergency departments

RATIONALE, AIMS AND OBJECTIVES

Patients with acute abdominal pain are a common presentation in hospital emergency departments; however, international studies have demonstrated that hospitals often lack clinical protocols to guide care. This study aimed to investigate whether Australian hospital emergency departments have acute abdominal pain clinical protocols, identify hospital-level predictors of the presence of these clinical protocols, and assess the quality of protocols.

METHODS

A survey was sent to all Australian hospitals with emergency departments, collecting data on hospital characteristics and the presence of acute abdominal pain clinical protocols. Participating hospitals (n = 73, 26% response rate) were also asked to provide a copy of these protocols. The quality of these protocols was assessed using Appraisal of Guidelines for REsearch & Evaluation (AGREE) II.

RESULTS

Slightly more than half (n = 40) of the hospitals surveyed had acute abdominal pain clinical protocols, while 16 had a general pain protocol. In binomial logistic regression, two independent variables were related to the presence of a protocol, geographic region (P = 0.008) and advanced practice nurses/nurse practitioners' presence on staff (P = 0.024). The mean score for the overall quality assessment of these protocols was 4.2 on a seven-point Likert scale; in terms of the six domains of quality, "Clarity of presentation" and "Scope and purpose" were highest. The overall quality of clinical protocols increased with remoteness, χ² (3) = 8.341, P = 0.039, and was lower in hospitals with medical staff on site (U = 2.5, P = 0.007).

CONCLUSION

There is a documented standard for pain management of acute abdominal pain in about three quarters of participating Australian emergency departments. The use and quality of clinical protocols is influenced by the physical location of hospitals and staff and skill mix of clinicians.

Incidence, characteristics and outcomes of patients that return to Emergency Departments. An integrative review

BACKGROUND

Unplanned return visits account for up to 5% of Emergency Department presentations in Australia and have been associated with adverse events and increased costs. A large number of studies examine the incidence, characteristics and outcomes of unplanned return visits but few studies examine the reasons for return from a patient perspective. The objective of this integrative review was to determine the incidence, characteristics, outcomes and reasons for unplanned return visits to Emergency Departments.

METHOD

An integrative literature review design was employed to conduct a structured search of the literature using the databases CINAHL, MEDLINE, PubMed, ProQuest and EMBASE (inception to June 2018). Results were screened using predefined criteria and final studies collated and appraised using a quality assessment tool.

RESULTS

Fifty-two primary research articles were included in the review. The timeframe used to capture unplanned return visits varied and the incidence ranged between 0.07% and 33%. The majority of patients who return unplanned to the Emergency Department are subsequently discharged (51% and 90%) without an adverse event.

CONCLUSION

There is no consensus on the timeframe employed to classify unplanned return visits to the Emergency Department and the commonly used 72h lacks evidence. Routine statewide data linkage to capture return visits to other facilities is needed to ensure accurate data about this vulnerable patient group. Further research that focuses on patient and clinician perspectives is required to facilitate the development of local strategies to reduce the incidence of avoidable unplanned return visits.

Nonspecific abdominal pain in the Emergency Department: malignancy incidence in a nationwide Swedish cohort study

INTRODUCTION

The role of emergency physicians is to identify patients in need of immediate treatment, but also to identify symptoms indicative of serious, if not immediately life-threatening conditions.

AIM

To assess whether symptoms described as nonspecific abdominal pain (NSAP) could be the first indication of an abdominal malignancy.

MATERIALS AND METHODS

This was a nationwide registry-based cohort study of all patients discharged with NSAP from Swedish Emergency Departments (EDs) during the year 2011, based on Swedish patient registries of inpatient and outpatient care, and the cause of death registry, studying patients diagnosed with de novo cancer within a year after their NSAP discharge.

