Assessing Abdominal Pain in the ED: Ensuring Safe Management & Care
0
TOC Will Appear Here

Assessing Abdominal Pain in Adults: A Rational, Cost-Effective, and Evidence-Based Strategy

14,491 views
Below is a free preview. Log in or subscribe for full access. Or, get a free sample article Emergency Department Management of Abnormal Uterine Bleeding in the Nonpregnant Patient:
Please provide a valid email address.
Table of Contents
 
About This Issue

Patients with abdominal pain are common in the ED, but you need a strategy for quickly identifying patients who are at high risk for life-threatening causes of pain, and you need to order testing and consultation that improves the accuracy of your clinical assessment.

What are the 4 groups of patients with abdominal pain who are frequently misdiagnosed?

Why do elderly patients with appendicitis often have little or no abdominal pain?

In women of childbearing age, is there a realistic algorithm to distinguish gastroenteritis from appendicitis, ectopic pregnancy, and PID?

What role should prior abdominal surgeries have in assessing abdominal pain?

What are the 18 high-yield historical questions to ask patients who present with abdominal pain?

Fever, high WBC, low blood pressure, tachycardia: how reliable are these in pointing to a cause for abdominal pain?

Pain location, migration, tenderness, and guarding: what each one can (and can’t) tell you about what is going on.

When pelvic and testicular exams are must-dos.

What are the highest-yield lab tests? CBC? Lipase or amylase? CRP?

When x-ray is all you need, and when CT is a must.

Will opioids make diagnosis more difficult?

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Epidemiology
  6. Pathophysiology
  7. Differential Diagnosis
    1. The Elderly
    2. Patients With Human Immunodeficiency Virus
    3. Women of Childbearing Age
    4. Patients With Prior Abdominal Surgery
  8. Emergency Department Evaluation
    1. History
    2. Physical Examination
      1. Vital Signs
        • Temperature
        • Respiratory Rate
        • Blood Pressure
        • Heart Rate
      2. Abdominal Examination
        • Palpation
        • Location of Tenderness
        • Guarding
        • Peritoneal Signs
        • Signs: Murphy, Psoas, Obturator, Rovsing
        • Auscultation
      3. Pelvic Examination
      4. Rectal Examination
      5. Testicular Examination
      6. Serial Examinations
  9. Diagnostic Studies
    1. Laboratory Testing
      1. Complete Blood Cell Count
      2. C-Reactive Protein
      3. Lipase and Amylase
      4. Lactate
      5. Urinalysis
    2. Imaging Studies
      1. Plain Films
      2. Views
      3. Ultrasound
      4. Computed Tomography
      5. Magnetic Resonance Imaging
      6. Electrocardiogram
  10. Treatment
    1. Analgesia for Acute Abdominal Pain
  11. Controversies and Cutting Edge
    1. Clinical Decision Rules
    2. Clinical Policies
  12. Disposition
    1. Observation Units
  13. Summary
  14. Risk Management Pitfalls in Evaluating Patients With Abdominal Pain
  15. Time- and Cost-Effective Strategies
  16. Case Conclusions
  17. Clinical Pathways
    1. Clinical Pathway for Patients Aged < 50 Years With Abdominal Pain
    2. Clinical Pathway for Patients Aged > 50 Years With Abdominal Pain
    3. Clinical Pathway for Women of Childbearing Potential With Lower Abdominal Pain
  18. Tables, Figures and Appendix
    1. Table 1. Abdominal Pain: Dangerous Mimics
    2. Table 2. Important Extra-Abdominal Causes of Abdominal Pain
    3. Table 3. Disease Spectrum in Acute Abdominal Pain, by Age
    4. Table 4. High-Yield Historical Questions in Abdominal Pain
    5. Table 5. Indications for Abdominal Plain Films for Abdominal Pain
    6. Table 6. Alvarado Score
    7. Figure 1. Sample Patient Chart for the Patient With Abdominal Pain
    8. Figure 2. Sample Discharge Instructions for the Patient With Abdominal Pain
    9. Appendix 1. Pros and Cons of Diagnostic Tools for Abdominal Pain in Various Disease Entities
  19. References

 

Abstract

The management of abdominal pain has changed significantly in the past 20 years, with increasing emphasis on identifying patients who are at high risk for occult pathology and worse outcomes. Emphasizing safe disposition over diagnosis, this issue identifies the important aspects of the history and physical examination, explores strengths and weaknesses of laboratory evaluations, and summarizes the pros and cons of the many types of imaging now available. With abdominal pain still the most common chief complaint seen in the emergency department, a new look at the evolution of assessment strategies is in order, such as new recommendations on the use of oral contrast, managing HIV patients on highly active antiretroviral therapy, maximizing use of bedside ultrasound, when and how to offer pain relief, and the value of serial examinations and observation to reduce costs and improve care.

Case Presentations

As you begin your shift, a 68-year-old woman presents with severe abdominal pain. She requires 4 mg of morphine before you can even talk to her. Surprisingly, her abdomen is soft, and not particularly tender. She is tachycardic to the 120s, and her pulse feels irregular. Her blood pressure is 100/50 mm Hg. It seems strange that her pain is so incongruent with her exam, and you wonder: What is the best imaging study to help clarify things?

In the next room, a 24-year-old man with no past medical history has presented with sudden, severe left lower quadrant pain followed by vomiting. He has normal vital signs except for tachycardia and a nontender abdomen. He seems too young to have diverticulitis, and since the pain is on the left side, you doubt appendicitis. A urinalysis is negative for blood, making renal colic less likely. Pain medication helps, and you wonder whether this is just gas or further diagnostic testing is needed…

 

Introduction

An experienced emergency clinician might compare the painful abdomen to the dark side of the moon—a terrain both indistinct and enigmatic. The patient’s history is frequently uncertain and the physical examination misleading. To further complicate the issue, “textbook” presentations of serious disease seem to exist only in print. After an extensive workup, patients with severe pain may prove to have gastroenteritis, while those with a seemingly benign belly are hiding a surgical catastrophe.

