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EMERGENCY OBSERVATION MEDICINE 0733-8627/01 $15.00 + .OO

ABDOMINAL PAIN AND

EMERGENCY DEPARTMENT
EVALUATION
Louis G. Graff IV, MD, FACEP, and Dave Robinson, MD, MS, FACEP

Abdominal pain is the most common chief complaint of patients in emer-

gency departments (EDs). It comprises 8% of the 100 million ED visits each
year.I3,26 Some patients with abdominal pain experience a catastrophic event,
such as ruptured abdominal aortic aneurysm. Most patients with abdominal
pain have a minor problem, such as dyspepsia. Overall, 20% to 25% of patients
with abdominal pain are found to have a serious condition requiring acute care
hospital admission.20The most common surgical emergency is appendicitis.
Since Fitz’s report of the surgical treatment of appendicitis in 1886,”j early
diagnosis and operation has been found to prevent appendicitis perforation.
This avoids acute complications (such as abscess formation and sepsis) and
delayed complications (such as scar formation with episodes of bowel obstruc-
tion and infer ti lit^).^^
Those patients who are not admitted usually are treated, released from the
ED, and do well. Lukens et alZ5reported that only 3% of abdominal pain patients
discharged from the ED require admission during the following 3 weeks. Yet, in
the primary care setting, an average of 1.32 visits are required to adequately
complete these patients’ work-up, with half found after evaluation to have a
diagnosis of nonspecific abdominal pain.23Gold and Azevedo17reported that the
abdominal pain work-up generated more use of ancillary services than all other
ambulatory complaints studied.
Identifying and managing abdominal pain is a dilemma for several reasons:
first, the definitive diagnosis is often obscure, with an unconfirmed or uncertain
diagnosis reported in over 40% of patients.*Failure to confirm a diagnosis results
in further testing and, often, return visits to the primary care provider or the

From the Department of Emergency Medicine, University of Connecticut School of Medi-

cine, Farmington; the Observation Unit, Department of Emergency Medicine, New
Britain General Hospital, New Britain, Connecticut (LGG); the Department of Emer-
gency Medicine, University of Texas-Houston Health Science Center; and the Diagnos-
tic Observation Center, Hermann Memorial Hospital, Houston, Texas (DR)

EMERGENCY MEDICINE CLINICS OF NORTH AMERICA

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VOLUME 19 NUMBER 1 FEBRUARY 2001 123
124 GRAFF N & ROBINSON

ED despite good long-term prognoses; second, the burden for establishing a

diagnosis and the large differential of presenting symptoms often obligates the
ED to repeat many of the tests or broaden the differential diagnosis of those
presenting with persistent pain. The difficulty in identifying the origin of abdom-
inal pain results in large numbers of negative work-up, unnecessary surgeries,
increased cost, and a burden on patient and hospital resources; third, the physi-
cian often faces the dilemma of when to declare the patient safe for discharge
and conclude the work-up in a timely manner despite a negative work-up or an
unclear diagnosis. A methodological approach to abdominal pain, including
judicious test ordering and the use of a period of observation, can reduce or
eliminate the dilemmas previously mentioned.

