Acute abdominal pain in the emergency department of a university hospital in Italy

Health care utilization of patients with acute abdominal pain before and after emergency department visits

BACKGROUND

Acute abdominal pain (AAP) is a major driver for capacity-use in emergency departments (EDs) worldwide. Yet, the health care utilization of patients with AAP before and after the ED remains unclear. The primary objective of this study was to describe adult patients presenting to the ED with AAP and their outpatient care (OC) use before and after the ED. Secondary objectives included description of hospitalization rates, in-hospital mortality, ED re-visits, and exploration of potential risk factors for hospitalization and ED re-visits.

METHODS

For the analysis, we combined routine hospital data from patients who visited 15 EDs in Germany in 2016 with their statutory health insurance OC claims data from 2014 to 2017. Adult patients were included based on a chief complaint or an ED diagnosis indicating unspecific AAP or the Manchester Triage System indicator "Abdominal pain in adults". Baseline characteristics, ED diagnosis, frequency and reason of hospitalization, frequency and type of prior-OC (prOC) use up to 3 days before and of post-OC use up to 30 days after the ED visit.

MAIN RESULTS

We identified 28,085 adults aged ≥ 20 years with AAP. 39.8% were hospitalized, 33.9% sought prOC before the ED visit (48.6% of them were hospitalized) and 62.7% sought post-OC up to 30 days after the ED visit. Hospitalization was significantly more likely for elderly patients (aged 65 and above vs. younger; adjusted OR 3.05 [95% CI 2.87; 3.25]), prOC users (1.71 [1.61; 1.90]) and men (1.44 [1.37; 1.52]). In-hospital mortality rate was 3.1% overall. Re-visiting the ED within 30 days was more likely for elderly patients (1.32 [1.13; 1.55) and less likely for those with prOC use (0.37 [0.31; 0.44]).

CONCLUSIONS

prOC use was associated with more frequent hospitalizations but fewer ED re-visits. ED visits by prOC patients without subsequent hospitalization may indicate difficulties of OC resources to meet the complex diagnostic requirements and expectations of this patient population. Fewer ED re-visits in prOC users indicate effective care in this subgroup.

The utility of the abdominal series in the emergency setting: a retrospective review

PURPOSE

The abdominal series (AXR) remains a frequently ordered test in the emergency department (ED), despite existing literature questioning its utility. The aim of this study was to characterize the use of the AXR in the ED by quantifying how often it is ordered and the frequency of subsequent imaging. Additionally, a time estimate in ED associated with the AXR was quantified. We hypothesized that there would be a low clinical utility of the AXR, and long associated time period spent in the ED.

METHODS

A retrospective audit of AXRs performed in the ED from January to December 2019 was performed. The local picture archiving and communication system (PACS) and electronic medical record were used to collect the variables.

RESULTS

Of 701 AXRs, 438 (62.4%) were reported normal, and 263 (37.6%) were abnormal. A Chi Squared test showed that the two variables (abdominal series result and follow up imaging completion) were significantly related, with p < 0.001. However, the effect size was small (Nagelkerke R square = 0.022). The average time spent in the ED for these patients was 7.27 h, and the average time between the AXR being ordered and interpreted was 1.31 h.

CONCLUSION

The majority of AXRs were reported as normal. Our results showed that AXR had a statistically significant, but low clinically significant predictive ability on subsequent imaging ordering. This supports our hypothesis that the AXR is of low clinical utility with respect to the rate of ordering follow up imaging. The AXR also translated to a quantifiable time interval during the patient's stay in ED. Minimizing overuse of the AXR may result in a decrease in patient duration in the ED.

ACUTE ABDOMEN IN INTENSIVE CARE UNIT: ETIOLOGY, COMORBIDITY AND SEVERITY OF 1,523 PATIENTS

BACKGROUND

Clinical features and outcomes of patients admitted to the intensive care unit due to acute abdomen are important to be investigated.

AIMS

To evaluate the outcomes of critically ill subjects with acute abdomen according to etiology, comorbidity and severity.

METHODS

Outcomes of 1,523 patients (878 women, mean age 66±18 years) consecutively admitted to a specialized gastrointestinal intensive care unit with different causes of acute abdomen from January 2012 to December 2019, were retrospectively evaluated according to etiology, comorbidity and severity.