This 20th anniversary issue of Emergency Medicine Practice will once again address the dilemma of abdominal pain and take another look at the structured approach to this complaint. The central principles include: (1) recognizing the high-risk patient, (2) selecting appropriate testing, and (3) using flexible clinical pathways. This issue emphasizes disposition over diagnosis, as it is not as important to identify an exact cause of abdominal pain as it is to recognize a surgical abdomen.

 

Critical Appraisal of the Literature

The broad scope of abdominal pain makes it less amenable to the large randomized double-blind studies seen with sepsis, stroke, or pulmonary embolism. Much of the emergency medicine literature focuses on incidence, causes, and misdiagnosis of abdominal pain. Some researchers concentrate on radiation-reduction strategies or clinical scoring systems to detect a particular cause of abdominal pain (such as appendicitis). The American College of Emergency Physicians Clinical Policy on acute abdominal pain has been “retired,” being last updated almost 20 years ago. For this update, except for the most common and deadly conditions, articles were chosen based more on clinical presentation and emergency evaluation of abdominal pain rather than on specific etiologies of abdominal pain.

 

Risk Management Pitfalls in Evaluating Patients With Abdominal Pain

1. “I didn’t think she needed a CT.”

The CT scan is the most revealing tool in the ED workup. Maintain a low threshold for obtaining CT in acute abdominal pain in the elderly.

7. “I thought it was just gastroenteritis.”

It is preferable to give a diagnosis of “nonspecific abdominal pain,” “undifferentiated abdominal pain,” or “abdominal pain of unknown etiology” than to assign a specific but unsupported diagnosis. A true diagnosis of gastroenteritis requires nausea, vomiting, and diarrhea.

9. “The pain was in the wrong spot!”

Consider the diagnosis of appendicitis in patients with right flank and right upper quadrant pain (and also left lower and, rarely, left upper quadrant pain). Patients with retrocecal appendicitis present with minimal or no right lower quadrant tenderness.

 

Tables, Figures and Appendix

Table 1. Abdominal Pain: Dangerous Mimics

 

