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Background: The POP score was developed as an easy screening tool for predicting obstetrics and gynecological (OBGYN) diseases in the emergency department (ED), and consists of three predictors, each representing one point: past history of OBGYN diseases, no fever or digestive symptoms, and peritoneal irritation signs). However, its external validity has not yet been evaluated. We aimed to perform the external validation of the POP score., Methods: This is a multi-center, retrospective cohort study using ED data of three tertiary care hospitals in Japan between Jan 2017 and October 2020. Young adult women aged 16-49 years with abdominal pain were included in the analysis. The probability of OBGYN diseases was calculated using a logistic regression model of the POP score. Predictions were compared with observations to evaluate the calibration of the model. Further, the diagnostic ability (sensitivity, specificity, and likelihood ratio) of the POP score was evaluated., Results: Of 66,599 ED visits, 1026 young adult women (median age [interquartile range]: 31 [23-41] years) were included for the analysis. The c-statistic was 0.645 [95% confidence interval (CI): 0.603-0.687]. The predicted probabilities of OBGYN diseases was generally well-calibrated to the observations. When the cut-off was set between 2 and 3 points for the ruling in of OBGYN diseases, the positive likelihood ratio was 9.72 [95% CI: 3.33-28.4]. When the cut-off was set between 0 and 1 points for ruling out of OBGYN diseases, negative likelihood ratio was 0.181 [95% CI: 0.059-0.558]., Conclusions: Using ED data of three tertiary care hospitals, we externally validated the POP score for prediction of OBGYN diseases in the ED. The POP score likely has clinical value for screening OBGYN diseases in young adult women with abdominal pain in the ED., Competing Interests: Declaration of Competing Interest TS is the Chief Executive Officer of TXP Medical Co. Ltd. and reports grants from AI Hospital Research grant from Japan Cabinet Office. TG is the Chief Scientific Officer of TXP Medical Co., Ltd. TXP Medical Co. Ltd. Provides the Next Stage ER system., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: The absence of a specific biomarker for acute mesenteric ischemia diagnosis results in a delay in diagnosis and treatment, as well as a high mortality rate. The current research examined whether the proteins adropin, HIF-1α, and apelin may be used to help in the early detection of acute mesenteric ischemia., Materials and Methods: A total of 20 patients with acute mesenteric ischemia, 20 patients with abdominal pain, and 20 healthy controls were included in the study. The levels of adropin, HIF-1, and apelin in the serum were determined using the ELISA method., Results: Adropin concentrations were significantly higher in the acute mesenteric ischemia group than in the abdominal pain and healthy control groups (p < 0.05). HIF-1α levels were considerably greater in patients with acute mesenteric ischemia compared to both the abdominal pain group and the healthy control group (p < 0.05). There was no difference in apelin levels between the acute mesenteric ischemia and abdominal pain groups (p > 0.05). HIF-1α was found to be moderate (AUC: 0.705) and adropin was found to be a weak biomarker (AUC: 0.692) in the ROC analysis for acute mesenteric ischemia., Conclusion: In this study of 20 patients with acute mesenteric ischemia, we found adropin and HIF-1α levels to be increased compared to patients with abdominal pain who did not have acute mesenteric ischemia., Competing Interests: Declaration of Competing Interest Authors state no conflict of interest. This research was supported by the Ataturk University Scientific Research Project (SRP: TTU-2020-8477)., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To evaluate the short-term mortality of adult patients presenting to the emergency department (ED) with altered mental status (AMS) as compared to other common chief complaints., Methods: Observational cohort study of adult patients (age ≥ 40) who presented to an academic ED over a 1-year period with five pre-specified complaints at ED triage: AMS, generalized weakness, chest pain, abdominal pain, and headache. Primary outcomes included 7 and 30-day mortality. Hazard ratios (HR) were calculated with 95% confidence intervals (CI) using Cox proportional hazards models adjusted for age, acuity level, and comorbidities., Results: A total of 9850 ED visits were included for analysis from which 101 (1.0%) and 295 (3.0%) died within 7 and 30 days, respectively. Among 683 AMS visits, the 7-day mortality rate was 3.2%. Mortality was lower for all other chief complaints, including generalized weakness (17/1170, 1.5%), abdominal pain (32/3609, 0.9%), chest pain (26/3548, 0.7%), and headache (4/840, 0.5%). After adjusting for key confounders, patients presenting with AMS had a significantly higher risk of death within 7 days of ED arrival than patients presenting with chest pain (HR 3.72, 95% CI 2.05 to 6.76, p < .001). Similarly, we found that patients presenting with AMS had a significantly higher risk of dying within 30 days compared to patients with chest pain (HR 3.65, 95% CI 2.49 to 5.37, p < .001), and headache (HR 2.09, 95% CI 1.09 to 4.01, p = .026). Differences were not statistically significant for comparisons with abdominal pain and generalized weakness, but confidence intervals were wide., Conclusion: Patients presenting with AMS have worse short-term prognosis than patients presenting to the ED with chest pain or headache. AMS may indicate an underlying brain dysfunction (delirium), which is associated with adverse outcomes and increased mortality., Competing Interests: Declaration of Competing Interest The authors of this manuscript have no conflict of interest to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The emergency department evaluation of patients with abdominal pain is most appropriately directed at identifying acute inflammation, infection, obstruction, or surgical disease. Doing so commonly involves "routine" (and often extensive) diagnostic imaging and laboratory testing. Benign mimics of serious visceral abdominal pain that can be diagnosed by physical exam and confirmed with local anesthetic injections have been identified over the last century. These syndromes derive from painful irritation of the intercostal nerves by a mobile rib below, or from impingement of the cutaneous branches of those same intercostal nerves as they penetrate the abdominal wall. These peripheral neuropathic mimics of visceral abdominal pain continue to go unrecognized and underdiagnosed., Methods: Our purpose is to review the affirmative diagnosis of non-visceral abdominal pain by physical examination., Results: The consequences of failure to identify these conditions are considerable. In the search for a diagnosis that is literally at the provider's fingertips, patients frequently undergo months to years of fruitless and often invasive diagnostic tests, not uncommonly including unsuccessful surgeries., Conclusions: With proper consideration of and appropriate testing for visceral etiologies, a carefully directed physical examination may yield an affirmative diagnosis in a percentage of these common emergency department patients., (Published by Elsevier Inc.)