TRADITIONAL APPROACH

The traditional approach in the ED to the patient with acute abdominal

pain is similar to the evaluation of any ED patient. The physician performs a
history and physical examination, then orders stat testing, such as a complete
blood count, urinalysis, and radiograph. Two to 3 hours after the patient’s
arrival, the physician discharges those patients who are judged to have a benign
condition and admits to the hospital patients who have a serious disease.
A thorough history is the initial step in the ED evaluation of the patient
with acute abdominal pain. The location of the pain is important in forming a
differential diagnosis. Right upper quadrant pain suggests gallbladder disease
or hepatitis; right lower quadrant pain suggests acute appendicitis or, in women,
ovarian or tuba1 problems. The quality of the complaint may suggest the cause
of the condition. Burning pain may be due to gastritis or peptic ulcer. Sharp,
penetrating pain can be secondary to acute pancreatitis. The severity of the
pain may not have any relationship to the seriousness of the condition. Acute
nephrolithiasis is described as severe, incapacitating pain, yet for most patients
the condition is not serious, and they spontaneously pass their stone. The
duration of the pain can also be a clue to diagnosis. Acute appendicitis evolves
over 1to 2 days. Other conditions, such as a ruptured ovarian cyst, are a sudden
event. The timing of the pain can aid the physician. Pain that begins after eating
suggests peptic ulcer disease; pain that begins 2 weeks after menstruation
suggests ovulation disorder of mittleschmertz. The context of the pain can also
aid in the evaluation of patients with abdominal pain. Pain that begins during
physical activity may be secondary to a rectus abdominal muscle tear and
hematoma. Associated signs and symptoms can also be helpful in clarifying the
diagnosis. Patients with acute appendicitis usually have anorexia, nausea, and
vomiting; patients with mittelschmertz may have pain in the same location as
appendicitis but usually do not have the associated symptoms of anorexia,
nausea, and vomiting.
The patient’s age and gender deserve special focus from the physician
during the initial evaluation. Patients at the extremes of age often present
atypically and require even greater attention to details of the history to avoid
missing the diagnosis. The very young cannot express themselves to the physi-
cian about what their symptoms are or where pain is located. The elderly may
not be able to express themselves as well as when they were younger, especially
those with Alzheimer’s disease. They also do not mount as vigorous an inflam-
matory response, which usually is the source of many of the findings of their
illness. women with abdominal pain have a much more complex differential
diagnosis than men. Women may have pregnancy-related problems, and they
 ABDOMINAL PAIN AND EMERGENCY DEPARTMENT EVALUATION 125

have additional pelvic organs ( e g , ovary, fallopian tubes) that may develop
problems. Women patients require additional vigilance from the physician in
their ED evaluation to avoid missing the diagnosis.
The physical examination is the second step in the initial evaluation of a
patient with acute abdominal pain. With palpation, the physician can confirm if
the process causing the abdominal pain is localized to one area of the abdomen.
Right upper quadrant processes include cholecystitis or hepatitis; right lower
quadrant process includes appendicitis, mittleschmertz, ovarian cyst, and ectopic
pregnancy; left lower quadrant processes may include an obstetrical problem,
such as ectopic pregnancy, or a local problem, such as diverticulitis. Auscultation
may be used by the physician to identify findings such as the absence of bowel
sounds with an ileus. If ascites are present, percussion can be used to identify
this finding.
During the initial evaluation, the emergency physician evaluates the patient
with selected stat tests such as urinalysis, complete blood count, electrolytes,
amylase, lipase, and liver enzymes. These findings may aid the physician in
forming an initial clinical impression but usually are not diagnostic. For example,
leukocytosis is consistent with acute appendicitis but is present with many other
conditions as well.

PROBLEM WITH THE TRADITIONAL APPROACH

After the initial history, physical examination, and diagnostic tests, disposi-
tion decisions can be difficult on many patients. If the patient has clear evidence
of a specific disease, then a lengthy evaluation is not necessary. The patient is
admitted or released, depending on the seriousness of the disease condition and
the need for acute care hospital therapy. Many patients, however, do not have
clear evidence of the cause of their acute condition after the initial evaluation.
In these patients, the physician makes a probability of disease estimate.30At
some threshold for probability of disease, the physician discusses with the
patient his or her concern about their condition and recommends admission to
the hospital.3O When the probability of disease is lower than this threshold, the
physician reassures the patient and releases him or her.30The problem with a
traditional ED approach, limited to admission or discharge only, is that patients
must meet a higher threshold for further testing to occur. Any threshold for
admission of the ED patient to the hospital is a balance between what the
physician feels to be an appropriate diagnostic work-up and the use of limited
hospital resources, including time.
If there is a relatively high threshold for considering disease, above which
the physician admits the patient, quality of care problems arise for some patients
not meeting that threshold. If a patient falls below this threshold, the physician
reassures them and releases them. Whereas many patients with acute appendici-
tis initially present with classic symptoms (i.e., migration of pain to the right
lower quadrant, nausea, vomiting, and fever), just as many have nonspecific
These appendicitis patients often are released home with false
reassurance from the physician that they are fine, or admitted to the hospital
without their diagnosis being identified. In either case, needed surgery is de-
layed.
Appendicitis patients who are missed during the initial evaluation have few
documented signs or symptoms of appendicitis. Using Alvarados’ validated
appendicitis “MANTRELS” scoring system, Graff et alZofound these patients to
have an average appendicitis score of 2 out of 10 points. Rusnak et a13’ examined
126 GRAFF IV & ROBINSON