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

  1. Centers for Disease Control and Prevention. National Hospital Ambulatory Medical Care Survey: 2010 emergency department summary tables. 2010. Accessed May 10, 2019. (CDC website)
  2. Meltzer AC, Pines JM, Richards LM, et al. US emergency department visits for adults with abdominal and pelvic pain (2007-13): trends in demographics, resource utilization and medication usage. Am J Emerg Med. 2017;35(12):1966-1969. (Review)
  3. Marco CA, Schoenfeld CN, Keyl PM. Abdominal pain in geriatric emergency patients: variables associated with adverse outcomes. Acad Emerg Med. 1998;5(12):1163-1168. (Retrospective)
  4. Sanson TG, O’Keefe KP. Evaluation of abdominal pain in the elderly. Emerg Med Clin North Am. 1996;14(3):615-627. (Review)
  5. de Dombal FT. The OMGE acute abdominal pain survey - progress report, 1986. Scand J Gastroenterol. 1988;144:35-42. (Prospective; 10,682 patients)
  6. Cooper GS, Shlaes DM, Salata RA. Intraabdominal infection: differences in presentation and outcome between younger patients and the elderly. Clin Infect Dis. 1994;19(1):146-148. (Retrospective; 131 patients)
  7. Lewis LM, Banet GA, Blanda M, et al. Etiology and clinical course of abdominal pain in senior patients: a prospective, multicenter study. J Gerontol A Biol Sci Med Sci. 2005;60(8):1071-1076. (Prospective observational; 360 patients)
  8. Laurell H, Hansson LE, Gunnarsson U. Acute abdominal pain among elderly patients. Gerontology. 2006;52(6):339-344. (Prospective observational; 2289 patients)
  9. Brewer R, Golden F, Hitch D, et al. Abdominal pain: an analysis of 1,000 consecutive cases in a university hospital emergency room. Am J Surg. 1976;131(2):219-223. (Retrospective; 1000 patients)
  10. Miettinen P, Pasanen P, Lahtinen J, et al. Acute abdominal pain in adults. Annales Chirurgiae et Gynaecologiae. 1996;85(1):5-9. (Prospective; 639 patients)
  11. Lyon C, Clark DC. Diagnosis of acute abdominal pain in older patients. Am Fam Physician. 2006;74(9):1537-1544. (Review)
  12. Bender JS. Approach to the acute abdomen. Med Clin North Am. 1989;73(6):1413-1422. (Review)
  13. Bugliosi T, Meloy T, Vukov L. Acute abdominal pain in the elderly. Ann Emerg Med. 1990;19(12):1383-1386. (Retrospective; 127 patients)
  14. Rothrock SG, Greenfield RH. Acute abdominal pain in the elderly: clues to identifying serious illness, part I— clinical presentation and diagnostic strategies. Emerg Med Rep. 1992;13:175-184. (Review)
  15. Rothrock SG, Greenfield RH. Acute abdominal pain in the elderly: clues to identifying serious illness, part II—diagnosis and management of common conditions. Emerg Med Rep. 1992;13:185-193. (Review)
  16. Horattas MC, Guyton DP, Wu D. A reappraisal of appendicitis in the elderly. Am J Surg. 1990;160(3):291-293. (Retrospective; 96 patients)
  17. Esses D, Birnbaum A, Bijur P, et al. Ability of CT to alter decision making in elderly patients with acute abdominal pain. Am J Emerg Med. 2004;22(4):270-272. (Prospective observational cohort; 104 patients)
  18. Gardner CS, Jaffe TA, Nelson RC. Impact of CT in elderly patients presenting to the emergency department with acute abdominal pain. Abdom Imaging. 2015;40(7):2877-2882. (Retrospective study; 464 patients aged ≥80 years)
  19. Telfer S, Fenyo G, Holt PR, et al. Acute abdominal pain in patients over 50 years of age. Scand J Gastroenterol. 1988;144(Suppl):47-50. (Prospective; 2406 patients)
  20. Reid M, Tien P. Diarrhea in HIV infected patients In: Chin R, Frazee B, Coralic Z, eds. Emergency Management of Infectious Diseases. 2nd ed. Cambridge, UK: Cambridge University Press; 2018:181-187. (Textbook chapter)
  21. Garcia LS, Arrowood M, Kokoskin E, et al. Laboratory diagnosis of parasites from the gastrointestinal tract. Clin Microbiol Rev. 2018;31(1). (Guideline)
  22. Morpeth SC, Thielman NM. Diarrhea in patients with AIDS. Curr Treat Options Gastroenterol. 2006;9(1):23-37. (Review)
  23. Beatty GW. Diarrhea in patients infected with HIV presenting to the emergency department. Emerg Med Clin North Am. 2010;28(2):299-310. (Review)
  24. Anonymous. Case records of the Massachusetts General Hospital: weekly clinicopathological exercises: case 17-1996: a 48-year-old man with the acquired immunodeficiency syndrome, abdominal pain, and bloody diarrhea [clinical conference]. N Engl J Med. 1996;334(22):1461-1467. (Review)
  25. Mueller GP, Williams RA. Surgical infections in AIDS patients. Am J Surg. 1995;169(5A Suppl):34S-38S. (Review)
  26. Parente F, Cernuschi M, Antinori S, et al. Severe abdominal pain in patients with AIDS: frequency, clinical aspects, causes, and outcome. Scand J Gastroenterol. 1994;29(6):511-515. (Retrospective review; 458 patients)
  27. Katz MH, French DM. AIDS and the acute abdomen. Emerg Med Clin North Am. 1989;7(3):575-589. (Review)
  28. Hamada Y, Nishijima T, Watanabe K, et al. High incidence of renal stones among HIV-infected patients on ritonavir-boosted atazanavir than in those receiving other protease inhibitor-containing antiretroviral therapy. Clin InfectDis. 2012;55(9):1262-1269. (Retrospective; 35 patients)
  29. Sobnach S, Ede C, Van Der Linde G, et al. A retrospective evaluation of the modified Alvarado score for the diagnosis of acute appendicitis in HIV-infected patients. Eur J Trauma Emerg Surg. 2018;44(2):259-263. (Restrospective; 133 patients)
  30. Stengel CL, Seaberg DC, MacLeod BA, et al. Pregnancy in the emergency department: risk factors and prevalence among all women. Ann Emerg Med. 1994;24(4):697-700. (Prospective; 191 patients)
