Etiology and clinical course of abdominal pain in senior patients: a prospective, multicenter study

Trends in visits, imaging, and diagnosis for emergency department abdominal pain presentations in the United States, 2007-2019

OBJECTIVES

Abdominal pain is the most common reason for visit (RFV) to the emergency department (ED) for adults, yet no standardized diagnostic pathway exists for abdominal pain. Optimal management is age-specific; symptoms, diagnoses, and prognoses differ between young and old adults. Availability and knowledge of the effectiveness of various imaging modalities have also changed over time. We compared diagnostic imaging rates for younger versus older adults to identify practice patterns of abdominal imaging across age groups over time.

METHODS

We analyzed weighted, nationally representative data from the National Hospital Ambulatory Medical Care Survey 2007-2019 for adult ED visits with a primary RFV of abdominal pain. We included 23,364 sampled visits, representing 123 million visits.

RESULTS

From 2007 to 2019, total visits increased for ages 18-45 (p < 0.001), 46-64 (p < 0.001), and 65+ (p = 0.032). The percentage of visits with primary RFV of abdominal pain increased from 9.4% to 11.6% for ages 18-45, 7.8%-9.0% for ages 46-64, and 6.0%-6.5% for 65+. Computed tomography (CT) scan rates increased over time from 26.2% of all patients receiving a CT scan to 42.6%. Relative percentage change in abdominal CT scans was greatest for older adults, with a 30.3% increase, compared to 24.0% for middle-aged adults and 15.0% for young adults. Test positivity, defined as receiving an emergency general surgical diagnosis after CT or ultrasound, increased from 17.2% in 2007 to 22.9% in 2019 (p < 0.01). Of the older adults with abdominal pain in 2019, 13% received an X-ray only, which is neither sensitive nor specific for acute pathology in older adults.

CONCLUSIONS

Despite more abdominal pain ED visits and increased imaging rates per visit, test positivity continues to rise. Our findings do not support claims that CT and ultrasound are being used less appropriately over time, but demonstrate widespread use of X-rays, which are potentially ineffective for abdominal pain.

Role of Fecal Calprotectin in Patients Presenting to the Emergency Department with Abdominal Pain with or without Diarrhea or Rectal Bleeding

BACKGROUND AND OBJECTIVE

Abdominal pain is a frequent reason for admission to the Emergency Department. It may be a symptom of an underlying "organic" disease or a "functional" manifestation without an underlying anatomic or physiologic alteration. The evaluation of patients with abdominal pain is a challenge for the emergency physician and the selection of patients for second-level radiological examinations or endoscopic procedures is not always easy to perform. Faecal calprotectin could be a useful diagnostic marker to distinguish between "organic" or "functional" form and its determination could be helpful to select patients for further examinations in the context of an emergency setting.

MATERIALS AND METHODS

This is an observational and retrospective study on 146 patients with abdominal pain and/or diarrhea (with or without rectal bleeding) admitted to the Emergency Department of Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, who collected a fecal sample to evaluate fecal calprotectin. We evaluated and correlated the level of fecal calprotectin with the final diagnosis they received.

RESULTS

50/146 patients (34,24%) received a diagnosis of acute diverticulitis, in particular, 14/50 (28%) were complicated and 36/50 (72%) were uncomplicated; 4/146 (2,7%) were cholangitis, 32/146 (21,9%) were colitis, 6/146 (4,1%) gastritis, 42/146 (28,7%), Irritable bowel syndrome and 12/146 (8,2%) Inflammatory bowel disease. For the differential diagnosis between Irriable or inflammatory bowel diseses, our study showed a VPP and a VPN of 100% meanwhile for the differential diagnosis between Acute complicated and uncomplicated diverticulitis, our study showed a VPP of 40% and a VPN of 84%.

CONCLUSION

In the emergency setting, faecal calprotectin could be a helpful marker to select patients with abdominal pain who need second-level radiological examinations or endoscopic procedures, guiding the emergency physician in the evaluation of such a complex and wideranging symptom.

Abdominal Pain in the Emergency Department: How to Select the Correct Imaging for Diagnosis

Abdominal pain is a common presenting complaint in the emergency department, and utilization of diagnostic imaging is often a key tool in determining its etiology. Plain radiography has limited utility in this population. Computed tomography (CT) is the imaging modality of choice for undifferentiated abdominal pain. Ultrasound and magnetic resonance imaging may be helpful in specific scenarios, primarily in pediatrics and pregnancy, and offer the benefit of eliminating ionizing radiation risk of CT. Guidance for imaging selection is determined by location of pain, special patient considerations, and specific suspected etiologies. Expert guidance is offered by the American College of Radiology Appropriateness Criteria^® which outlines imaging options based on location of pain.