a series of cases where the appendicitis patient's diagnosis was missed in the
ED and the patient sued the physician. The authors found that these patients had
few clinical signs or symptoms of appendicitis at the time of their pre~entation.~~
When the initial physician misses the diagnosis of appendicitis, the patient's
outcome worsens. Brender et a17 found that the initial physician missed many
appendicitis presentations. The perforation rate was increased in those presenta-
tions initially missed by the physician (66.7% versus 39.5y0).~ Time delay from
the initial physician evaluation until surgery was greater in perforated than in
nonperforated patients (38.8 hours versus 10.5 h o ~ r s )Savrin
.~ et a138found 45%
of appendicitis patients with perforation had been evaluated by a physician and
released home with the diagnosis missed. Schere et a139found the percentage of
appendicitis patients whose diagnosis was missed by the physician was 17.6%
for patients with perforation compared with 5.3% for appendicitis patients
without perforation. Buchman et a19 found the diagnosis was missed in 27.1%
of appendicitis patients, which resulted in 4.6 days' delay before the patient was
admitted to the hospital. Cacioppo et all1 examined the changes from 1980 to
1987 as insurance payers created road blocks to patients being referred to a
surgeon for evaluation. These authors found the percentage of patients not
evaluated by a surgeon initially increased from 7.9% to 24.1%. Those patients
not referred to the surgeon by the initial physician had 3.5 days' delay before
surgery with the perforation rate increased from 26.3% to 40.5%." Traditionally,
the physician has failed to diagnose appendicitis in 10% to 27% of cases with
many patients experiencing adverse outcomes, such as perforation and abscess
formation.
When a physicians' practice is limited to admit or discharge an ED patient
with abdominal pain, usage problems also arise. Physicians admit patients to
the hospital who have a probability of disease greater than the threshold to
admit. Some of these patients do have a serious disease, but most do not. The
average rate of false positive surgery rate ranges from 20% to 30%.31*42 This
results in unnecessary surgery to avoid delays in performing surgery and re-
sulting perforation. In 1984, Berry and Malt4 summarized the first 100 years of
management of appendicitis. This included a review of 23 studies with 13,848
patients and the first 100 years of experience with appendicitis at Massachusetts
General Hospital, where the first appendectomy was perf~rmed.~ They con-
cluded that low diagnostic accuracy was necessary (high false-positive surgery
rate) to reduce the risk of perforation. They recommended a 23% false-positive
surgery rate as the ideal balance for the s ~ r g e o nThe
. ~ consequences of negative
laparotomy result in a threefold waste of hospital resources, unnecessary compli-
cations to the patient, and expense to the health care system.18 Gough et all8
found the incidence of noninflammed appendices removed was 29.6% and
was nearly twice as high in women than men. Postoperative complications
reached 6.7%.l8

OBSERVATION: THE THIRD PATHWAY

Observation offers a third disposition pathway to address problems in

quality and use. The physician does not have to release those patients with a
low probability of disease; they may be evaluated further to ensure the safety
of their release. The few patients with serious disease can be identified. Usage
problems also can be addressed because low probability and moderate probabil-
ity of disease patients do not have to be admitted after the ED evaluation.
During the 10 to 12 hours of observation unit evaluation, approximately 20% of
patients will be found to have a serious disease and be admitted to the hospital;
 ABDOMINAL PAIN AND EMERGENCY DEPARTMENTEVALUATION 127