  31. Ramoska EA, Sacchetti AD, Nepp M. Reliability of patient history in determining the possibility of pregnancy. Ann Emerg Med. 1989;18(1):48-50. (Prospective; 208 patients)
  32. Kielar AZ, Chong ST. Acute abdominal pain in pregnant patients: evidence-based emergency imaging. In: Kelly A, Cronin P, Puig S, et al., eds. Evidence-Based Emergency Imaging: Optimizing Diagnostic Imaging of Patients in the Emergency Care Setting. Cham: Springer International Publishing; 2018:399-413. (Textbook chapter)
  33. Rothrock SG, Green SM, Dobson M, et al. Misdiagnosis of appendicitis in non-pregnant women of childbearing age. J Emerg Med. 1995;13(1):1-8. (Retrospective; 174 patients)
  34. Najem AZ, Barillo DJ, Spillert CR, et al. Appendicitis versus pelvic inflammatory disease: a diagnostic dilemma. Am Surg. 1985;51(4):217-222. (Retrospective; 145 patients)
  35. Robinson JA, Burch BH. An assessment of the value of the menstrual history in differentiating acute appendicitis from pelvic inflammatory disease. Surg Gynecol Obstet. 1984;159(2):149-152. (Retrospective)
  36. Silver BE, Patterson JW, Kulick M, et al. Effect of CBC results on ED management of women with lower abdominal pain. Am J Emerg Med. 1995;13(3):304-306. (Retrospective; 100 women)
  37. Bongard F, Landers DV, Lewis F. Differential diagnosis of appendicitis and pelvic inflammatory disease. A prospective analysis. Am J Surg. 1985;150(1):90-96. (Prospective study; 118 women)
  38. Kereshi B, Lee KS, Siewert B, et al. Clinical utility of magnetic resonance imaging in the evaluation of pregnant females with suspected acute appendicitis. Abdom Radiol (NY). 2018;43(6):1446-1455. (Retrospective study; 212 MRI examinations)
  39. Maung AA, Johnson DC, Piper GL, et al. Evaluation and management of small-bowel obstruction: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S362-S369. (Literature review and guidelines)
  40. Herron DM, Bloomberg R. Complications of bariatric surgery. Minerva Chir. 2006;61(2):125-139. (Review)
  41. Lewis KD, Takenaka KY, Luber SD. Acute abdominal pain in the bariatric surgery patient. Emerg Med Clin North Am. 2016;34(2):387-407. (Review)
  42. Mitchell MT. Bariatric imaging: technical aspects and postoperative complications. Appl Radiol. 2008;37(2):10. (Review)
  43. Gunn AA. The acute abdomen: the role of computer-assisted diagnosis. Baill Clin Gastroenterol. 1991;5(3 Pt 1):639-665. (Review)
  44. Lawrence PC, Clifford PC, Taylor IF. Acute abdominal pain: computer-aided diagnosis by non-medically qualified staff. Ann R Coll Surg Engl. 1987;69(5):233-234. (Prospective, blinded; 153 patients)
  45. Walker SJ, West CR, Colmer MR. Acute appendicitis: does removal of a normal appendix matter, what is the value of diagnostic accuracy, and is surgical delay important? Ann R Coll Surg Engl. 1995;77(5):358-363. (Prospective; 248 patients)
  46. Brown TW, McCarthy ML, Kelen GD, et al. An epidemiologic study of closed emergency department malpractice claims in a national database of physician malpractice insurers. Acad Emerg Med. 2010;17(5):553-560. (Epidemiologic study; 11,529 closed malpractice claims)
  47. Selbst SM, Friedman MJ, Singh SB. Epidemiology and etiology of malpractice lawsuits involving children in US emergency departments and urgent care centers. Pediatr Emerg Care. 2005;21(3):165-169. (Retrospective review; 2283 closed malpractice claims)
  48. Buckius MT, McGrath B, Monk J, et al. Changing epidemiology of acute appendicitis in the United States: study period 1993-2008. J Surg Res. 2012;175(2):185-190. (Epidemiologic study; Nationwide Inpatient Sample dataand US Census data)
  49. de Dombal FT. The diagnosis of acute abdominal pain with computer assistance: worldwide perspective. Annales de Chirurgie. 1991;45(4):273-277. (Systematic review; 100,000 patients)
  50. Sutton GC. Computer-aided diagnosis: a review. Br J Surg. 1989;76(1):82-85. (Review)
  51. Rusnak RA, Borer JM, Fastow JS. Misdiagnosis of acute appendicitis: common features discovered in cases after litigation. Am J Emerg Med. 1994;12(4):397-402. (Retrospective, review)
  52. Levinson W, Roter DL, Mullooly JP, et al. Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277(7):553-559. (Multivariate analysis; comparative)
  53. Karcz A, Korn R, Burke MC, et al. Malpractice claims against emergency physicians in Massachusetts: 1975-1993. Am J Emerg Med. 1996;14(4):341-345. (Prospective, comparative; 549 patients)
  54. Humphreys T, Shofer FS, Jacobson S, et al. Pre-formatted charts improve documentation in the emergency department. Ann Emerg Med. 1992;21(5):534-540. (Prospective)
  55. Golledge J, Toms AP, Franklin IJ, et al. Assessment of peritonism in appendicitis. Ann R Coll Surg Engl. 1996;78(1):11-14. (Prospective; 100 patients)
  56. Ashdown HF, D’Souza N, Karim D, et al. Pain over speed bumps in diagnosis of acute appendicitis: diagnostic accuracy study. BMJ. 2012;345. (Prospective; 101 patients)
  57. Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA. 1996;276(19):1589-1594. (Review)
  58. Dikicier E, Altintoprak F, Ozdemir K, et al. Stump appendicitis: a retrospective review of 3130 consecutive appendectomy cases. World J Emerg Surg. 2018;13(1):22. (Retrospective review; 3130 patients)
  59. Ros SP. Evaluation of a tympanic membrane thermometer in an outpatient clinical setting. Ann Emerg Med. 1989;18(9):1004. (Prospective; 102 patients)
  60. Hooker EA, Houston H. Screening for fever in an adult emergency department: oral vs tympanic thermometry. South Med J. 1996;89(2):230-234. (322 patients)
  61. Kresovich-Wendler K, Levitt MA, Yearly L. An evaluation of clinical predictors to determine need for rectal temperature measurement in the emergency department. Am J Emerg Med. 1989;7(4):391-394. (Comparative, cross-sectional; 366 patients)