RESULTS

The most common causes of acute abdomen were obstructive and inflammatory, particularly large bowel obstruction (27%), small bowel obstruction (18%) and acute pancreatitis (17%). Overall mortality was 13%. Surgery was required in 34% of patients. Median length of stay in the hospital was 9 [1-101] days. On univariate analysis mortality was significantly associated with age, APACHE II, Charlson comorbidity index, requirement for surgery and malignancy (p<0.0001), but only APACHE II, Charlson comorbidity index and surgical interventional remained significant on multivariate analysis.

CONCLUSIONS

Critically ill patients admitted to the intensive care unit with acute abdomen constitute a heterogeneous group of subjects with different prognosis. Mortality is more related to the severity of the disease, comorbidity and need for surgery than to the etiology of the acute abdomen.

Perplexing Tubo-Ovarian Abscess Presentation from an Inflammatory Process in a Patient with an Inconclusive Computed Tomography Scan

A tubo-ovarian abscess (TOA) is an infectious mass of the adnexa. This article presents a well-documented case of a 27-year-old female presenting to the emergency department with a TOA. Physical exam findings and an initial computed tomography scan (CT) with contrast revealed a right iliopsoas abscess, an inflammatory process in the right lower quadrant, later diagnosed as a TOA with the use of ultrasound (US) without a history of sexually transmitted infection (STI). The clinical decision tree utilized in this patient's case highlights the importance of keeping a TOA high on the list of differential diagnoses while investigating appendicitis and other inflammatory pathologies in the lower abdomen.

Rare causes of abdominal pain: a primer for the admitting general surgeon

The broad uptake of the acute surgical unit (ASU) model of surgical care in Australia has resulted in general surgeons becoming increasingly involved in the management of patients with acute abdominal pain (AAP), some of whom will be labelled as having non-specific abdominal pain (NSAP) (Kinnear N, Jolly S, Herath M, et al. The acute surgical unit: An updated systematic review and meta-analysis. review. Int. J. Surg. 2021;94:106109; Lehane CW, Jootun RN, Bennett M, Wong S, Truskett P. Does an acute care surgical model improve the management and outcome of acute cholecystitis? ANZ J. Surg. 2010;80:438-42). NSAP patients lack a clear diagnosis of surgical pathology based on standard clinical, laboratory and imaging work-up, although they may require ASU admission for pain control and assessment. This article provides a review of uncommon conditions, presenting as AAP, that could possibly be mis-labelled as NSAP, with a focus on aspects of the presentation that may aid diagnosis and management including specific demographic features, clinical findings, key investigations and initial treatment priorities for ASU clinicians. Ultimately, most of the conditions discussed will not require surgical intervention, however, they require a diagnosis to be made and initial treatment planning before on-referral to the appropriate specialty. For the on-call general surgeon, some knowledge of these conditions and an index of suspicion are invaluable for the prompt diagnosis and efficient management of these patients.

Renal artery thrombosis. A case of acute flank pain in a patient with a new onset of renal failure and atrial fibrillation

Renal artery thrombosis is a severe and often misdiagnosed entity, that represents a true medical emergency in which renal infarction can occur. The diagnosis is often a challenge for the emergency physicians since it can mimic other more common diseases, including renal colic. We report the case of an 82-year-old man who presented to our emergency department for abdominal pain, nausea, and vomiting resulting from right renal artery thrombosis and infarction caused by misdiagnosed atrial fibrillation. Starting from our experience, we recommend to always keep renal thromboembolism in the differential diagnosis in a patient with sudden onset of flank/abdominal pain, high levels of lactate dehydrogenase and/or haematuria since early diagnosis and proper treatment are the keys to rapid recovery.

[The abdominal pain unit as a treatment pathway : Structured care of patients with atraumatic abdominal pain in the emergency department]

BACKGROUND

Patients with atraumatic abdominal pain are common in the emergency department and have a relatively high hospital mortality, with a very wide spectrum of different causes. Rapid, goal-directed diagnosis is essential in this context.

METHODS

In a Delphi process with representatives of different disciplines, a diagnostic treatment pathway was designed, which is called the Abdominal Pain Unit (APU).

RESULTS

The treatment pathway was designed as an extended event process chain. Crucial decision points were specified using standard operating procedures.

DISCUSSION

The APU treatment pathway establishes a consistent treatment structure for patients with atraumatic abdominal pain. It has the potential to improve the quality of care and reduce intrahospital mortality over the long term.

The NSW Pathology Atlas of Variation: Part I-Identifying Emergency Departments With Outlying Laboratory Test-Ordering Practices

STUDY OBJECTIVE

Abdominal pain and chest pain are leading reasons for emergency department (ED) presentations, with laboratory tests frequently ordered to aid the diagnostic process. Our study aims to identify EDs with outlying laboratory ordering practices for patients presenting with undifferentiated abdominal pain and chest pain.