the other 80% are safely released, avoiding hospitalization at 50% of the cost
and charges of admission to the hospital. With the third pathway, the physician
can be more discriminating in deciding who to commit to expensive hospitaliza-
tion without unwanted risk to patient safety.
Clinical changes over time illustrate the benefit of observation in patients
whose diagnosis is not clear after the initial ED evaluation.20Patients with
appendicitis develop more signs and symptoms during evaluation in the ED
observation unit. Judging patients by the 10 point appendicitis scoring system,
Graff et a P found that during 12 hours of observation the amount of clinical
findings in patients with appendicitis increased from 6.8 to 7.8 points. They also
found that patients without appendicitis during 12 hours of observation cleared
their clinical findings with appendicitis scores decreasing from 3.8 to 1.6.20
Formation of a probability of disease estimate from clinical findings and consid-
eration of the changes (delta) over a 12-hour period of observation (Fig. 1)
clarifies the patient's diagnosis.
In evaluating patients for appendicitis, Lewis et a124found serial examina-
tion was the best approach to minimize perforation risk while reducing delays
to diagnosis.24To identify patients with appendicitis who present with atypical
symptoms, the physician needs to decrease the threshold for extended evaluation
of abdominal pain patients. Appendicitis patients whose diagnosis is initially
missed have few signs and symptoms of appendicitis (Fig. 2). Observation is a

.-c

-8

-10 -
3 4 5 6 7 8 9 10

Initial Appendicitis Score

Figure 1. Probability of appendicitis after observation: calculation from initial and change
in appendicitis score. Bottom curve = 24%; second curve = 33%; third curve = 62%;
fourth curve = 97%; top curve = 100%. (From Graff LG, Radford MJ, Werne CW:
Probability of appendicitis before and after observation. Ann Emerg Med 20503-507,1991;
with permission.)
128 GRAFF FJ & ROBINSON

Figure 2. Amount of clinical findings of appendicitis in abdominal pain patients. First bar
= misses (patients with appendicitis whose diagnosis is missed by the initial physician);
second bar = false positives (patients without appendicitis who are taken to surgery for
suspected appendicitis; third bar = true positives (patients with appendicitis identified by
initial physician).

method for the physician to perform extended evaluation of abdominal pain

patients whose diagnosis might be acute appendicitis with atypical or early
presentation. Nonappendicitis patients who have surgery for suspected appendi-
citis have many of the signs and symptoms of acute appendicitis (see Fig. 2).
Observation is a method for the physician to perform extended evaluation of
nonappendicitis abdominal pain patients who have many findings of appendici-
tis. The Observation approach provides the framework for today’s ED alternative
to hospital admission.
Physicians can use observation to improve their performance, decreasing
false positive decisions (i.e., unnecessary surgery or hospital admission). Up
through the 1960s, abdominal pain patients usually were admitted to the hospital
for The physician examined the patient once per day on rounds,
with only 25% of acute appendicitis patients being taken to surgery during the
first 24 hours.28During the early 1970s at John Hopkins University Hospital,
White et a1@showed that intensive observation (physical examinations every 8
hours rather than once per day) could nearly eliminate false positive decisions.
They found the normal appendix rate decreased from 15% to 1.9% after imple-
menting an observation program, but there was no increase in perforation (26.7%
before and 27.5% after).43A prospective trial by T h ~ m s o nfound
~ ~ similar results.
In this study there was a single observer’s serial examinations, hourly vital sign
changes, and basic laboratory and radiographic tests of patients who present to
the ED with abdominal pain.42By 12 hours, 135 of 153 patients (88.2%)completed
the observation period without l a p a r ~ t o m yDuring
. ~ ~ the observation period, 18
of 153 patients (11.8%)required There were no reported complications
because of the delay to early surgery, and there were no return visits for
abdominal pain patients discharged after observation.
Since the 1970s, many other hospitals have implemented observation pro-
grams and found similar results. In Pennsylvania, a 28-hospital study of the care
of appendicitis patients found normal appendicitis rates varying from 4% to
28% (mean 14%).3Hospitals with low normal appendix rates were those with
formal, explicit observation program^.^ The surgeons at these hospitals followed
a philosophy that appendicitis was an urgent but not critical emergency3 They
judged that perforation occurs over 1 to 2 days, so a deliberate approach with
 ABDOMINAL PAIN AND EMERGENCY DEPARTMENT EVALUATION 129