Evaluation and disposition of older adults presenting to the emergency department with abdominal pain

BACKGROUND

Abdominal pain is the most common chief complaint in US emergency departments (EDs) among patients over 65, who are at high risk of mortality or incident disability after the ED encounter. We sought to characterize the evaluation, management, and disposition of older adults who present to the ED with abdominal pain.

METHODS

We performed a survey-weighted analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS), comparing older adults with a chief complaint of abdominal pain to those without. Visits from 2013 to 2017 to nationally representative EDs were included. We analyzed 81,509 visits to 1211 US EDs, which projects to 531,780,629 ED visits after survey weighting. We report the diagnostic testing, evaluation, management, additional reasons for visit, and disposition of ED visits.

RESULTS

Among older adults (≥65 years), 7% of ED visits were for abdominal pain. Older patients with abdominal pain had a lower probability of being triaged to the "Emergent" (ESI2) acuity on arrival (7.1% vs. 14.8%) yet were more likely to be admitted directly to the operating room than older adults without abdominal pain (3.6% vs. 0.8%), with no statistically significant differences in discharge home, death, or admission to critical care. Ultrasound or CT imaging was performed in 60% of older adults with abdominal pain. A minority (39%) of older patients with abdominal pain received an electrocardiogram (EKG).

CONCLUSIONS

Abdominal pain in older adults presenting to EDs is a serious condition yet is triaged to "emergent" acuity at half the rate of other conditions. Opportunities for improving diagnosis and management may exist. Further research is needed to examine whether improved recognition of abdominal pain as a syndromic presentation would improve patient outcomes.

Improving mortality in older adult trauma patients: Are we doing better?

BACKGROUND

Older adult trauma is associated with high morbidity and mortality. Individuals older than 65 years are expected to make up more than 21% of the total population and almost 39% of trauma admissions by 2050. Our objective was to perform a national review of older adult trauma mortality and identify associated risk factors to highlight potential areas for improvement in quality of care.

MATERIALS AND METHODS

This is a retrospective cohort study of the National Trauma Data Bank including all patients age ≥65 years with at least one International Classification of Diseases, Ninth Revision, Clinical Modification trauma code admitted to a Level I or II US trauma center between 2007 and 2015. Variables examined included demographics, comorbidities, emergency department vitals, injury characteristics, and trauma center characteristics. Multilevel mixed-effect logistic regression was performed to identify independent risk factors of in-hospital mortality.

RESULTS

There were 1,492,759 patients included in this study. The number of older adult trauma patients increased from 88,056 in 2007 to 158,929 in 2015 (p > 0.001). Adjusted in-hospital mortality decreased in 2014 to 2015 (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.86-0.91) when compared with 2007 to 2009. Admission to a university hospital was protective (OR, 0.83; 95% CI, 0.74-0.93) as compared with a community hospital admission. There was no difference in mortality risk between Level II and Level I admission (OR, 1.00; 95% CI, 0.92-1.08). The strongest trauma-related risk factor for in-patient mortality was pancreas/bowel injury (OR, 2.25; 95% CI, 2.04-2.49).

CONCLUSION

Mortality in older trauma patients is decreasing over time, indicating an improvement in the quality of trauma care. The outcomes of university based hospitals can be used as national benchmarks to guide quality metrics.

LEVEL OF EVIDENCE

Therapeutic/Care Management, Level IV.

Disaster Diagnoses in Geriatric Patients with Abdominal Pain

Care of geriatric patients with abdominal pain can pose significant diagnostic and therapeutic challenges to emergency physicians. Older adults rarely present with classic signs, symptoms, and laboratory abnormalities. The incidence of life-threatening emergencies, including abdominal aortic aneurysm, mesenteric ischemia, perforated viscus, and other surgical emergencies, is high. This article explores the evaluation and management of several important causes of abdominal pain in geriatric patients with an emphasis on high-risk presentations.