METHODS

This was a retrospective observational study of 519,597 patients who presented with the complaint of abdominal or chest pain at 44 major hospital EDs across New South Wales, Australia, from January 2017 to September 2018. For each condition, we evaluated the risk-adjusted rate of ordering at least 1 laboratory test and of each of the top 15 ordered tests. We used funnel plots to graph variations in test ordering and identify EDs with outlying test-ordering practices. EDs lying above or below the 99.8% funnel control limits were regarded as outliers.

RESULTS

From 3,360,152 unplanned presentations, abdominal pain and chest pain represented 8.8% (n=296,809) and 6.6% (n=222,788) of all cases, respectively. No major outliers were observed for ordering at least one laboratory test; however, variations were observed for individual tests. For abdominal pain, the top 3 tests with the highest ordering variation included glucose (20 outlier EDs), C-reactive protein (10 outliers), and calcium-magnesium-phosphate (7 outliers). For chest pain, the top 3 tests with the highest ordering variation were glucose (21 outlier EDs), C-reactive protein (17 outliers), and liver function test (14 outliers).

CONCLUSION

Identifying EDs with outlying laboratory-ordering practices is the first step in initiating context-specific evaluation of whether outlying variations are unwarranted.

Appropriateness of Computed Tomography and Ultrasound for Abdominal Complaints in the Emergency Department

OBJECTIVE

The purpose of this study was to evaluate the appropriateness of ultrasound (US) and computed tomography (CT) examinations ordered in the emergency department (ED) for abdominal complaints.

MATERIALS AND METHODS

We reviewed 154 CTs and 154 US orders for appropriateness using evidence-based recommendations by the American College of Radiology. The sample was powered to show a prevalence of inappropriate orders of 25% with a margin of error of 7.5%. Findings in the final reports were compared to the initial clinical diagnosis classified in 4 categories: normal, compatible with initial diagnosis, alternative diagnosis, and inconclusive. We also evaluated the frequency in which a second imaging modality was ordered on the same visit.

RESULTS

A total of 135 CT and 143 US examinations had complete clinical information to allow evaluation of order appropriateness. The rate of inappropriate orders was 36.3% for CT and 84.4% for US. The final report of appropriate orders was significantly more likely to demonstrate findings compatible with the initial diagnosis for both CT (76.7% vs 20.4%, P < 0.0001) and US (38.9% vs 14.4%, P = 0.0093). Inappropriately ordered CT scans were more likely to show no abnormalities (46.9 vs 16.3%, P = 0.0001). An additional imaging order with a secondary modality was requested in 20% of the inappropriate US orders, and 8.2% of the inappropriate CT orders.

CONCLUSION

The prevalence of inappropriate examinations in the ED was 36.3% for CT and 84.4% for US. Appropriately ordered exams were more likely to yield imaging findings compatible with the initial diagnosis for both modalities.

Factors associated with the development of acute general surgical pathology in medical in-patients

BACKGROUND

Medical inpatients can develop acute general surgical conditions. However, this is rare. The presence of multiple acute pathologies delays diagnosis and these patients have poorer prognoses.

AIM

To determine the incidence, risk factors and prognosis of medical inpatients developing acute general surgical conditions.

METHODS

A single-centre retrospective case-control study was conducted over one year in the United Kingdom. Medical patients developing acute surgical pathology were identified using the local referral system. For each case, two controls were selected from a pool of medical in-patients receiving no general surgical input during their admission. Patient records were used to collect hospital admission details, demographic and laboratory data. Univariate analysis and multi-variable analysis were performed.

RESULTS

The study included 42 cases and 84 controls. The incidence of general surgical pathology in medical in-patients was 2.3/1000 admissions/year. In multivariate analysis, risk factors associated with developing general surgical pathology were previous abdominal surgery (Odds Ratio [OR] =3.68, 95% Confidence interval [CI]: 1.43 to 9.48, p=0.007) and doubling from baseline creatinine (OR=18.9, 95%CI: 2.57 to 139, p=0.004). Patients with surgical pathology had longer in-patient stays (22.8 vs 9.4 days, p<0.001) and a higher inpatient mortality (23.8% vs 7.1%, p=0.011). Development of surgical pathology was strongly associated with mortality (OR=4.06, 95%CI: 1.36 to 12.1).

