ABDOMINAL PAIN
References and Abstracts

1. Unique Identifier 95275362
Author Powers RD; Guertler AT
Institution Division of Emergency Medicine, University of Virginia Health Sciences Center, Charlottesville, USA.
Title Abdominal pain in the ED: stability and change over 20 years.
Source Am J Emerg Med 1995 May;13(3): p301-3
ISSN 0735-6757
Abstract

Abdominal pain (AP) is a common presenting complaint in emergency department (ED) patients. A 1972 study reported that unsupervised surgical residents in a university hospital ED were unable to make a specific diagnosis in 41% of 1,000 AP patients. In the intervening time, ED availability of diagnostic technology has increased, and the reference hospital acquired full-time emergency medicine (EM) faculty. To assess what changes occurred in the evaluation and epidemiology of AP, a similar study was done at the same hospital. The study design was a review of records of 1,000 consecutive ED patients with AP seen in 1993 at a 58,000-visit public Level I trauma center ED. The percentage of ED patients (4% to 5%) with AP was unchanged. Frequency of hospital admission dropped from 27.4% (1972) to 18.3% (1993). There was marked increase in the specificity of diagnoses, with only 24.9% in 1993 diagnosed as undifferentiated abdominal pain (UDAP). There were eight cases of missed appendicitis in 1972 and none in 1993. One 1993 patient with acute cholecystitis was initially misdiagnosed as having UDAP. Advances in technology and EM faculty presence were temporally associated with improved diagnostic accuracy in patients with AP in a university hospital ED. As compared with 20 years ago, fewer patients required hospitalization, more were assigned a specific diagnosis, and there were fewer cases of missed surgical disease.

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2. Unique Identifier 92039459
Author Simmen HP; Decurtins M; Rotzer A; Duff C; Brutsch HP; Largiader F
Institution Department of Surgery, University Hospital, Zurich, Switzerland.
Title Emergency room patients with abdominal pain unrelated to trauma: prospective analysis in a surgical university hospital.
Source Hepatogastroenterology 1991 Aug;38(4): p279-82
ISSN 0172-6390
Abstract

During an 8-month-period, 241 patients suffering from abdominal pain unrelated to trauma (mean age 48 years) attended the emergency room of the Department of Surgery of the University Hospital, Zurich. Forty-three percent presented during working hours, while 57% were admitted during the night or at the weekend. Clinical examination, abdominal roentgenograms (upright and supine) and sonography were the most commonly used diagnostic tools. Forty percent suffered from abdominal pain of unknown origin. The most common diagnosis on admission was appendicitis, but only half of these cases proved to be appendicitis. In 36% the diagnosis on admission corresponded both to the initial diagnosis made by a member of staff during his first visit, and to the final diagnosis. The initial diagnosis agreed with the final diagnosis in 57%. In 10% of the patients the cause of pain was not elucidated despite extensive diagnostic procedures. High technology and sophisticated diagnostic evaluation are less important than the clinical evaluation. The decision between operative and nonoperative treatment was based mainly on clinical findings.

3. Unique Identifier 95181755
Author de Dombal FT
Institution Clinical Information Science Unit, University of Leeds, United Kingdom.
Title Acute abdominal pain in the elderly.
Source J Clin Gastroenterol 1994 Dec;19(4): p331-5
ISSN 0192-0790
Abstract

In this article, I review the diagnosis and immediate prognosis of acute abdominal pain in elderly patients. I draw on published work and on three major series of patients, one collected since 1976 by the World Organization of Gastroenterology (OMGE) Research Committee, one by the 1986 United Kingdom National Study of Human and Computer-Aided Diagnosis, and one by the European Community 1993 Concerted Action on Acute Abdominal Pain. These series include approximately 42,000 patients. Acute abdominal pain in the elderly patient presents a significant and challenging problem. Diagnostic accuracy is lower, and mortality far higher, than in younger patients. Reasons for these differences are multifactorial: the case mix is different, the evolution and prognosis of specific diseases are different, and the ways in which diseases present are also different in elderly patients. It is not difficult therefore to understand why serious problems in management occur. I conclude by discussing implications of existing studies and the literature that--if implemented--should significantly improve both management resource utilization and patient outcome.