Acute abdominal disease with nonspecific symptoms in the elderly: A case series

Acute stomach disease in elderly patients often lacks characteristic clinical manifestations. Presentations may differ from those in younger patients and are often complicated by concomitant diseases, delayed presentation, and misdiagnosis. Incorrect diagnosis and treatment can lead to medical-related death claims. We investigated eight cases of elderly fatality due to acute abdominal diseases in forensic autopsy cases. Although most fatalities were unwitnessed, possibly due to the characteristics of elderly individuals, recent social backgrounds, and involvement with health care, some cases of possible misdiagnosis suggested that physicians should carefully consider atypical clinical manifestations and the characteristics of elderly individuals when the managing abdominal symptoms, particularly in primary health care. Our investigation of these forensic autopsy cases indicated the particular importance of peritoneal adhesions as an unexpected cause of acute abdomen in the elderly due to strangulation ileus, even among those with no history of abdominal surgery or trauma. Diagnosis of acute stomach symptoms can be difficult in elderly patients. Pathophysiological examination and autopsy analyses can thus contribute to early-stage diagnosis and prevention of acute stomach symptoms in elderly patient populations.

Routine versus selective computed tomography in non-traumatic acute abdominal pain: meta-analysis of randomised trials

PURPOSE

To compare the routine vs. selective use of computed tomography (CT) in patients presenting with non-traumatic acute abdominal pain (AAP) to a surgical service.

METHODS

We conducted a systematic review of literature and meta-analysis of outcomes according to PRISMA statement standards to compare the routine vs. selective use of CT in adult patients presenting with non-traumatic AAP.

RESULTS

Analysis of 722 patients from 4 randomised controlled trials showed no difference between the routine CT and selective CT groups in terms of proportion of correct diagnoses (OR 1.36,95% CI 0.89, 2.07, P = 0.15), mortality (RD 0.03, 95% CI - 0.08, 0.02, P = 0.27] and length of hospital stay (LOS) [MD - 0.26, 95% CI - 2.07, 1.55, P = 0.78).

CONCLUSIONS

The routine use of CT does not improve the proportion of correct diagnoses and mortality compared to selective use of CT in adult patients with non-traumatic AAP. The available evidence regarding the influence of routine CT on LOS may be subject to type 2 error. These findings, however, may not apply to the elderly patient with AAP and further studies are required.

Identifying, Analyzing, and Visualizing Diagnostic Paths for Patients with Nonspecific Abdominal Pain

BACKGROUND

Diagnosis is complex, uncertain, and error-prone. Symptoms such as nonspecific abdominal pain are especially challenging. A diagnostic path consists of diagnostic steps taken from initial presentation until a diagnosis is obtained or the evaluation ends for other reasons. Analysis of diagnostic paths can reveal patterns associated with more timely and accurate diagnosis. Visual analytics can be used to enhance both analysis and comprehension of diagnostic paths.

OBJECTIVE

This article applies process-mining methods to extract and visualize diagnostic paths from electronic health records (EHRs).

METHODS

Patient features, actions taken (i.e., tests, referrals, etc.), and diagnoses obtained for 501 adult patients (half female, half ≥50 years of age) presenting with abdominal pain were extracted from an EHR database to construct diagnostic paths from a hospital system in suburban Chicago, Illinois, United States. A stable diagnosis was defined as the same diagnosis recorded twice in a 12-month period; a working diagnosis was recorded only once. Three different types of path visualizations were obtained.

RESULTS

A stable diagnosis was obtained in 63 (13%) patients after 12 months. In 271 (54%) patients, a working diagnosis was obtained. Mean path duration was 145.3 days (standard deviation, 195.1 days). These 63 patients received 75 stable diagnoses.

CONCLUSION

Structured EHR data can be used to construct diagnostic paths to gain insight into diagnostic practices for complaints such as abdominal pain.

Etiologies and outcomes of emergency surgery for acute abdominal pain: an audit of 1456 cases in a single center

PURPOSE

There are few studies that have reported the details of emergency surgery for acute abdominal pain. This study aimed to clarify the etiologies and outcomes of emergency abdominal surgery among patients in different age categories.

METHODS

Between January 2014 and December 2016, 1456 patients aged 7 years or older who underwent emergency surgery for acute abdominal pain at our institution were enrolled in this study. The patients were divided into three age groups: 7-17 years (n = 146), 18-64 years (n = 628), and 65 years or older (n = 682). The clinical characteristics, etiology of abdominal emergency surgery, and surgical outcomes were compared among the three groups.

RESULTS

The proportion of patients with comorbid conditions significantly increased with increasing ages. In patients in between 7 and 17 and in those between 18 and 64 years, acute appendicitis was the most frequent etiology, followed by bowel obstruction. Conversely, the most frequent etiology was bowel obstruction, followed by biliary disease in patients 65 years or older. The morbidity and mortality rate were 12% and 0.2% in patients 18-64 years, and 25% and 1.8% in patients 65 years or older (P < 0.001 and P = 0.004, respectively). In the group of patients 65 years or older, more patients were transferred to different hospitals for rehabilitation or recovery.