RESULTS

Of 24 801 patients discharged with NSAP in 2011, 2.2% were assigned a cancer diagnosis within 12 months. Almost 20% of patients diagnosed with a malignancy died within the year, and 16% of these deaths occurred within a month after the ED visit. The majority of patients with cancer were 60 years of age or older, and thus significantly older than the remaining NSAP patients. Patients with malignancies also had a greater number of comorbidities than the remaining NSAP patients (P<0.01).

CONCLUSION

A small percentage of patients discharged with NSAP from Swedish EDs are diagnosed with a malignancy within a year. Patients aged 60 years or older and with comorbidities were over-represented in terms of developing malignancies after discharge. Emergency physicians should be aware of the fact that diffuse abdominal symptoms in elderly patients could be the first sign of an underlying malignancy and more liberally refer such patients for follow-up in primary care.

Exercise-Induced Abdominal Wall Muscle Injury Resulting in Rhabdomyolysis and Mimicking an Acute Abdomen

BACKGROUND

Rhabdomyolysis is characterized by muscle necrosis and release of intracellular constituents, causing muscle pain, weakness, and myoglobinuria. This can be attributed to muscle injury after strenuous exercise. If the abdominal wall is involved, clinical presentation may resemble an acute abdomen.

CASE

A 27-year-old woman, gravida 4 para 2, presented with swelling and pain of the mons pubis and abdominal pain after intense powerlifting 2 days prior. A computed tomography scan was performed, revealing abdominal wall inflammation. Although myoglobinuria was absent, there was high suspicion for rhabdomyolysis, which was confirmed by an elevated creatine kinase level. The patient improved after receiving intravenous fluids and abstaining from physical activity.

CONCLUSION

Abdominal wall muscle injury resulting in rhabdomyolysis can imitate an acute abdomen in a healthy woman presenting with abdominal pain and swelling.

Acute Abdominal Pain Assessment in the Emergency Department: The Experience of a Greek University Hospital

Background

Acute abdominal pain (AAP) is a common symptom in the emergency department (ED). Because abdominal pain can be caused by a wide spectrum of underlying pathology, evaluation of abdominal pain in the ED requires a comprehensive approach, based on patient history, physical examination, laboratory tests and imaging studies. The aim of this study was to investigate predictive factors for admission to the hospital in patients who presented to the ED with AAP as the main symptom.

Methods

This prospective observational study enrolled 125 patients who presented with AAP in the ED of the Patras University Hospital in western Greece. The sample of patients who enrolled in the study was representative of patients who receive care in this academic institution. All patients underwent clinical examination, laboratory testing and radiological assessment. Clinical and laboratory data were analyzed in an attempt to identify clinical or laboratory factors predicting hospital admission.

Results

Based on clinical, laboratory and radiologic evaluation, 37.6% of patients enrolled in the study were admitted to the hospital, whereas 62.4% were not admitted. Compared to patients who were not admitted, patients admitted to the hospital had higher age and significantly higher inflammatory markers, white blood count and C-reactive protein (CRP). Binary logistic regression analysis showed that abnormal imaging findings (odds ratio (OR) = 6.47, 95% confidence interval (CI): 2.11 - 19.77, P < 0.001) and elevated serum CRP levels (OR = 6.24, 95% CI: 2.16 - 18.03, P < 0.001) were significant predictive factors for hospital admission.

Conclusions

Assessment of AAP remains a challenging problem in the ED. Comprehensive history combined with detailed clinical examination, appropriate laboratory testing and radiologic imaging facilitates effective assessment of patients who present in the ED with AAP and guides the decision to admit patients to the hospital for further care.

Epidemiology and outcomes of acute abdominal pain in a large urban Emergency Department: retrospective analysis of 5,340 cases

BACKGROUND

Acute abdominal pain (AAP) accounts for 7-10% of all Emergency Department (ED) visits. Nevertheless, the epidemiology of AAP in the ED is scarcely known. The aim of this study was to investigate the epidemiology and the outcomes of AAP in an adult population admitted to an urban ED.