  62. Tandberg D, Sklar D. Effect of tachypnea on the estimation of body temperature by an oral thermometer. N Engl J Med. 1983;306(16):945. (Prospective)
  63. Khodorkovsky B, Youssef E, Adamakos F, et al. Does initial temperature in the emergency department predict outcomes in patients admitted for sepsis? J Emerg Med. 2018;55(3):372-377. (Retrospective cohort)
  64. Hafif A, Gutman M, Kaplan O, et al. The management of acute cholecystitis in elderly patients. Am Surg. 1991;57(10):648-652. (Retrospective; 131 patients)
  65. Huber DF, Martin EW, Cooperman M. Cholecystectomy in elderly patients. Am J Surg. 1983;146(6):719-722. (Comparative; 93 patients)
  66. Hirsch SB, Wilder JR. Acute appendicitis in hospital patients aged over 60 years. Mt Sinai J Med. 1987;54(1):29-33. (Retrospective)
  67. Magidson PD, Martinez JP. Abdominal pain in the geriatric patient. Emerg Med Clin North Am. 2016;34(3):559-574. (Review)
  68. Berger T, Green J, Horeczko T, et al. Shock index and early recognition of sepsis in the emergency department: pilot study. West J Emerg Med. 2013;14(2):168-174. (Retrospective cohot; 2524 patients)
  69. Hu WS, Lin CL. CHA2DS2-VASc score in the prediction of ischemic bowel disease among patients with atrial fibrillation: Insights from a nationwide cohort. Int J Cardiol. 2017;235:56-60. (Prospective observational)
  70. Thompson WHF, Dawes RFH, Carter S. Abdominal wall tenderness: a useful sign in chronic abdominal pain. Br J Surg. 1991;78(2):223-225. (Prospective; 72 patients)
  71. Thomson H, Francis DM. Abdominal-wall tenderness: a useful sign in the acute abdomen. Lancet. 1977;2(8047):1053-1054. (Retrospective; 120 patients)
  72. Yamamoto W, Kono H, Maekawa M, et al. The relationship between abdominal pain regions and specific diseases: an epidemiologic approach to clinical practice. J Epidemiol. 1997;7(1):27-32. (Prospective; 489 patients)
  73. McBurney C. Experience with early operative interference in cases of disease of the vermiform appendix. NY Med J. 1889;50:676-684. (Historical reference)
  74. Ramsden WH, Mannion RA, Simpkins KC, et al. Is the appendix where you think it is--and if not does it matter? Clin Radiol. 1993;47(2):100-103. (Retrospective)
  75. Öztürk S, Kurtulus Öztürk E, Kebapçi M. Acute left upper quadrant appendicitis associated with intestinal malrotation. J Emerg Med Case Rep. 2018;9(2):33-35. (Case report; 1 patient)
  76. Naik MB, Rao KS. Laparoscopic appendectomy in situs inversus totalis. J Evol Med Dent Sci. 2015;4(29):5064-5067. (Case report; 1 patient)
  77. de Dombal F. Diagnosis of acute abdominal pain. New York, NY: Churchill Livingstone Inc; 1991. (Textbook)
  78. McNamara R. Abdominal pain in the elderly. In: Tintinalli J, Kelen G, Stapczynski S, et al., eds. Emergency Medicine: a Comprehensive Study Guide. New York: McGraw-Hill Education; 2004:515-519. (Textbook)
  79. Liddington MI, Thomson WH. Rebound tenderness test. Br J Surg. 1991;78(7):795-796. (Prospective; 142 patients)
  80. Bennett DH, Tambeur Luc JMT, Campbell WB. Use of coughing test to diagnose peritonitis. BMJ. 1994;308(6940):1336. (Prospective)
  81. Jeddy TA, Vowles RH, Southam JA. “Cough sign”: a reliable test in the diagnosis of intra-abdominal inflammation. Br J Surg. 1994;81(10):279. (Prospective)
  82. Markle Gt. A simple test for intraperitoneal inflammation. Am J Surg. 1973;125(6):721-722. (Review)
  83. Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med. 2012;5:789-797. (Review)
  84. Singer AJ, Brandt LJ. Pathophysiology of the gastrointestinal tract during pregnancy. Am J Gastroenterol. 1991;86(12):1695-1712. (Review)
  85. Adedeji OA, McAdam WA. Murphy’s sign, acute cholecystitis and elderly people. J R Coll Surg Edinburgh. 1996;41(2):88-89. (Retrospective)
  86. Eskelinen M, Ikonen J, Lipponen P. Contributions of history-taking, physical examination, and computer assistance to diagnosis of acute small-bowel obstruction: a prospective study of 1333 patients with acute abdominal pain. Scand J Gastroenterol. 1994;29(8):715-721. (Prospective; 1333 patients)
  87. Breum BM, Rud B, Kirkegaard T, et al. Accuracy of abdominal auscultation for bowel obstruction. World J Gastroenterol. 2015;21(34):10018-10024. (Prospective; 53 patients)
  88. Mitchell C, Prabhu M. Pelvic inflammatory disease: current concepts in pathogenesis, diagnosis and treatment. Infect Dis Clin North Am. 2013;27(4):793-809. (Review)
  89. Farrukh S, Sivitz AB, Onogul B, et al. The additive value of pelvic examinations to history in predicting sexually transmitted infections for young female patients with suspected cervicitis or pelvic inflammatory disease. Ann Emerg Med. 2018;72(6):703-712. (Prospective observational; 288 patients)
  90. Linden JA, Grimmnitz B, Hagopian L, et al. Is the pelvic examination still crucial in patients presenting to the emergency department with vaginal bleeding or abdominal pain when an intrauterine pregnancy is identified on ultrasonography? A randomized controlled trial. Ann Emerg Med. 2017;70(6):825-834. (Prospective randomized; 207 patients)
  91. Dixon JM, Elton RA, Rainey JB, et al. Rectal examination in patients with pain in the right lower quadrant of the abdomen. BMJ. 1991;302(6773):386-389. (Retrospective; 1204 patients)
  92. Bonello JC, Abrams JS. The significance of a “positive” rectal examination in acute appendicitis. Dis Col Rect. 1979;22(2):97-101. (Retrospective; 495 patients)
  93. Quinn J, Zeleny T, Rajaratnam V, et al. Debate: the per rectal/digital rectal examination exam in the emergency department, still best practice? Int J Emerg Med. 2018;11(1):20. (Review)