CONCLUSIONS

This study demonstrated significant differences among patients in different age categories in terms of the etiologies and outcomes of emergency abdominal surgery.

Feasibility of predictive model by clinical and laboratory parameters for risk stratification of geriatric abdominal pain

Background:

Assessment of geriatric patients presented with abdominal pain had been challenge for emergency physicians with the ageing population. A rapid, reproducible risk stratification model for the assessment of the need for admission for geriatric abdominal pain would be required to identify low-risk patients to be managed as out-patient basis.

Objective:

Assess the feasibility of risk stratification model to predict the need of hospital admission based on readily available bedside parameters in emergency departments.

Methods:

This is a multicenter retrospective cohort study in four emergency departments. Patients aged at least 65 who presented with chief complaint of abdominal pain within the previous 7 days of attendance as the chief complaint were included. Chart review was performed for the included patients. The primary outcome was defined as a composite of mortality, abdominal surgery or endoscopic treatment, and other inpatient treatments for abdominal diseases within 14 days, surrogating the need of hospital admission. Logistic regression was modeled to identify independent predictors. The diagnostic accuracy of the risk model was evaluated with the receiver operating characteristic curve and compared with the clinical gestalt of decision for hospital admission by the attending physician.

Results:

In total, 553 patients were included. Symptoms of upper gastrointestinal bleeding, non-ambulatory presenting status, pain duration, focal abdominal tenderness, hyperglycemia, leukocytosis, and elevated creatinine were independent predictors of the outcome. The area under the receiver operating characteristic curve of the predicted probabilities of the logistic model was 0.741. In keeping for a low-risk criterion to achieve more than 90% sensitivity, the predictive model would only achieve 18.2% specificity which was inferior to clinical gestalt for hospital admission (sensitivity 99.3%, specificity 44.3%).

Conclusion:

Risk stratification model by clinical assessment and laboratory markers alone were inadequate and inferior to clinical gestalt for identification of the group of patients requiring inpatient treatment.

Case Report: Large ileal intramural hematoma presenting as an intestinal obstruction in a patient on Warfarin with incidental breast cancer

Intramural hematoma of the gastrointestinal (GI) tract, which can present as abdominal pain or obstruction, can be a rare complication of oral anticoagulants, in particular Warfarin. In this case report, we describe an 81-year-old female patient presenting with abdominal pain, nausea, and vomiting with a previous history of rectorrhagia. The patient was receiving Warfarin therapy due to cardiac valve replacement for the past 8 years. Laboratory workup revealed elevated INR and anemia. Diagnosis of ileal intramural hematoma was based on ultrasound and CT scan findings. The patient was treated by conservative approaches including administration of fresh frozen plasma, cessation of oral intake, and fluid resuscitation. In CT images, a mass on the left breast and lymphadenopathy on the left axilla were also noticed. Given that most GI intramural hematomas caused by over-anticoagulation are treated non-surgically, considering a patient's drug history, especially in older patients with abdominal pain and obstruction symptoms, is of particular importance.

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.

Rectal colonic mural hematoma following enema for constipation while on therapeutic anticoagulation

Causes of colonic and recto-sigmoid hematomas are multifactorial. Patients can present with a combination of dropping hemoglobin, bowel obstruction and perforation. Computed tomography imaging can provide clues to a diagnosis of intramural hematoma. We present a case of rectal hematoma and a review of current management literature. A 72-year-old male on therapeutic anticoagulation for a pulmonary embolism, was administered an enema resulting in severe abdominal pain unresponsive to blood transfusion. A sigmoid colectomy with end colostomy was performed. Although rare, colonic and recto-sigmoid hematomas should be considered as a possible diagnosis for adults with abdominal pain on anticoagulant therapy.

Abdominal Pain in the Geriatric Patient

Abdominal pain in the elderly can be a challenging and difficult condition to diagnose and treat. The geriatric population has significant comorbidities and often takes polypharmacy that can mask symptoms. The presentation of common conditions can be different than that in the younger population, often lacking the traditional indicators of disease, making it of pivotal importance for the clinician to consider a wide differential during their workup. It is also important to consider extra-abdominal abnormality that may manifest as abdominal pain.

Impact of CT in elderly patients presenting to the emergency department with acute abdominal pain

PURPOSE

The purpose of the study was to document the clinical impact of CT in elderly patients presenting to the emergency department (ED) with abdominal pain.