METHODS

We made a retrospective analysis of all records of ED visits for AAP during the year 2014. All the patients with repeated ED admissions for AAP within 5 and 30 days were scrutinized. Five thousand three hundred and forty cases of AAP were analyzed.

RESULTS

The mean age was 49 years. The most frequent causes were nonspecific abdominal pain (NSAP) (31.46%), and renal colic (31.18%). Biliary colic/cholecystitis, and diverticulitis were more prevalent in patients aged >65 years (13.17% vs. 5.95%, and 7.28% vs. 2.47%, respectively). Appendicitis (i.e., 4.54% vs. 1.47%) and renal colic (34.48% vs. 20.84%) were more frequent in patients aged <65 years. NSAP was the most common cause in both age classes. Renal colic was the most frequent cause of ED admission in men, whereas NSAP was more prevalent in women. Urinary tract infection was higher in women. Overall, 885 patients (16.57%) were hospitalized. Four hundred and eighty-five patients had repeated ED visits throughout the study period. Among these, 302 patients (6.46%) were readmitted within 30 days, whereas 187 patients (3.82%) were readmitted within 5 days. Renal colic was the first cause for ED readmission, followed by NSAP. In 13 cases readmitted to the ED within 5 days, and in 16 cases readmitted between 5-30 days the diagnosis was changed.

CONCLUSIONS

Our study showed that AAP represented 5.76% of total ED visits. Two conditions (i.e., NSAP and renal colic) represented >60% of all causes. A large use of active clinical observations during ED stay (52% of our patients) lead to a negligible percentage of changing diagnosis at the second visit.

Emergency abdominal MRI: current uses and trends

When evaluating the abdomen in the emergency setting, CT and ultrasound are the imaging modalities of choice, mainly because of accessibility, speed and lower relative cost. CT has the added benefit of assessing the whole abdomen for a wide spectrum of gastrointestinal disease, whereas ultrasound has the benefit of avoiding ionizing radiation. MRI is another tool that has demonstrated increasing utility in the emergency setting and also avoids the use of ionizing radiation. MRI also has the additional advantage of excellent soft-tissue contrast. However, widespread use of MRI in the emergency setting is limited by availability and relative cost. Despite such limitations, advances in MRI technology, including improved pulse sequences and coil technology and increasing clinician awareness of MRI, have led to an increased demand in abdominal MRI in the emergency setting. This is particularly true in the evaluation of acute pancreatitis; choledocholithiasis with or without cholecystitis; acute appendicitis, particularly in pregnant patients; and, in some cases, Crohn's disease. In cases of pancreatitis and Crohn's disease, MRI also plays a role in subsequent follow-up examinations.

The role of mean platelet volume in patients with non-specific abdominal pain in an emergency department

Introduction

Platelets play an important role in inflammation. Mean platelet volume (MPV) may be a useful parameter for inflammatory conditions, in differentiating between non-specific abdominal pain (NSAP) and conditions requiring surgery, or early diagnosis of abdominal pain as a serious problem for emergency services.

Aim

To investigate the role of MPV on NSAP admittance to the emergency department.

Material and methods

The study consisted of 330 patients (186 female and 144 male, with mean age 49 ±20 years) with NSAP and 249 patients with abdominal pain (144 female and 105 male, with mean age 49 ±19 years) applied to our emergency service and enrolled to our study. Medical history, physical examination, complete blood count (CBC), and biochemical parameters were evaluated. Haematological parameters were measured by Beckman Coulter LH 780 instrument. Data were compared using Student's t test, and p < 0.05 was accepted as statistically significant.

Results

The MPV were significantly lower in patients with NSAP than in others (p = 0.025). There was no significant difference between both sexes with regard to MPV (p > 0.05). Moreover, the other haematological parameters (haemoglobin, platelet, or WBC counts) were not statistically different between both groups (p > 0.05).

Conclusions

The MPV may be a useful, simple, and inexpensive parameter to diagnose or differentiate between NSAP and other conditions.