  94. Bass JB, Couperus KS, Pfaff JL, et al. A pair of testicular torsion medicolegal cases with caveats: the ball’s in your court. Clin Pract Cases Emerg Med. 2018;2(4):283-285. (Case studies; 2 patients)
  95. Anderson JB, Williamson RC. Testicular torsion in Bristol: a 25-year review. Br J Surg. 1988;75(10):988-992. (Case review; 670 patients)
  96. Sessions AE, Rabinowitz R, Hulbert WC, et al. Testicular torsion: direction, degree, duration and disinformation. J Urol. 2003;169(2):663-665. (Medical record review; 200 males)
  97. Graff L, Radford MJ, Werne C. Probability of appendicitis before and after observation. Ann Emerg Med. 1991;20(5):503-507. (Retrospective; 252 patients)
  98. Boendermaker AE, Coolsma CW, Emous M, et al. Efficacy of scheduled return visits for emergency department patients with non-specific abdominal pain. Emerg Med J. 2018;35(8):499-506. (Retrospective; 358 patients)
  99. Chen W, Mo JJ, Lin L, et al. Diagnostic value of magnetic resonance cholangiopancreatography in choledocholithiasis. World J Gastroenterol. 2015;21(11):3351-3360. (Meta-analysis; 25 studies, 2310 patients)
  100. Puylaert JB. Ultrasound of colon diverticulitis. Dig Dis. 2012;30(1):56-59. (Review)
  101. Ripolles T, Agramunt M, Martinez MJ, et al. The role of ultrasound in the diagnosis, management and evolutive prognosis of acute left-sided colonic diverticulitis: a review of 208 patients. Eur Radiol. 2003;13(12):2587-2595. (Retrospective review; 208 hospitalized patients)
  102. Abboud ME, Frasure SE, Stone MB. Ultrasound diagnosis of diverticulitis. World J Emerg Med. 2016;7(1):74-76. (Review and case report; 2 patients)
  103. Zhao DL, Liu XD, Zhao CL, et al. Multislice spiral CT angiography for evaluation of acute aortic syndrome. Echocardiography. 2017;34(10):1495-1499. (Retrospective; 36 patients)
  104. Adams DJ, et al. The value of computed tomography in the assessment of suspected ruptured abdominal aortic aneurysm. J Vasc Surg. 1998;27(3):431. (Prospective; 652 patients)
  105. Shuman WP, Hastrup W Jr, Kohler TR, et al. Suspected leaking abdominal aortic aneurysm: use of sonography in the emergency room. Radiology. 1988;168(1):117-119. (Retrospective; 60 patients)
  106. Kestler A, Kendall J. Emergency ultrasound in first-trimester pregnancy. In: Connolly J, Dean A, Hoffman B, et al., eds. Emergency Point-of-Care Ultrasound. 2nd ed. Oxford UK: John Wiley and Sons; 2017. (Textbook)
  107. Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis. 2017;65(12):e45-e80. (Guidelines)
  108. Lau W, Ho Y, Chu K, et al. Leucocyte count and neutrophil percentage in appendicectomy for suspected appendicitis. Aust N Z J Surg. 1989;59(5):359-398. (Prospective; 1032 patients)
  109. Lyons D, Waldron R, Ryan T, et al. An evaluation of the clinical value of the leucocyte count and sequential counts in suspected acute appendicitis. Br J Clin Pract. 1987;41(6):794-796. (Prospective)
  110. Miskowiak J, Burcharth F. The white cell count in acute appendicitis. A prospective blinded study. Dan Med Bull. 1982;29(4):210-211. (Prospective, blinded study)
  111. Nase HW, Kovalcik PH, Cross GH. The diagnosis of appendicitis. Am Surg. 1980;46(9):504-507. (Retrospective; 359 patients)
  112. Bower RJ, Bell MJ, Ternberg JL. Controversial aspects of appendicitis management in children. Arch Surg. 1981;116(7):885-887. (Review)
  113. Doraiswamy NV. Leucocyte counts in the diagnosis and prognosis of acute appendicitis in children. Br J Surg. 1979;66(11):782-784. (Retrospective; 225 patients)
  114. Eriksson S, Granstrom L. Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis. Br J Surg. 1995;82(2):166-169. (Comparative, prospective; 40 patients)
  115. Chi CH, Shiesh SC, Chen KW, et al. C-reactive protein for the evaluation of acute abdominal pain. Am J Emerg Med. 1996;14(3):254-256. (Multivariate analysis; 143 patients)
  116. Fenyo G. Diagnostic problems of acute abdominal diseases in the aged. Acta Chir Scand. 1974;140:396-405. (Review)
  117. Gruber PJ, Silverman RA, Gottesfeld S, et al. Presence of fever and leukocytosis in acute cholecystitis. Ann Emerg Med. 1996;28(3):273-277. (Retrospective review; 198 patients)
  118. Badgett RG, Hansen CJ, Rogers CS. Clinical usage of the leukocyte count in emergency room decision making. J Gen Intern Med. 1990;5(3):198-202. (Retrospective)
  119. Carmeli Y, et al. Utility of clinical symptoms versus laboratory tests for evaluation of acute gastroenteritis. Dig Dis Sci. 1996;41(9):1749. (Retrospective; 163 patients)
  120. Hallan S, Asberg A. The accuracy of C-reactive protein in diagnosing acute appendicitis--a meta-analysis. Scand J Clin Lab Invest. 1997;57(5):373-380. (Retrospective review; 3436 patients)
  121. Albu E, Miller BM, Choi Y, et al. Diagnostic value of C-reactive protein in acute appendicitis. Dis Col Rect. 1994;37(1):49-51. (Blinded, prospective; 56 patients)
  122. Jha V, Jha AK. Comparative study of C-reactive protein in cases of acute abdominal pain. Internat J Sci Res. 2017;6(12):17-19. (Case control; 80 patients)
  123. Coyle JP, Brennan CR, Parfrey SF, et al. Is serum C-reactive protein a reliable predictor of abdomino-pelvic CT findings in the clinical setting of the non-traumatic acute abdomen? Emerg Radiol. 2012;19(5):455-462. (Retrospective; 241 patients)
  124. Clavien PA, Robert J, Meyer P, et al. Acute pancreatitis and normoamylasemia. Not an uncommon combination. Ann Surg. 1989;210(5):614-620. (Prospective; 318 patients)
  125. Berk J, Fridhandler L, Webb S. Does hyperamylasemia in the drunken alcoholic signify pancreatitis? Am J Gastroenterol. 1979;71(6):557-562. (Retrospective)