CONCLUSION

The development of acute surgical pathology in medical in-patients is rare but associated with longer in-patient stays and higher mortality. We have identified risk-factors associated with the development of surgical pathology which can be used to identify patients at risk of surgical pathology. This article is protected by copyright. All rights reserved.

Is the ACS-NSQIP Risk Calculator Accurate in Predicting Adverse Postoperative Outcomes in the Emergency Setting? An Italian Single-center Preliminary Study

Background

The ACS-NSQIP surgical risk calculator (SRC) is an open-access online tool that estimates the chance for adverse postoperative outcomes. The risk is estimated based on 21 patient-related variables and customized for specific surgical procedures. The purpose of this monocentric retrospective study is to validate its predictive value in an Italian emergency setting.

Methods

From January to December 2018, 317 patients underwent surgical procedures for acute cholecystitis (n = 103), appendicitis (n = 83), gastrointestinal perforation (n = 45), and intestinal obstruction (n = 86). Patients’ personal risk was obtained and divided by the average risk to calculate a personal risk ratio (RR). Areas under the ROC curves (AUC) and Brier score were measured to assess both the discrimination and calibration of the predictive model.

Results

The AUC was 0.772 (95%CI 0.722–0.817, p < 0.0001; Brier 0.161) for serious complications, 0.887 (95%CI 0.847–0.919, p < 0.0001; Brier 0.072) for death, and 0.887 (95%CI 0.847–0.919, p < 0.0001; Brier 0.106) for discharge to nursing or rehab facility. Pneumonia, cardiac complications, and surgical site infection presented an AUC of 0.794 (95%CI 0.746–0.838, p < 0.001; Brier 0.103), 0.836 (95%CI 0.790–0.875, p < 0.0001; Brier 0.081), and 0.729 (95%CI 0.676–0.777, p < 0.0001; Brier 0.131), respectively. A RR > 1.24, RR > 1.52, and RR > 2.63 predicted the onset of serious complications (sensitivity = 60.47%, specificity = 64.07%; NPV = 81%), death (sensitivity = 82.76%, specificity = 62.85%; NPV = 97%), and discharge to nursing or rehab facility (sensitivity = 80.00%, specificity = 69.12%; NPV = 95%), respectively.

Conclusions

The calculator appears to be accurate in predicting adverse postoperative outcomes in our emergency setting. A RR cutoff provides a much more practical method to forecast the onset of a specific type of complication in a single patient.

Acute Abdominal Pain: Missed Diagnoses, Extra-Abdominal Conditions, and Outcomes

Abdominal pain (AP) is a common reason for presentation to an emergency department (ED). With this prospective, observational all-comer study, we aimed to answer three questions: Which diagnoses are most often missed? What is the incidence of extra-abdominal causes? What is the prognosis of abdominal pain in a tertiary urban European ED? Participants were systematically interviewed for the presence of 35 predefined symptoms. For all patients with abdominal pain, the index visit diagnoses were recorded. Related representation was defined as any representation, investigation, or surgery related to the index visit (open time frame). If a diagnosis changed between index visit and representation, it was classified as missed diagnosis. Among 3960 screened presentations, 480 (12.1%) were due to AP. Among 63 (13.1%) related representations, the most prevalent causes were cholelithiasis, gastroenteritis, and urinary retention. A missed diagnosis was attributed to 27 (5.6%) presentations. Extra-abdominal causes were identified in 162 (43%) presentations. Thirty-day mortality was comparable to that of all other ED patients (2.2% vs. 2.1%). Patients with abdominal pain had a low risk of representation, and the majority of representations due to missed diagnoses were of benign origin. The high incidence of extra-abdominal causes is noteworthy, as this may induce change to differential diagnosis of abdominal pain.

Retrospective cohort study on clinical predictors for acute abnormalities on CT scan in adult patients with abdominal pain

PURPOSE

Identification of clinical predictors of acute and surgical pathologies on abdominal CT in patients with non-traumatic abdominal pain (NTAP).

METHODS

Retrospective chart review cohort study of adults who had abdominal CT scans for investigation of NTAP in the Emergency Department in a tertiary care center in Lebanon. Multivariate analyses were performed to identify predictors of pathologies on CT scan.