4. Unique Identifier 87027259
Author Adams ID; Chan M; Clifford PC; Cooke WM; Dallos V; de Dombal FT; Edwards MH; Hancock DM; Hewett DJ; McIntyre N; et al
Title Computer aided diagnosis of acute abdominal pain: a multicentre study.
Source Br Med J (Clin Res Ed 1986 Sep 27;293(6550): p800-4
ISSN 0267-0623
Abstract

A multicentre study of computer aided diagnosis for patients with acute abdominal pain was performed in eight centres with over 250 participating doctors and 16,737 patients. Performance in diagnosis and decision making was compared over two periods: a test period (when a small computer system was provided to aid diagnosis) and a baseline period (before the system was installed). The two periods were well matched for type of case and rate of accrual. The system proved reliable and was used in 75.1% of possible cases. User reaction was broadly favourable. During the test period improvements were noted in diagnosis, decision making, and patient outcome. Initial diagnostic accuracy rose from 45.6% to 65.3%. The negative laparotomy rate fell by almost half, as did the perforation rate among patients with appendicitis (from 23.7% to 11.5%). The bad management error rate fell from 0.9% to 0.2%, and the observed mortality fell by 22.0%. The savings made were estimated as amounting to 278 laparotomies and 8,516 bed nights during the trial period--equivalent throughout the National Health Service to annual savings in resources worth over 20m pounds and direct cost savings of over 5m pounds. Computer aided diagnosis is a useful system for improving diagnosis and encouraging better clinical practice.

5. Unique Identifier 94331616
Author Chui DW; Owen RL
Institution Department of Medicine, University of California, San Francisco.
Title AIDS and the gut.
Source J Gastroenterol Hepatol 1994 May-Jun;9(3): p291-303
ISSN 0815-9319
Abstract

There are increasing challenges for the practising gastroenterologist in treating AIDS-related gastrointestinal diseases. The differential diagnoses of dysphagia and odynophagia include cytomegalovirus (CMV) and herpes simplex virus (HSV) infection, non-specific aphthous ulceration and non-AIDS oesophageal diseases, especially reflux oesophagitis. Chronic subacute abdominal pain with nausea, vomiting, early satiety and weight loss is suggestive of an obstructive lesion caused by lymphoma or Kaposi's sarcoma. Severe acute abdominal pain can indicate pancreatitis or intestinal perforation due to cytomegalovirus. Right upper quadrant pain (with or without fever, vomiting or abnormal liver function tests with a cholestatic profile) is suggestive of hepatobiliary pathology including cholecystitis, cholangitis, acalculous cholecystitis and AIDS cholangiopathy. Diarrhoea is the most common gastrointestinal symptom of AIDS, affecting 50-90% of patients. Causes of AIDS diarrhoea include protozoa (Cryptosporidium parvum, Isospora belli, Enterocytozoon bieneusi, Septata intestinalis, Cyclospora spp, Entamoeba histolytica and Giardia lamblia), bacteria (Mycobacterium avium-intracellulare, Clostridium difficile, Salmonella, Shigella and Campylobacter jejuni), and viruses (CMV, HSV and possibly HIV). Chronic diarrhoea, malnutrition and weight loss can shorten the life-span of patients with AIDS. Elemental diets, isotonic formulas, medium chain triglycerides and total parenteral nutrition have been tried with little success in AIDS patients with severe diarrhoea and wasting.

6. Unique Identifier 94360175
Author Parente F; Cernuschi M; Antinori S; Lazzarin A; Moroni M; Fasan M; Rizzardini G; Rovati V; Morandi E; Molteni P; et al
Institution Dept. of Gastroenterology, L. Sacco Hospital, Milan, Italy.
Title Severe abdominal pain in patients with AIDS: frequency, clinical aspects, causes, and outcome.
Source Scand J Gastroenterol 1994 Jun;29(6): p511-5
ISSN 0036-5521
Abstract

BACKGROUND: The exact prevalence of abdominal pain in AIDS patients, as well as the entire spectrum of causative disorders, has not yet been well defined. In addition, the existing data derive almost exclusively from surgical series describing only those patients who have undergone emergency surgical procedures.
METHODS: We reviewed our experience with patients presenting with severe abdominal pain from a large series of non-selected consecutive AIDS patients seen at our institution over a period of 4 years.
RESULTS: Of 458 patients, 71 (15%) had severe abdominal pain, and its occurrence was associated with a reduced patient survival. Specific diagnoses were made premortem in 42 patients (59%), potential causes of pain were identified at postmortem examination in 23 patients (33%), whereas no specific causes were found in 6 patients (8%). Most of the causative disorders (65%) were AIDS-related, whereas HIV-independent pathologic conditions were found in only 18% of the patients. The predominant site of pain, combined with a few key symptoms, had a high predictive diagnostic value in nearly half of the patients. The indications for emergency laparotomy were limited and substantially similar to those of the non-HIV population.
CONCLUSIONS: Severe abdominal pain frequently complicates the course of AIDS, and its occurrence is associated with reduced survival. In most patients it is due to disorders closely associated with the HIV infection. Specific causes of pain may be identified in most of the cases by an appropriate diagnostic evaluation.