METHODS

This retrospective IRB-approved study from 2006 to 2013 evaluated 464 patients ≥80 years (mean 89 years, range 80-100: M150, W314), who presented to the ED with acute abdominal symptoms and underwent CT. CTs were divided into those negative and positive for actionable findings, defined as potentially requiring a change in surgical or medical management. Physician diagnosis, treatment plan, and disposition before and after CT were reviewed in the electronic medical record to assess CT influence on management and disposition. CT diagnosis was confirmed with final clinical diagnosis, surgical intervention, pathology, and follow-up. Descriptive statistics were used.

RESULTS

CTs were positive in 55%. The most common diagnoses were SBO (18%), diverticulitis (9%), non-ischemic vascular-related emergency (6%), bowel ischemia (4%), appendicitis (3%), and colonic obstruction (2%). These diagnoses were clinically unsuspected prior to CT in 43% (p < 0.05), with significant difficultly in diagnosing SBO (p < 0.05), diverticulitis (p < 0.01), and colonic obstruction (p < 0.01). Positive CT results influenced treatment plans in 65%, surgical in 48%, and medical in 52%. Disposition from the ED was significantly affected by CT (p < 0.001), 65% of admissions with positive CT (p < 0.001) and 63% of discharges with negative CT (p < 0.001).

CONCLUSION

Utilization of abdominopelvic CT in geriatric patients presenting to the ED with acute abdominal symptoms strongly influences clinical management and significantly affects disposition. As the US population ages, the clinical impact of emergent CT in the elderly will intensify.

Assessing the prevalence and clinical relevance of positive abdominal and pelvic CT findings in senior patients presenting to the emergency department

The purpose of our study was to retrospectively evaluate the prevalence and clinical relevance of positive abdominal and pelvic CT findings for patients 65 years of age and older, when compared with all other scanned adult Emergency Department (ED) patients, at a single tertiary care hospital. Our hypothesis was that there is an increased prevalence and clinical relevance of positive abdominal/pelvic CT findings in senior patients. A research ethics board-approved retrospective review of all adult patients who underwent an emergency CT of the abdomen and pelvis for acute nontraumatic abdominal and/or pelvic signs and symptoms was performed. Two thousand one hundred two patients between October 1, 2011, and September 30, 2013, were reviewed. Six hundred thirty-one patients were included in the <65 group (298 men and 333 women; mean age 46, age range 18-64), and 462 were included in the >65 group (209 men and 253 women; mean age 77.6, age range 65-99). Overall, there were more positive CT findings for patients <65 (389 positive cases, 61.6 %) compared with the >65 group (257 positive cases, 55.6 %), which was a statistically significant difference (p < 0.03). Moreover, with the exception of complicated appendicitis cases, which were more common in the >65 group, there were no statistically significant differences in the clinical/surgical relevance of the positive CT findings between the two groups. The findings of our retrospective study therefore refute our hypothesis that there is an increased prevalence of positive abdominal CT findings in patients >65. This may be related to ED physicians at our institution being more hesitant to order CT examinations for the younger population, presumably due to radiation concerns. However, older patients in our series were more likely to present with complicated appendicitis, and a lower threshold for ordering CT examinations of the abdomen and pelvis in this patient population should therefore be considered.

Emergency gastrointestinal surgery in the elderly

The main problem in management of elderly patients who present to the emergency department with abdominal pain is related to difficulties in establishing a diagnosis, because of frequently impaired communication as well as to unusual clinical and laboratory presentations, resulting in delayed management. Early use of pertinent imaging may reduce this delay. Surgical procedures in the elderly do not differ from those in younger patients, but their associated morbidity is different. Assessing co-morbidities and patient frailty, as well as taking into consideration the diagnosis, patients' wishes and status should help in decision-making. Therapeutic decisions should involve surgeons, anesthesiologists and geriatricians alike, both pre- and postoperatively, with the goal of optimizing patients' rehabilitation and offering good and appropriate care while ensuring the humane, social and financial aspects.

Emergency surgery in the elderly: challenges and solutions

Elderly patients frequently present with surgical emergencies to health care providers, and outcomes in this group of patients remain poor. Contributing factors include frailty, preexisting comorbidity, polypharmacy, delayed diagnosis, and lack of timely and consultant-led treatment. In this review, we address common emergency surgical presentations in the elderly and highlight the specific challenges in caring for these patients. We summarize 20 years of reports by various medical bodies that have aimed to improve the care of these patients. To improve morbidity and mortality, several aspects of care need to be addressed. These include accurate and timely preoperative assessment to identify treatable pathology and, where possible, to consider and correct age-specific disease processes. Identification of patients in whom treatment would be futile or associated with high risk is needed to avoid unnecessary interventions and to give patients and carers realistic expectations. The use of multidisciplinary teams to identify common postoperative complications and age-specific syndromes is paramount. Prevention of complications is preferable to rescue treatment due to the high proportion of patients who fail to recover from adverse events. Even with successful surgical treatment, long-term functional decline and increased dependency are common. More research into emergency surgery in the elderly is needed to improve care for this growing group of vulnerable patients.