Systemic classification for a new diagnostic approach to acute abdominal pain in children

PURPOSE

With previous methods based on only age and location, there are many difficulties in identifying the etiology of acute abdominal pain in children. We sought to develop a new systematic classification of acute abdominal pain and to give some helps to physicians encountering difficulties in diagnoses.

METHODS

From March 2005 to May 2010, clinical data were collected retrospectively from 442 children hospitalized due to acute abdominal pain with no apparent underlying disease. According to the final diagnoses, diseases that caused acute abdominal pain were classified into nine groups.

RESULTS

The nine groups were group I "catastrophic surgical abdomen" (7 patients, 1.6%), group II "acute appendicitis and mesenteric lymphadenitis" (56 patients, 12.7%), group III "intestinal obstruction" (57 patients, 12.9%), group IV "viral and bacterial acute gastroenteritis" (90 patients, 20.4%), group V "peptic ulcer and gastroduodenitis" (66 patients, 14.9%), group VI "hepatobiliary and pancreatic disease" (14 patients, 3.2%), group VII "febrile viral illness and extraintestinal infection" (69 patients, 15.6%), group VIII "functional gastrointestinal disorder (acute manifestation)" (20 patients, 4.5%), and group IX "unclassified acute abdominal pain" (63 patients, 14.3%). Four patients were enrolled in two disease groups each.

CONCLUSION

Patients were distributed unevenly across the nine groups of acute abdominal pain. In particular, the "unclassified abdominal pain" only group was not uncommon. Considering a systemic classification for acute abdominal pain may be helpful in the diagnostic approach in children.

Abdominal Pain

Acute abdominal pain represents the cardinal symptom of a large number of intra-abdominal pathologies. Because of multiple organ systems, varied pathology from life threatening to benign, and differences in presentation related to sex and age, identifying a final diagnosis is a challenge. The clinician’s goal for patients with acute abdominal pain is to rapidly identify whether the underlying cause requires an urgent or immediate surgical intervention. By developing a systematic approach to evaluating patients with abdominal pain, clinicians can generate a differential diagnosis to ensure appropriate treatment and improved patient outcomes. The purpose of this article is to provide clinicians with a framework for evaluating the complaint of acute abdominal pain and recognizing patients who require expedited evaluation.

Acute abdominal pain in childhood and adolescence: assessing the impact of sonography on diagnosis and treatment

PURPOSE

To assess the impact of ultrasonography on defining the diagnostic and therapeutic pathways for pediatric patients admitted to the emergency department for acute abdominal pain.

METHODS

We performed a retrospective study of all patients aged <16 years with acute abdominal pain who underwent ultrasound examination at our Diagnostic Imaging Department from October 2010 to March 2012. We investigated for each patient the pathway following ultrasound examination and definitive diagnosis. The impact of ultrasonography was defined based on the frequency with which the information resulting from this examination confirmed or denied the diagnostic suspicion made by the emergency physician on the basis of clinical and laboratory findings.

RESULTS

In 497/729 patients (69 %), ultrasound examination did not determine variations in the diagnostic and therapeutic pathways, either because it confirmed the outcome of clinical examination and laboratory tests, or because, even addressing in the opposite direction to these, the emergency physician did not consider its result because of being particularly alarmed or sufficiently reassured by clinical examination and laboratory tests. In the remaining 232/729 cases (31 %), ultrasound examination determined an increase or a reduction of the provided care and attention (subsequently proved justified in the vast majority of cases) in spite of what was initially assessed based on clinical examination and laboratory tests.

CONCLUSIONS

The results of our retrospective study demonstrated that ultrasonography was a valuable tool in the management of pediatric patients with acute abdominal pain together with clinical examination and laboratory tests.

Treating acute pain in the hospitalized patient

Many hospitalized patients report moderate-to-severe pain despite the use of epidural or patient-controlled analgesia. This article will explore the use of multimodal options for analgesia in hospitalized patients and focus on a difficult-to-treat acute pain condition, abdominal pain.