RESULTS

This study included 147 patients who had abdominal CT scans for NTAP. Mean age was 39.8 ± 15.1 years and 58.5 % of patients were females. Less than half (44.9 %) had normal scans. Women had significantly higher rates of normal scans compared to males. Right lower quadrant (RLQ) tenderness was associated with significantly higher odds of having acute abnormalities on CT and of having surgical diagnoses, while epigastric tenderness was negatively associated with these two outcomes. Right and left upper quadrants and diffuse abdominal tenderness, and an abnormal neutrophil count were found to be associated with surgical diagnoses on CT.

CONCLUSIONS

Women are less likely to have acute and surgical pathologies on CT ordered for non traumatic abdominal pain. Epigastric tenderness is negatively associated with abnormal and surgical CT results while RLQ tenderness is associated with an abnormal CT that is likely surgical in nature. These findings should help improve diagnostic accuracy of ordering providers and improve resource utilization.

Acute cholecystitis or simple biliary colic after an emergency presentation: why it matters

BACKGROUND

Laparoscopic cholecystectomy (LC) is often performed during the index admission after emergency presentation for acute biliary pain. Many patients have acute cholecystitis (AC) that may increase operative difficulty and complications. Our primary aim was to assess the validity of Tokyo Guidelines (TG18) for diagnosing AC by comparison with the admitting team diagnosis, operative findings and histopathology. The secondary aim was to assess outcomes after same-admission or delayed LC.

METHODS

Retrospective analysis of patients who underwent LC after presenting to a tertiary hospital emergency department over a 12-month period was conducted.

RESULTS

A total of 139 patients underwent LC with no mortality or bile duct injury. A diagnosis of AC made by the admitting surgical team had sensitivity of 84% and specificity of 57%. The TG18 diagnosis had sensitivity of 84% and specificity of 53%. A diagnosis of AC by the admitting surgical team correlated well with TG18 criteria diagnosis. There was poor correlation between clinical and histopathological diagnoses. Nine percent of patients had complications and 4% required conversion to open procedure. Patients with a clinical diagnosis of AC had longer post-operative length of stay and more complications compared with those who had non-AC diagnosis. There was no difference in outcomes between same-admission LC or delayed LC.

CONCLUSION

TG18 diagnosis of AC does not improve accuracy of diagnosis or predictability of a poor outcome over the admitting surgical team diagnosis. Same-admission LC for patients with AC is associated with similar outcomes compared to those who undergo delayed LC.

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.

One-Month Follow-Up of Patients with Unspecified Abdominal Pain Referring to the Emergency Department; a Cohort Study

INTRODUCTION

About one third of patients referring to emergency department (ED) with abdominal pain, are discharged without a definite diagnosis. This study aimed to investigate the one-month outcome of patients with unspecified abdominal pain.

METHODS

This cohort study was conducted on subjects who were evaluated in ED with unspecified abdominal pain and were referred to the gastroenterology clinic and followed for one month. Finally, they were divided into two groups of cases with clear cause of abdominal pain and unclear cause of abdominal pain and patients' characteristics were compared between the groups.

RESULTS

150 cases with the mean age of 40.68 ± 18.34 years were studied (53.3% female). After one month, 67 (44.7%) patients still complained of abdominal pain. A definitive cause of abdominal pain was established in 88 (58.7%) cases. There was not any significant difference between groups regarding, sex distribution (p = 012), duration of pain (p = 0.11), history of previous similar pain (p = 0.136), pain radiation (p = 0.737), length of hospital stay (p = 0.51), and presence of anorexia (p = 0.09), nausea and vomiting (p= 0.50), fever (p = 1.0), diarrhea (p = 0.23), and constipation (p = 0.07). There was a significant difference between the groups regarding location of pain (p = 0.017), age (p = 0.001) and history of comorbid diseases (p = 0.046). The predictive factors of finding a clear cause for abdominal pain in one-month follow-up, were leukocytosis (OR: 5.92 (95% CI: 2.62 - 13.39); p < 0.001), age (OR: 2.78 (95% CI: 1.15 - 6.71); p = 0.023), and outpatient follow-up (OR: 1.04 (95% CI: 1.02 - 1.07); p < 0.001).

CONCLUSION

Approximately, 40% of patients who were discharged with unspecified abdominal pain did not receive a clear diagnosis after one month of follow-up. Older age, leucocytosis in initial evaluations, and outpatient follow-up increased the probability of finding a clear cause for abdominal pain in the mentioned cases.