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.

Actinomyces infection causing acute right iliac fossa pain

This is a case of a 75-year-old man being admitted to the on-call surgical department with acute abdominal pain. On arrival he was clinically dehydrated and shocked with localised pain over McBurney's point and examination findings were suggestive of appendiceal or other colonic pathology. Full blood testing revealed a white cell count of 38×10(9)/L and a C reactive protein (CRP) of 278 mg/L. A CT scan revealed a gallbladder empyema that extended into the right iliac fossa. This case highlights the potential for a hyperdistended gallbladder empyema to present as acute right iliac fossa pain with blood tests suggestive of complicated disease. Further analysis confirmed Actinomyces infection as the underlying aetiology prior to a laparoscopic subtotal cholecystectomy. This case serves to remind clinicians of this as a rare potential cause of atypical gallbladder pathology.

Journal club: Acute abdominal pain in elderly patients: effect of radiologist awareness of clinicobiologic information on CT accuracy

OBJECTIVE

The purpose of this study was to assess whether the availability of clinicobiologic findings would affect the diagnostic performance of CT of elderly emergency department patients with nontraumatic acute abdominal pain.

MATERIALS AND METHODS

The cases of 333 consecutively registered patients 75 years old or older presenting to the emergency department with acute abdominal pain and who underwent CT were retrospectively reviewed by two radiologists blinded or not to the patient's clinicobiologic results. Diagnostic accuracy was calculated according to the level of correctly classified cases in both the entire cohort and a surgical subgroup and was compared between readings performed with and without knowledge of the clinicobiologic findings. Agreement between each reading and the reference diagnosis and interobserver agreement were assessed with kappa statistics.

RESULTS

In both the entire cohort (87.4% vs 85.3%, p = 0.07) and the surgical group (94% vs 91%, p = 0.15), there was no significant difference in CT accuracy between diagnoses made when the radiologist was aware and those made when the radiologist was not aware of the clinicobiologic findings. Agreement between the CT diagnosis and the final diagnosis was excellent whether or not the radiologist was aware of the clinicobiologic findings.

CONCLUSION

In the care of elderly patients, CT is accurate for diagnosing the cause of acute abdominal pain, particularly when it is of surgical origin, regardless of the availability of clinical and biologic findings. Thus CT interpretation should not be delayed until complete clinicobiologic data are available, and the images should be quickly transmitted to the emergency physician so that appropriate therapy can be begun.

Comparative approach to non-traumatic acute abdominal pain between elderly and non-elderly in the emergency department: a study in rural Greece

Background

Acute abdominal pain is one of the most common symptoms that emergency department physicians encounter during their practice. The difficult task of early diagnosis and management of abdominal pain becomes more complicated when it involves elderly patients. The aim of this study was to evaluate the presence of age based differences regarding the management of acute non-traumatic abdominal pain in the Emergency Department.

Methods

We retrospectively analyzed the medical records of 933 patients with acute non-traumatic abdominal pain in the emergency department of a regional hospital during one year period.

Results

There were no differences between native and foreign elder patients regarding the use of imaging studies and discharge status. Although no differences were detected regarding the clinical presentation and management within the Emergency Department, elder patients with abdominal pain had a higher likelihood of being admitted for further hospitalization and were more often submitted to diagnostic examinations. The elder group had a trend towards lower number of cases of non-specific abdominal pain in comparison with the non-elders. Between male and female elders no statistically significant differences were detected.

Conclusions

A thorough work-up is essential for all patients. The clinician should always be alerted, since elderly patients may require more tests and they should have a low threshold for hospital admission.

[Unclear abdominal pain in central emergency admissions. An algorithm]

One of the chief complaints in the emergency department is abdominal pain which is associated with a large spectrum of possible underlying diagnoses. Life-threatening diseases have to be identified urgently to treat them rapidly either conservatively or by surgical intervention. The algorithm presented in this article starts with the triage in the emergency department. After triage the first step in the algorithm is an interdisciplinary communication to start the standardized diagnostic process which includes medical history, clinical examination, laboratory analyses, ultrasound and electrocardiogram. Further diagnostic escalation should be done in unspecific and urgent cases of abdominal pain after consulting a specialist. In approximately 30 % of patients with abdominal pain on admittance to an emergency department the cause remains unclear after undergoing the diagnostic process. In these cases it can be useful for risk stratification to transfer the patient to a ward related to the emergency department for observation und further diagnostics.