  126. Bloch RS, Weaver DW, Bouwman DL. Acute alcohol intoxication: significance of the amylase level. Ann Emerg Med. 1983;12(5):294-296. (Retrospective; 58 patients)
  127. Gumaste VV, Roditis N, Mehta TS, et al. Serum lipase levels in non pancreatic abdominal pain versus acute pancreatitis. Am J Gastroenterol. 1993;88(12):2051-2055. (Retrospective; 95 patients)
  128. Chase CW, Barker DE, Russell WL, et al. Serum amylase and lipase in the evaluation of acute abdominal pain. Am Surg. 1996;62(12):1028-1033. (Retrospective; 306 patients)
  129. Richards C, Ishihara K, Grayson C, et al. Serum lactate predicts resource utilization, but not surgical need, in the emergency department. J Surg Res. 2018;226:89-93. (Retrospective; 753 patients)
  130. Scott JH 3rd, Amin M, Harty JI. Abnormal urinalysis in appendicitis. J Urol. 1983;129(5):1015. (Retrospective; 100 patients)
  131. Arnbjornsson E. Bacteriuria in appendicitis. Am J Surg. 1988;155(2):356-358. (Retrospective; 194 patients)
  132. Pomper SR, Fiorillo MA, Anderson CW, et al. Hematuria associated with ruptured abdominal aortic aneurysms. Internat Surg. 1995;80(3):261-263. (Retrospective; 30 patients)
  133. Kim TH, Oh SH, Park KN, et al. Factors associated with absent microhematuria in symptomatic urinary stone patients. Am J Emerg Med. 2018;36(12):2187-2191. (Retrospective; 798 patients)
  134. Maglinte DD, Balthazar EJ, Kelvin FM, et al. The role of radiology in the diagnosis of small-bowel obstruction. AJR Am J Roentgenol. 1997;168(5):1171-1180. (Review)
  135. Campbell JP, Gunn AA. Plain abdominal radiographs and acute abdominal pain. Br J Surg. 1988;75(6):554-556. (Retrospective; 5080 patients)
  136. Boyd R, Gray AJ. Role of the plain radiograph and urinalysis in acute ureteric colic. J Accid Emerg Med. 1996;13(6):390-391. (Prospective; 60 patients)
  137. Scott VR, Rothrock SG, Parrish G, et al. Plain abdominal radiography in the detection of major disease in the elderly. Acad Emerg Med. 1995;2:374-375. (Retrospective)
  138. Maglinte DD, Reyes BL, Harmon BH, et al. Reliability and role of plain film radiography and CT in the diagnosis of small-bowel obstruction. AJR Am J Roentgenol. 1996;167(6):1451-1455. (Blinded retrospective analysis; 78 patients)
  139. Gorelik U, Ulish Y, Yagil Y. The use of standard imaging techniques and their diagnostic value in the workup of renal colic in the setting of intractable flank pain. Urology. 1996;47(5):637-642. (Retrospective review; 288 patients)
  140. Field S, Guy PJ, Upsdell SM, et al. The erect abdominal radiograph in the acute abdomen: should its routine use be abandoned? Br Med J (Clin Res Ed). 1985;290(6486):1934-1936. (Prospective; 102 patients)
  141. Mirvis SE, Young JW, Keramati B, et al. Plain film evaluation of patients with abdominal pain: are three radiographs necessary? AJR Am J Roentgenol. 1986;147(3):501-503. (Retrospective review; 252 patients)
  142. Flak B, Rowley VA. Acute abdomen: plain film utilization and analysis. Can Assoc Radiol J. 1993;44(6):423-428. (Review)
  143. Felson B, Wiot JF. Another look at pneumoperitoneum. Semin Roentgenol. 1973;8(4):437-443. (Review)
  144. Rice RP, Thompson WM, Gedgaudas RK. The diagnosis and significance of extraluminal gas in the abdomen. Radiol Clin North Am. 1982;20(4):819-837. (Review)
  145. Roh JJ, Thompson JS, Harned RK, et al. Value of pneumoperitoneum in the diagnosis of visceral perforation. Am J Surg. 1983;146(6):830-833. (Retrospective)
  146. King A, Tyransky A, Coffman A, et al. A formalized three-year emergency medicine residency ultrasound education curriculum. J Ed Teach Emerg Med. 2016;1(2):C1-C13. (Curriculum)
  147. Seyedhosseini J, Nasrelari A, Mohammadrezaei N, et al. Inter-rater agreement between trained emergency medicine residents and radiologists in the examination of gallbladder and common bile duct by ultrasonography. Emerg Radiol. 2017;24(2):171-176. (Prospective observational study; 7 residents, 3 radiologists, 200 patients)
  148. Valley VT, Mateer JR, Aiman EJ, et al. Serum progesterone and endovaginal sonography by emergency physicians in the evaluation of ectopic pregnancy. Acad Emerg Med. 1998;5(4):309-313. (Prospective; 314 patients)
  149. Kaplan BC, Dart RG, Moskos M, et al. Ectopic pregnancy: prospective study with improved diagnostic accuracy. Ann Emerg Med. 1996;28(1):10-17. (Prospective; 481 patients)
  150. Pines JM. Trends in the rates of radiography use and important diagnoses in emergency department patients with abdominal pain. Med Care. 2009;47(7):782-786. (Retrospective study of 2001 to 2005 National Hospital Ambulatory Medical Care Surveydata; 38.8 million patient encounters)
  151. Rao PM, Rhea JT, Novelline RA, et al. Helical CT technique for the diagnosis of appendicitis: prospective evaluation of a focused appendix CT examination. Radiology. 1997;202(1):139-144. (Prospective; 100 patients)
  152. Rao PM, Rhea JT, Novelline RA, et al. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Engl J Med. 1998;338(3):141-146. (Prospective; 100 patients)
  153. Kessner R, Barnes S, Halpern P, et al. CT for acute nontraumatic abdominal pain—is oral contrast really required? Acad Radiol. 2017;24(7):840-845. (Prospective observational; 348 patients)
  154. Monetti F, Bhangu A, Di Saverio S, et al. CT evaluation of appendicitis. In: Catena F, Di Saverio S, Ansaloni L, et al., eds. CT Scan in Abdominal Emergency Surgery. Cham: Springer International Publishing; 2018:75-85. (Textbook chapter)
  155. Garcia EM, Camaco, MA, Karolyi DR, et al. ACR Appropriateness Criteria® right lower quadrant pain-suspected appendicitis. J Am Coll Radiol. 2018;15(11s):S373-S387. (Practice guidelines)