The association between insurance status and diagnostic imaging for acute abdominal pain among emergency department patients in the United States, 2005-2014

Introduction and objectives: Acute abdominal pain (AAP) is one of the most common complaints in the emergency department (ED). Rapid diagnosis is essential and is often achieved through imaging. Computed tomography (CT) is widely considered an exemplary test in the diagnosis of AAP in adult patients. As previous studies show disparities in healthcare treatment based on insurance status, our objective was to assess the association between insurance status and frequency of CT ordered for adult patients presenting to the ED with AAP from 2005 to 2014. Methods: This study used the National Hospital and Ambulatory Medical Care Survey: Emergency Department Record (NHAMCS) database, which collects data over a randomly assigned 4 week period in the 50 states and DC, to perform an observational retrospective analysis of patients presenting to the ED with AAP. Patients with Medicaid, Medicare or no insurance were compared to patients with private insurance. The association between insurance status and frequency of CT ordered was measured by obtaining odds ratios along with 95% CIs adjusted for age, gender and race/ethnicity. Results: Individuals receiving Medicaid are 20% less likely to receive CT than those with private insurance (OR 0.8, CI 0.6-0.99, p = .046). Those on Medicare or who are uninsured have no difference in odds of obtaining a CT scan compared to patients with private insurance. Additional findings are that black patients are 42% less likely to receive a CT scan than white patients. Conclusions and implications: Patients on Medicaid are significantly less likely to receive a CT when presenting to the ED with AAP. Differences in diagnostic care may correlate to inferior health outcomes in patients without private insurance.

Peripheral neuropathic mimics of visceral abdominal pain: Can physical examination limit diagnostic testing?

BACKGROUND

The emergency department evaluation of patients with abdominal pain is most appropriately directed at identifying acute inflammation, infection, obstruction, or surgical disease. Doing so commonly involves "routine" (and often extensive) diagnostic imaging and laboratory testing. Benign mimics of serious visceral abdominal pain that can be diagnosed by physical exam and confirmed with local anesthetic injections have been identified over the last century. These syndromes derive from painful irritation of the intercostal nerves by a mobile rib below, or from impingement of the cutaneous branches of those same intercostal nerves as they penetrate the abdominal wall. These peripheral neuropathic mimics of visceral abdominal pain continue to go unrecognized and underdiagnosed.

METHODS

Our purpose is to review the affirmative diagnosis of non-visceral abdominal pain by physical examination.

RESULTS

The consequences of failure to identify these conditions are considerable. In the search for a diagnosis that is literally at the provider's fingertips, patients frequently undergo months to years of fruitless and often invasive diagnostic tests, not uncommonly including unsuccessful surgeries.

CONCLUSIONS

With proper consideration of and appropriate testing for visceral etiologies, a carefully directed physical examination may yield an affirmative diagnosis in a percentage of these common emergency department patients.

Diagnostic Accuracy of Serum and Urine S100A8/A9 and Serum Amyloid A in Probable Acute Abdominal Pain at Emergency Department

Study Design

This study was performed to investigate the diagnostic values of some inflammatory biomarkers in abdominal pain.

Methods

Patients over 18 years of age with acute recent abdominal pain who presented to the Emergency Department were evaluated. Serum and urinary samples were taken and evaluated for serum and urine S100A8/A9 and serum amyloid A. All patients were referred to a surgeon and were followed up until the final diagnosis. In the end, the final diagnosis was compared with the levels of biomarkers.

Results

Of a total of 181 patients, 71 underwent surgery and 110 patients did not need surgery after they were clinically diagnosed. Mean levels of serum and urine S100A8/A9 had a significant difference between two groups, but serum amyloid A did not show. The diagnostic accuracy of serum S100A8/A9, urine S100A8/A9, and serum amyloid A was 86%, 79%, and 50%, respectively, in anticipation of the need or no need for surgery in acute abdominal pain.

Conclusions

Our study showed that in acute abdominal pain, serum and urine S100A8/A9 can be useful indicators of the need for surgery, but serum amyloid A had a low and nonsignificant diagnostic accuracy.

Functional Dyspepsia and Irritable Bowel Syndrome: Beyond Rome IV

BACKGROUND

The correct diagnosis of functional gastrointestinal disorders (FGIDs) is quite a challenge. The overlaps between syndromes can complicate the interpretation of clinical data.

SUMMARY

The incidence of functional digestive disorders and irritable bowel syndrome are still underestimated with the currently applied diagnostic tools, and the management of the seemingly elusive disease is not satisfactory. For this reason, the "Rome" criteria were created to provide a better understanding and classification of FGIDs. Key Messages: Rome diagnostic criteria and recommendations should be used in the design and performance of clinical studies in the field of functional dyspepsia and irritable bowel syndrome.

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.