Emergency department observation units and the older patient

An increasing number of emergency departments (EDs) are providing extended care and monitoring of patients in ED observation units (EDOUs). EDOUs can be useful for older adults as an alternative to hospitalization and as a means of risk stratification for older adults with unclear presentations. They can also provide a period of therapeutic intervention and reassessment for older patients in whom the appropriateness and safety of immediate outpatient care are unclear. This article discusses the general characteristics of EDOUs, reviews appropriate entry and exclusion criteria for older adults in EDOUs, and discusses regulatory implications of observation status for patients with Medicare.

Does gender influence emergency department management and outcomes in geriatric abdominal pain?

Prior studies have suggested gender-based differences in the care of elderly patients with acute medical conditions such as myocardial infarction and stroke, but it is unknown whether these differences are seen in the care of abdominal pain. The objective of this study was to examine differences in evaluation, management, and diagnoses between elderly men and women presenting to the Emergency Department (ED) with abdominal pain. For this observational cohort study, a chart review was conducted of consecutive patients aged 70 years or older presenting with a chief complaint of abdominal pain. Primary outcomes were care processes (e.g., receipt of pain medications, imaging) and clinical outcomes (e.g., hospitalization, etiology of pain, and mortality). Of 131 patients evaluated, 60% were women. Groups were similar in age, ethnicity, insurance status, and predicted mortality. Men and women did not differ in the frequency of medical (56% vs. 57%, respectively), surgical (25% vs. 18%, respectively), or non-specific abdominal pain (19% vs. 25%, respectively, p = 0.52) diagnoses. Similar proportions underwent abdominal imaging (62% vs. 68%, respectively, p = 0.42), received antibiotics (29% vs. 30%, respectively, p = 0.85), and opiates for pain (35% vs. 41%, respectively, p = 0.50). Men had a higher rate of death within 3 months of the visit (19% vs. 1%, respectively, p < 0.001). Unlike prior research in younger patients with abdominal pain and among elders with other acute conditions, we noted no difference in management and diagnoses between older men and women who presented with abdominal pain. Despite a similar predicted mortality and ED evaluation, men had a higher rate of death within 3 months.

Impact of surgeon-performed ultrasound on diagnosis of abdominal pain

Background:

A randomised study was performed to evaluate the diagnostic accuracy of surgeon-performed ultrasound in the emergency department for patients presenting with abdominal pain.

Methods:

Surgeons responsible for the examination of study patients underwent 4 weeks of ultrasound training. 800 patients who were attending the emergency department for abdominal pain were randomised to undergo or not undergo surgeon-performed ultrasound as a complement to standard examination. The preliminary diagnosis made by the surgeon, with or without ultrasound, was compared with the final diagnosis made by a senior surgeon 6–8 weeks later.

Results:

Diagnostic accuracy was significantly higher in the group examined with ultrasound (64.7% vs 56.8%, p = 0.027). Ultrasound proved to be helpful in making or confirming a correct diagnosis in 24.1% of cases receiving ultrasound and to contribute in 2.9%. In 22.3% of patients the diagnosis of non-specific pain was confirmed by normal findings. Ultrasound was misleading in 10.2% of cases and had no influence on the diagnosis in 40.0%.

Conclusion:

For patients with acute abdominal pain, higher diagnostic accuracy is achieved when surgeons use ultrasound as a diagnostic complement to standard examination. The use of bedside ultrasound should be considered in emergency departments.

Identifying high-risk patients for triage and resource allocation in the ED

Five-point triage assessment scales currently used in many emergency departments (EDs) across the country have been shown to be accurate and reliable. We have found the system to be highly predictive of outcome (hospital admission, intensive care unit/operating room admission, or death) at either extreme of the scale but much less predictive in the middle triage group. This is problematic because the middle triage acuity group is the largest, in our experience comprising almost half of all patients. Patients triaged to the 2 highest acuity categories (A and B) have admission/ED death rates of 76% and 43%, respectively. In contrast, the 2 lowest acuity categories (D and E) have admission/ED death rates of 1% or less. The middle category (C), however, has an overall admission/ED death rate of 10%, too high to be comfortable with prolonged delays in the ED evaluation of these patients. We studied this group to determine if easily obtainable clinical factors could identify higher-risk patients in this heterogeneous category. Data were obtained from a retrospective, cross-sectional study of all patients seen in 2001 at an urban academic hospital ED. The main outcome measure for multivariate logistic regression models was hospital admission among patients triaged as acuity C. Acuity C patients who were 65 years or older, presenting with weakness or dizziness, shortness of breath, abdominal pain, or a final diagnosis related group diagnosis of psychosis, were more likely to be admitted than patients originally triaged in category B. These findings suggest that a few easily obtainable clinical factors may significantly improve the accuracy of triage and resource allocation among patients assigned with a middle-acuity score.