7. Unique Identifier 95301874
Author Rothrock SG; Green SM; Dobson M; Colucciello SA; Simmons CM
Institution Department of Emergency Medicine, Orlando Regional Medical Center, Florida 32806, USA.
Title Misdiagnosis of appendicitis in nonpregnant women of childbearing age [see comments]
Source J Emerg Med 1995 Jan-Feb;13(1): p1-8
ISSN 0736-4679
Abstract

A retrospective case series was conducted at a teaching hospital with an emergency department (ED) census of 100,000 patients per year to identify the incidence of, and factors associated with, the misdiagnosis of appendicitis in nonpregnant women aged 15 to 45 years. There were 174 nonpregnant women identified with a pathologic diagnosis of appendicitis. Clinical features were then compared between patients misdiagnosed (seen in prior 10 days and given an incorrect diagnosis) and those who were initially diagnosed correctly. The results showed that 33% of the women with appendicitis were initially misdiagnosed. The most common misdiagnoses included pelvic inflammatory disease, gastroenteritis, and urinary infections. Misdiagnosed women more frequently exhibited diffuse and bilateral lower abdominal pain and tenderness, cervical motion, and right adnexal tenderness. Misdiagnosed women also had a lower incidence of right lower quadrant pain and tenderness, and peritoneal signs. In addition, misdiagnosis was associated with an increased incidence of perforation, abscess formation, and an increase in the total length of hospitalization. In conclusion, the incidence of misdiagnosis of appendicitis in women of childbearing age is high. Women who are misdiagnosed have less typical symptoms and physical findings and more frequent abnormal pelvic findings than those who are diagnosed correctly. Emergency physicians should be aware that atypical signs and symptoms are associated with misdiagnosed appendicitis in nonpregnant women of childbearing age.

8. Author American College of Emergency Physicians
Title Clinical policy: Critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumatic acute abdominal pain
Source Annals of Emergency Medicine, Volume 36, Number 4, October 2000

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9. Unique Identifier 73003217
Author Staniland JR; Ditchburn J; De Dombal FT
Title Clinical presentation of acute abdomen: study of 600 patients.
Source Br Med J 1972 Aug 12;3(823): p393-8
ISSN 0007-1447

10 Unique Identifier 91338987
Author Liddington MI; Thomson WH
Institution Department of Surgery, Gloucestershire Royal Hospital, UK.
Title Rebound tenderness test [see comments]
Source Br J Surg 1991 Jul;78(7): p795-6
ISSN 0007-1323
Abstract

The usefulness of the rebound tenderness test in indicating peritonitis was prospectively assessed in 142 unselected patients admitted as emergencies with abdominal pain and tenderness. It was found to be of no predictive value.

11. Unique Identifier 91167763
Author Dixon JM; Elton RA; Rainey JB; Macleod DA
Institution University Department of Surgery, Royal Infirmary of Edinburgh.
Title Rectal examination in patients with pain in the right lower quadrant of the abdomen [see comments]
Source BMJ 1991 Feb 16;302(6773): p386-8
ISSN 0959-8138
Abstract

OBJECTIVE--To determine whether rectal examination provides any diagnostic information in patients admitted to hospital with pain in the right lower quadrant of the abdomen. DESIGN--Casualty officer or surgical registrar recorded symptoms and signs on admission on detailed forms. Final diagnosis was noted on discharge from hospital.
SETTING--District general hospital.
PATIENTS--1204 Consecutive patients admitted to hospital with pain in the right lower quadrant of the abdomen as their major complaint; 1028 had a rectal examination on admission.
MAIN OUTCOME MEASURES--Odds ratio for each symptom and sign related to final diagnosis. Results of multiple logistic regression analysis for acute appendicitis.
RESULTS--Right sided rectal tenderness, present in 309 of those examined, was more common in patients with acute appendicitis (odds ratio 1.34, p less than 0.05). This odds ratio was considerably less than that for other clinical signs--namely, tenderness in the right lower quadrant (odds ratio 5.09), rebound tenderness (3.34), guarding (3.07), and muscular rigidity in the abdomen (5.03). In the logistic regression analysis of patients with acute appendicitis, when allowance was made for the presence or absence of rebound tenderness, rectal tenderness on the right lost its significance. Six patients had masses palpable rectally, of which three were palpable on abdominal examination; the other three patients had acute appendicitis. No other unexpected diagnoses were established, and no useful additional diagnostic information was obtained by routine rectal examination.
CONCLUSION--If patients presenting with pain in the right lower quadrant of the abdomen are tested for rebound tenderness then rectal examination does not give any further diagnostic information.

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