short-term observation is safe and reasonable. Thomson et a142reviewed the

literature on the evaluation of abdominal pain patients for appendicitis with
and without observation. They compared the results of three studies on hospitals
with explicit observation programs with the results of nine studies where there
was no use of ~bservation.~~ The normal appendix rate was significantly lower
where observation was the accepted approach (60%versus 20%).42

OBSERVATION AND DIAGNOSTIC IMAGING

The ability to use high-tech tests, such as computed tomographic (CT)

scanning, also illustrates the value of observation in patients whose diagnosis is
not clear after the initial ED evaluation. Computed Tomography scanning has
been shown to improve physician decision-making in patients with moderate
probability of appendicitis. Rao et aP3 examined the effect of CT scan use on
patients with moderate probability of appendicitis and found that 53 of 100
patients had appendicitis in contrast to the ED, where only 3 of 100 patients
have appendicitis. Physicians prospectively recorded their disposition decisions
before and after CT scan results. Computed tomographic scan imaging results
decreased false negative decisions with 18 of the patients with appendicitis
being observed and then taken to surgery that otherwise would have been
released after their ED e v a l ~ a t i o nComputed
.~~ tomographic scan imaging results
also decreased false positive decisions with 13 nonappendicitis patients not
taken to surgery who otherwise would have been taken to surgery after the
surgeon’s initial e v a l ~ a t i o n . ~ ~
Observation enables the physician to judiciously use advanced diagnostic
testing in the evaluation of abdominal pain patients. These tests are costly and
not appropriate for patients whose diagnosis is clear after the initial physician
evaluation. These patients should be taken to surgery right after the ED evalua-
tion without the added cost of such testing. Advanced diagnostic tests also are
not appropriate for patients whose likelihood of appendicitis is very low. Few
will be found to have a positive test in such circumstances, and most of these
will be false positive^.^^

OBSERVATION STRATEGIES

A successful observation strategy for abdominal pain requires safety, effi-

ciency, and prudent use of resources. Safety is the primary goal of any successful
observation program. The physician seeks to accurately detect abdominal pathol-
ogy without delaying surgery. Efficiency is inherent in the observation program.
Patients are evaluated with an accelerated protocol over 10 to 12 hours rather
than during a 2- to 3-day hospitalization. Fewer personnel are required to
provide services to the observation patient during the accelerated protocol.
Duplicate physician and nursing assessments during hospitalization are avoided.
In addition, the physician can often avoid expensive diagnostic testing. The
patient with abdominal pain, unlike the patient with chest pain, often develops
changes in their signs and symptoms during the observation period, aiding the
physician in clarifying the patient’s diagnosis.
Safe patient care requires good physician-to-physician communications. The
emergency physician is screening 100 abdominal pain patients to find the 2 or 3
with acute appendicitis to refer to the surgeon for definitive care. The astute
emergency physician must recognize the subtle changes during the abdominal
pain observation period and be able to objectively categorize these changes and
130 GRAFF IV & ROBINSON

relay this information to the consultant, if needed. Delays in care or disputes in