Point-of-care Urine Trypsinogen Testing for the Diagnosis of Pancreatitis

OBJECTIVES

To assess a point-of-care (POC) urine trypsinogen (UT) test for the diagnosis of pancreatitis in the emergency department (ED).

METHODS

This was a prospective cohort study of a convenience sample of patients presenting to the ED with abdominal pain or symptoms suggestive of pancreatitis. A 3-minute POC UT test (Actim Pancreatitis; Medix Biochemica, Kauniainen, Finland) was compared with plasma lipase and amylase measurements, imaging results when performed, and final discharge diagnoses. The criterion standard was a final discharge diagnosis of acute pancreatitis.

RESULTS

Of 191 patients included in this study, 17 patients were diagnosed with either acute or acute-on-chronic pancreatitis. The sensitivity and specificity of UT for acute pancreatitis were, respectively, 100% (95% confidence interval [CI] = 77% to 100%) and 96% (95% CI = 92% to 98%). Seven of the 17 patients with pancreatitis (41%) had diagnostic findings on CT and positive UT tests but had nondiagnostic plasma lipase and amylase levels.

CONCLUSIONS

A POC UT screening test for pancreatitis in the ED compared favorably with plasma lipase and amylase levels. Future studies should be performed to explore whether this test in the ED setting has better clinical utility than plasma lipase or amylase.

Quantifying the usefulness of CT in evaluating seniors with abdominal pain

OBJECTIVES

(1) Determine if older patients with abdominal pain who receive emergency department (ED) abdominal CT have changes in diagnosis and/or disposition more often than similar patients without CT; (2) compare physician confidence in diagnosis and disposition for patients with versus without CT; (3) document factors that most influence physician's decision to order abdominal CT in this population.

METHODS

ED patients 60 years of age or older, with acute non-traumatic abdominal pain were enrolled over a 6-week period. Physicians documented a preliminary and final ED diagnosis and disposition, along with pre- and post-evaluation confidence levels. Decision to order CT, along with clinical information most influencing that decision, was noted. Physician confidence levels and percent change in diagnosis and disposition were compared for patients with versus without CT.

RESULTS

One hundred and twenty-six patients comprised study sample. Abdominal CT rate was 59% (95%CI, 50-67%). CT was associated with an increased change in diagnosis (46%; 95%CI, 4-58% versus 29%; 95%CI, 16-42%), but no change in disposition between patients with versus without CT. Preliminary diagnostic confidence was lower for EPs who ordered a CT than for those who did not (p<0.001). Patient history most influenced ordering CT, whereas prior lab/imaging results most influenced not ordering CT.

CONCLUSION

Patients with CT had a change in diagnosis more often than those without. Preliminary diagnostic confidence was lower in CT group. Percent change in disposition did not differ between groups. Physicians most often ordered CT based on history and did not order CT when other diagnostic evaluation supported a specific diagnosis.

The use of abdominal computed tomography in older ED patients with acute abdominal pain

The objectives of this study were to determine the prevalence of use of abdominal computed tomography (CT) in older ED patients with acute nontraumatic abdominal pain, describe the most common diagnostic CT findings, and determine the proportion of diagnostic CT results. This was a prospective, observational, multicenter study of 337 patients 60 years or older. History was obtained prospectively; charts were reviewed for radiographic findings, dispositions, diagnoses, and clinical course, and patients were followed up at 2 weeks for additional information. The prevalence of use of abdominal CT was 37%. The most common diagnostic findings were diverticulitis (18%), bowel obstruction (18%), nephrolithiasis (10%), and gallbladder disease (10%). Eight percent of patients had findings suggestive of neoplasm. Overall, 57% of CT results were diagnostic (95% confidence interval [CI], 49%-66%), 75% (95% CI, 63%-84%) for patients requiring acute medical or surgical intervention, and 85% (95% CI, 62%-97%) for patients requiring acute surgical intervention. CT use is highly prevalent in older ED patients with acute abdominal pain. CT results are often diagnostic, especially for patients with emergent conditions.