  156. Wilhelm-Leen E, Montez-Rath ME, Chertow G. Estimating the risk of radiocontrast-associated nephropathy. J Am Soc Nephrol. 2017;28(2):653-659. (Risk estimate using Nationwide Inpatient Sample)
  157. Aycock RD, Westafer LM, Boxen JL, et al. Acute kidney injury after computed tomography: a meta-analysis. Ann Emerg Med. 2018;71(1):44-53. (Meta-analysis; 28 studies, 107,335 participants)
  158. American College of Radiology; ACR Committee on Drugs and Contrast Media. ACR Manual on Contrast Media, Version 10.3; 2018. Accessed May 10, 2019. (Practice guidelines)
  159. Millet I, Sebbane M, Molinari N, et al. Systematic unenhanced CT for acute abdominal symptoms in the elderly patients improves both emergency department diagnosis and prompt clinical management. Eur Radiol. 2017;27(2):868-877. (Prospective; 401 patients)
  160. Samaras N, Chevalley T, Samaras D, et al. Older patients in the emergency department: a review. Ann Emerg Med. 2010;56(3):261-269. (Review)
  161. Howlett DC, Drinkwater K, Frost C, et al. The accuracy of interpretation of emergency abdominal CT in adult patients who present with non-traumatic abdominal pain: results of a UK national audit. Clin Radiol. 2017;72(1):41-51. (Retrospective;50 patients)
  162. Kinner S, Pickhardt PJ, Riedesel EL, et al. Diagnostic accuracy of MRI versus CT for the evaluation of acute appendicitis in children and young adults. AJR Am J Roentgenol. 2017;209(4):911-919. (Prospective; 48 patients)
  163. Laghi A. Acute appendicitis and negative or inconclusive results at initial US in adult, pediatric, and pregnant patients: what to do next? Radiology. 2018;288(3):728-729. (Review)
  164. Wrenn K, Slovis CM, Gongaware J. Using the “GI cocktail”: a descriptive study. Ann Emerg Med. 1995;26(6):687-690. (Retrospective; 97 patients)
  165. LoVecchio F, Oster N, Sturmann K, et al. The use of analgesics in patients with acute abdominal pain. J Emerg Med. 1997;15(6):775-779. (Prospective; 48 patients)
  166. Pace S, Burke TF. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med. 1996;3(12):1086-1092. (Blinded, prospective; 75 patients)
  167. Attard AR, Corlett MJ, Kidner NJ, et al. Safety of early pain relief for acute abdominal pain. BMJ. 1992;305(6853):554-556. (Prospective; 100 patients)
  168. Zoltie N, Cust MP. Analgesia in the acute abdomen. Ann R Coll Surg Engl. 1986;68(4):209-210. (Blinded, prospective; 288 patients)
  169. Frakes MA, Lord WR, Kociszewski C, et al. Efficacy of fentanyl analgesia for trauma in critical care transport. Am J Emerg Med. 2006;24(3):286-289. (Retrospective chart review; 100 trauma patients)
  170. Deaton T, Auten JD, Darracq MA. Nebulized fentanyl vs intravenous morphine for ED patients with acute abdominal pain: a randomized double-blinded, placebo-controlled clinical trial. Am J Emerg Med. 2015;33(6):791-795. (Randomized placebo-controlled double-blind trial; 40 patients)
  171. Roldan CJ, Chambers KA, Paniagua L, et al. Randomized controlled double-blind trial comparing haloperidol combined with conventional therapy to conventional therapy alone in patients with symptomatic gastroparesis. Acad Emerg Med. 2017;24(11):1307-1314. (Randomized controlled trial; 33 patients)
  172. Witsil JC, Mycyk MB. Haloperidol, a novel treatment for cannabinoid hyperemesis syndrome. Am J Ther. 2017;24(1):e64-e67. (Case studies; 4 patients)
  173. Karlow N, Schlaepfer CH, Stoll CRT, et al. A systematic review and meta-analysis of ketamine as an alternative to opioids for acute pain in the emergency department. Acad Emerg Med. 2018;25(10):1086-1097. (Meta-analysis; 3 studies, 261 patients)
  174. Unluer EE, Urnal R, Eser U, et al. Application of scoring systems with point-of-care ultrasonography for bedside diagnosis of appendicitis. World J Emerg Med. 2016;7(2):124-129. (Evaluation)
  175. McKay R, Shepherd J. The use of the clinical scoring system by Alvarado in the decision to perform computed tomography for acute appendicitis in the ED. Am J Emerg Med. 2007;25(5):489-493. (Retrospective review; 150 patient charts)
  176. Thomson HJ, Jones PF. Active observation in acute abdominal pain. Am J Surg. 1986;152(5):522-525. (Prospective study; 220 patients)
  177. Olshaker JS, Mason JD. The usefulness of serum electrolytes in the evaluation of acute adult gastroenteritis. Ann Emerg Med. 1989;18(3):258-260. (Retrospective; 281 patients)
  178. Hooton TM, Stamm WE. Diagnosis and treatment of uncomplicated urinary tract infection. Infect Dis Clin North Am. 1997;11(3):551-581. (Review)
  179. Katz A. ACEP on the Choose Wisely Campaign. Emergency Medicine News 2014. Accessed May 10, 2019. (Website)
  180. Summers SM, Scruggs W, Menchine MD, et al. A prospective evaluation of emergency department bedside ultrasonography for the detection of acute cholecystitis. Ann Emerg Med. 2010;56(2):114-122. (Prospective observational; 193 patients)
Already purchased this course?
Log in to read.
Purchase a subscription

Price: $449/year

140+ Credits!

Money-back Guarantee
Publication Information
Authors

Stephen Colucciello, MD, FACEP

Peer Reviewed By

Todd Taylor, MD; Nadia Maria Shaukat, MD, RDMS, FACEP

Publication Date

June 1, 2019

CME Expiration Date

July 1, 2022

Pub Med ID: 31124641

Get Permission

Content You Might Be Interested In

Acute Appendicitis in Pediatric Patients: An Evidence-Based Review

Emergency Department Management of Patients With Complications of Bariatric Surgery

Get A Sample Issue Of Emergency Medicine Practice
Enter your email to get your copy today! Plus receive updates on EB Medicine every month.
Please provide a valid email address.