the approach to abdominal pain observation and management can occur without
a defined protocol for physician communication. With a defined observation
strategy, information regarding dynamic changes in the quality of pain, localiza-
tion, or frequency of pain is adequately conveyed from physician to physician.
Criticism toward the emergency physician regarding the administration of anal-
gesia for abdominal pain may occur when a consultant has no serial examination
information and is unable to assess the patient prior to the administration of the
analgesic. An observation pathway with a defined role for the emergency physi-
cian and the consultant is designed to accurately assess dynamic changes in the
patient's pain, variations in laboratory values, serial examinations, and vital
signs and can improve the quality of information transferred between physicians
without the withholding of necessary pain relief.
Efficiency is possible with observation of abdominal pain patients. A multi-
disciplinary strategy for abdominal pain management from the ED provides an
opportunity to reduce hospital resources while ensuring patient safety. More
than one third of all patients admitted into surgical units with abdominal
complaints will have complete resolution of symptoms without treatment.14
These findings have also been demonstrated in childrenI5, admitted for lower
quadrant abdominal pain. Emergency department observation avoids unneces-
sary admissions, results in fewer laporatomies, and is not associated with in-
creased rates of appendicular perforation.@
Prudent use of resources is possible with a predefined observation pathway
that includes objective criteria to risk stratify patients over the observation
period and indications for advanced testing, such as CT or US. Low-risk patients
with improving criteria may be safely observed in the emergency setting without
unnecessary tests. High-risk presentations have earlier surgical consultation and
may avoid testing. Imprudent test ordering is especially difficult to accept at
smaller hospitals that do not have 24-hour ultrasound or CT testing except to
call in technicians. When the physician is not certain on the proper disposition
decision, he or she can observe the patient and schedule testing in the morning.
An accelerated diagnostic protocol (ADP) for abdominal pain patients can
be applied to any ED (Fig. 3). The protocol includes general definition of which
probability of disease patients are appropriate for observation. More specific
inclusion and exclusion criteria can be included in the protocol as well. Useful
criteria for acceptable risk patients for observation include:
Inclusion criteria
Undifferentiated abdominal pain not clarified by initial ED evaluation
Mild to Moderate suspicion of appendicitis
Exclusion criteria
Hemodynamically unstable-hypotension, tachycardia
Surgical abdomen
Pain for more than 2 weeks
Intoxication
Advanced pregnancy (more than 20 weeks)
Terminal illness
Immunosuppressed, transplant patients, or chronic steroid therapy
Unable to give reliable history or physical
Organic brain syndrome or psychiatric illness
Probability of appendicitis estimate can be made with Alvarado 10-point
appendicitis scoring system' with consideration of changes over observation
(see Fig. ,).I9 Decision points for surgery and advanced imaging should be
 Acute pain, unstable?
Exclusions? (Table 1) Send
Low Probabilitv labs, hydrate, probability of
I 1 - \ disease estimate
Moderate Probability
I High Probability (Table 2)
/ I Consider immediate surgical
interventionand admission
Patient is worse
132 GRAFF IV & ROBINSON

