Original Contribution
Abdominal pain in the ED: a 35 year retrospective

https://doi.org/10.1016/j.ajem.2010.01.045Get rights and content

Abstract

Objective

Research published in 1972 and 1993 has detailed the demographics, diagnoses, and diagnostic test utilization of adult patients presenting with nontraumatic abdominal pain to the emergency department (ED) at the University of Virginia Hospital. This is an update of those studies, designed to examine the present state of diagnosis and management of abdominal pain, as well as to look at trends during the 35-year span of the investigations.

Methods

One thousand consecutive adult patients presenting in the year 2007 with abdominal pain as their chief complaint were included in the analysis. Demographic data, discharge diagnosis, disposition, ED length of stay, charges, and diagnostic test utilization information were gathered and analyzed using electronic databases.

Results

These patients represented 6.5% of the total ED census. Sixty-five percent were female, 24.7% hospitalized, and 21% diagnosed with undifferentiated abdominal pain. Relative to 1993, there were more patients receiving specific diagnoses, (79% versus 75%) and a higher rate of hospitalization (24.7% versus 18.3%). Use of diagnostic testing has markedly increased in frequency, most notably computed tomography and ultrasound, which have risen 6-fold. One of these imaging modalities is now used in 42% of patient encounters. Visit times were longer and patient charges higher. There were 2 cases of missed surgical disease in 2007 compared with 1 in 1993 and 8 in 1972.

Conclusion

Over the past 35 years, ED management of atraumatic abdominal pain has become time, money, and resource intense. Widespread use of sophisticated imaging has had a small impact on diagnostic specificity but has not produced lower admission rates or fewer cases of missed surgical illness.

Introduction

Abdominal pain is one of the most common presenting complaints of emergency department (ED) patients and continues to be a diagnostic challenge for emergency physicians. There have been relatively few studies examining the ED evaluation of abdominal pain; they have shown that most patients are discharged, often without a specific diagnosis [1], [2], [3], [4]. The prognosis of those discharged is very good, with most having a benign course [5], [6]. Other studies have shown that although the specific diagnosis may not be clear to emergency physicians, they are very adept at determining whether abdominal pain patients are surgical or nonsurgical candidates [3], [5], [6], [7], [8], [9].

In 1972, a study at the University of Virginia examined data from patients presenting to the ED with abdominal pain [1]; the study was repeated on patients seen in 1992 and published in 1993 [3]. Both articles described the demographics of the patients, along with diagnosis, disposition, and resource utilization. In comparing patients during that 20-year span, it was noted that although the percentage of patients presenting with abdominal pain remained relatively constant (4% in 1972 and 5% in 1992), the admission rate decreased (27.4% in 1972 and 18.3% in 1992). The number of cases of missed appendicitis went from 8 in 1972 to zero in 1992. Diagnostic specificity increased over this interval, with 75% of patients receiving a specific diagnosis in 1992 compared with 59% in 1972. The authors commented that these changes were most likely due to the advent of a dedicated emergency medicine faculty, along with increased use of more accurate pregnancy testing and the ready availability of tests for serum bilirubin and amylase. In addition, by 1992, computed tomography (CT) and ultrasound imaging were available, although only a small percentage (6.8%) of abdominal pain patients received either of these advanced imaging studies.

The management of abdominal pain in the ED has continued to evolve since the 1993 publication. One change at the University of Virginia, along with many other teaching hospitals, has been the establishment of an emergency medicine residency. This provides the ED with a constant presence of house staff being trained in emergency medicine to complement full-time attending physician coverage. Although several new laboratory tests are available to emergency physicians, the most significant addition to the diagnostic armamentarium has been the widespread availability and use of advanced imaging, including CT and ultrasound. Computed tomography of the abdomen was not typically available as an ED test in 1992, and ultrasound was often relegated to weekday hours. Both are now widespread and frequently used in EDs.

Although the 1993 study is now more than 15 years old, it continues to be widely referenced and has not been duplicated on a similar scale. To establish whether there has been any appreciable change in the ED management of abdominal pain in the ensuing time, this study set out to update the University of Virginia abdominal pain study using similar methods to describe the care of patients in 2007 and contrast it with past practice. A secondary objective was to look at resource utilization and make comparisons in expenditures of time and money on these patients as their care has evolved.

The University of Virginia Hospital is a 600-bed tertiary-care public teaching hospital, located in Charlottesville, Va. The primary service area has a population of ∼200 000 living in mixed rural, suburban, and small city environs. In 1972, the ED cared primarily for adults and was staffed by Surgery and Medicine house staff with sporadic attending coverage by moonlighting faculty. The ED had a census of approximately 39 000. In 1993, there was a new facility combining adult and pediatric emergency care with a census of approximately 59 000. This was staffed by emergency medicine faculty providing 24-hour coverage. Full-time American Board of Emergency Medicine (ABEM)-certified physicians were present on most shifts. House staff consisted of interns from medicine, surgery, and pediatrics, second year surgery residents, and an upper-level medicine resident. Ultrasound was sporadically available, primarily during weekday and early evening hours; CT of the abdomen and pelvis was not generally available.

In 2007, the ED had a similar yearly census of approximately 60 000. There had been an emergency medicine residency in place for 13 years, providing consistent emergency medicine resident and faculty staffing. Medical students and interns and residents from other departments also rotated through and were directly supervised by ABEM-certified faculty. Computed tomography and ultrasound imaging were available through the Department of Radiology on all shifts. All patients presenting with abdominal pain were seen by a resident or student and then presented to an attending physician before final disposition was determined.

Section snippets

Methods

Using an electronic database generated from ED registration computers, the records of 1000 consecutive adult patients with a chief complaint of abdominal pain were selected for analysis. The methodology of case selection used in the previous studies was applied [1], [3]. Patients who voiced a complaint of abdominal pain, including pain in the epigastrium or any specific quadrant, abdominal cramps, groin pain, or stomach pain were included. Patients younger than 18 years and those with urinary

Demographics

Patients presenting to the ED with abdominal pain between January and March 2007 were included. During that time, a total of 15 417 patients were registered; the 1000 with abdominal pain comprised 6.6 % of the overall census and 7.9% of adults seen during this interval. Study patients ranged in age from 18 to 93 years with a median of 38 years. Sixty-five percent were female. Table 1 compares the demographics of the 2007 patients with those seen in 1972 and 1992. Relative to 1992, the recent

Discussion

This study demonstrates both consistency and change when past practice is compared with current. The demographics of patients with abdominal pain have changed minimally, with slight increases in frequency of presentation and median age. The sex ratio has remained constant at about two-thirds female. Patients are hospitalized with greater frequency than they were in 1992, but still less often than in 1972. Most patients receive laboratory testing, and more than half are imaged. Missed

Summary and conclusions

The nature of emergency care has changed; most large hospitals now have dedicated, well-trained, experienced clinicians staffing their EDs. This has likely resulted in improved patient care and patient satisfaction, and certain diseases such as appendicitis are rarely missed. In this single university hospital observational study, there has been both stability and change in the ED evaluation of abdominal pain during a 35-year span. The data reflect an enthusiastic embracing of diagnostic

Acknowledgments

Dr Hastings had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Neither author reports any financial conflicts of interest; the study was unfunded.

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    Current affiliation: Department of Medicine, New York University, New York, NY.

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