individualized for each hospital. The indications for surgical consultation and
hospital admission include:
Developed peritoneal signs or shock
Worsening abdominal tenderness during the observation period
Persistent pain or tenderness after observation period
Focalizing tenderness
Deteriorating vital signs
Identification of a surgical pathology (such as ectopic pregnancy or small
bowel obstruction)
Worsening toxicity as defined by clinical condition, laboratory, or ancillary
testing
Worsening or continued high appendicitis (MANTELS) score
Table 1 examines the many diagnostic testing options for the abdominal
pain patient.
Laboratory testing, radiography, and advanced diagnostic testing account
for the majority of charges to the low-risk individual that does not require
surgery. Differentiating surgical emergencies from nonsurgical emergencies often
require additional testing that may result in one of two strategies; The wait and
see strategy narrows the diagnosis through a series of progressively more specific
tests. This ordering pattern is cost-effective but could delay care and manage-
ment. Alternatively, ordering all laboratories and studies on initial presentation
(shot-gunning) may provide information earlier but may incur additional costs
through inappropriate ordering patterns. Table 1 illustrates the limitations of
single laboratory and radiographic testing.
The most frequently ordered study for abdominal pain is the complete
blood count (CBC). Complete blood count elevations in the context of abdominal
pain imply a more serious pathology. The CBC should never be used to make a
sole diagnosis of an abdominal pathology, as nearly 11%of normal adults have
elevated white blood cell (WBC) counts and 13% have left shifts. Conversely,
elevated CBCs occur in only 42% to 90% of those patients with confirmed
appendicitis. In a prospective trial of 382 children with appendicitis, only 13
(3.9%) had a normal CBC and no left shift, resulting in a 96% ~ensitivity.~
Unfortunately, elevated CBCs are reported with almost any infectious, inflam-
matory, or traumatic condition, reducing the specificity of CBC in some reports
less to than 50%.
Other than pregnancy testing, there are few laboratory tests that clearly are
indicated for all patients. The standard electrolyte panel, consisting of serum
sodium, chloride, potassium, blood urea nitrogen, and creatinine are rarely
helpful in the work-up of abdominal pain except to monitor the patient's
hydration status. Urinalysis is indicated in the evaluation of most patients with
abdominal pain but has limited use, except in the diagnosis of urinary tract
infections (UTI) in patients with urinary tract symptoms. It can be false positive
in up to 30% of appendicitis cases.4oBorrero6 noted that 24 of 134 (17.9%) of
symptomatic abdominal aortic aneurysms presenting to EDs were misdiagnosed
as nephrolithiasis. In this trial, 12 of the 14 patients with diagnostic delays
resulted from intravenous pyelograms testing6Furthermore, in a trial by Pomper
et a1,3* gross hematuria was found to be a significant cause of the delay in
arriving to the diagnosis of appendicitis.
Plain films routinely ordered for all presenting abdominal patients are
another example of an ordering practice that may no longer be necessary.'2,36
Abdominal radiographs are rarely helpful as an initial test for abdominal pain
except where bowel obstruction, foreign body, or perforated viscous is an imme-
diate concern. Even in these presentations, CT provides more information with
Table 1. DIAGNOSTIC STUDIES FOR COMMON ABDOMINAL PRESENTATIONS
Common Testing CBC Lytes UA Xray UIS CT Scan
Abdominal aortic aneurysm A A Y Y Angiogr
Appendicitis Y A Y Y C-reacti
Biliary tract disease A A Y' Y HIDA s
Bowel obstruction, perforation A A Y* Y Y
Cholecystitis A A Y' Y
Diverticulitis A A Y Y Barium
Ectopic pregnancy A A Y' HCG, pr
Gastroenteritis Y Y A Fecal le
Hernia A Physical
Intestinal infarction/ischemia A A A Y Angiogr
Ovarian torsion Y A Y Doppler
Pancreatitis A A Y Y Lipase*,
Pelvic inflammatory disease Y A A ESR, CR
Pyelonephritis Y Y
Renal colic A Y Y A Y Helical
Testicular torsion Y Y Doppler,
134 GRAFF rV & ROBINSON

little additional cost than a complete abdominal series. Using similar inclusion
criteria as noted previously, Rothrock et aP6reported a 48% reduction in unneces-
sary radiographs without missing any major disease. Campbell et all2reviewed
5080 patients with abdominal pain and reported that if the patient presented
with suspected appendicitis, UTI, or nonspecific abdominal pain, the radio-
graphs were not likely to be helpful and may, in fact, cloud the diagnosis.
Results from this trial support the conclusion that radiographs without clear
indication add little to the diagnosis and may actually delay the management of
abdominal pain.12
Observation of selected emergency department abdominal pain patients is
imperative. Early appropriate laboratories and radiographic testing combined
with observation can reduce cost and resource without jeopardizing safety. An
advantage of observation pathways is that the physician has the opportunity to
narrow his or her diagnosis by observation and is not obligated to shot-gun the
patient at presentation. The patient with mild diffuse abdominal pain may
develop focal findings in the right lower quadrant, improve, or even be found
to have other pathology clarified by serial evaluations.

SUMMARY

By approaching the abdominal pain patient in a systematic fashion, the

physician can improve his or her performance in evaluating the patient in a safe
and efficient manner without extensive or redundant tests.

References

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3. Banaszak P: Clinical quality improvement in a multihospital system: The Voluntary
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 ABDOMINAL PAIN AND EMERGENCY DEPARTMENT EVALUATION 135

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Louis G. Graff IV, MD, FACEP
New Britain General Hospital
100 Grand Street
New Britain, CT 06050