Objectives: Constipation is a common cause of abdominal pain in children presenting to the emergency department (ED). The objectives of this study were to determine the diagnostic evaluation undertaken for constipation and to assess the association of the evaluation with final ED disposition., Methods: A retrospective chart review of children presenting to the pediatric ED of a quaternary care children's hospital with abdominal pain that received a soap suds enema therapy., Results: A total of 512 children were included, 270 (52.7%) were female, and the median age was 8.0 (IQR: 4.0-11.0). One hundred and thirty eight patients (27%) had a digital rectal exam (DRE), 120 (22.8%) had bloodwork performed, 218 (43%) had urinalysis obtained, 397 (77.5%) had abdominal radiographs, 120 (23.4%) had abdominal ultrasounds, and 18 (3.5%) had computed tomography scans. Children who had a DRE had a younger median age (6.0, IQR: 3.0-9.25 vs. 8.0, IQR: 4.0-12.0; p<0.001) and were significantly less likely to have radiologic imaging (OR=0.50, 95% CI 0.32-0.78; p=0.002), but did not have an increased odds of being discharged home. After adjusting for gender, ethnicity, and significant past medical history those with an abdominal radiograph were less likely to be discharged to home (aOR=0.56, 95% CI 0.31-1.01; p=0.05)., Conclusions: The diagnostic evaluation of children diagnosed with fecal impaction in the ED varied. Abdominal imaging may be avoided if children receive a DRE. When children presenting to the ED with abdominal pain had an abdominal radiograph, they were more likely to be admitted., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Horton's disease is a systemic inflammatory vasculitis, usually found in persons over 50years old. It affects medium and large-sized arteries stemming from the external carotid, especially the superficial temporal arteries. It can affect extracranial large vessels but only rarely the aorta. Diagnosis of aortitis is difficult and its incidence is probably underestimated., Case Presentation: A 68-year-old Caucasian woman consulted in an emergency department for febrile abdominal pain with inflammatory syndrome. Abdomen was soft with right-side flank sensitivity. A contrast-enhanced CT scan showed aortitis from the descending aorta to the iliac arteries without complication. Because of age, clinical presentation and aortitis, Horton disease was suspected. The temporal artery biopsy showed a histological aspect of degenerative endarteritis with intimal thickening and luminal stenosis. High-dose corticosteroid therapy was introduced which improved clinical conditions and resulted in the amendment of the pain., Discussion: In the present case, this patient had Horton's disease, based on 3 criteria of The American College of Rheumatology (age, temporal artery abnormalities and inflammatory syndrome) associated with aortitis. However, aortitis is a rare complication of Horton disease and is a major cause of mortality inasmuch as it can be complicated by aneurysm and dissection. It is unusual to diagnose Horton's disease from aortitis symptoms without complications. The aorta represents the most severe localization of Horton's disease. It should not be ignored in etiological hypotheses regarding febrile abdominal pain in the elderly. Corticosteroids should be started rapidly at high doses and temporal artery biopsy should be planned., (Copyright © 2017. Published by Elsevier Inc.)

Appendicitis is a frequently encountered surgical problem in the Emergency Department (ED). Appendicitis typically results from obstruction of the appendiceal lumen, although trauma has been reported as an infrequent cause of acute appendicitis. Intestinal injury and hollow viscus injury following blunt abdominal trauma are well reported in the literature but traumatic appendicitis is much less common. The pathophysiology is uncertain but likely results from several mechanisms, either in isolation or combination. These include direct compression/crush injury, shearing injury, or from indirect obstruction of the appendiceal lumen by an ileocecal hematoma or traumatic impaction of stool into the appendix. Presentation typically mirrors that of non-traumatic appendicitis with nausea, anorexia, fever, and right lower quadrant abdominal tenderness and/or peritonitis. Evaluation for traumatic appendicitis requires a careful history and physical exam. Imaging with ultrasound or computed tomography is recommended if the history and physical do not reveal an acute surgical indication. Treatment includes intravenous antibiotics and surgical consultation for appendectomy. This case highlights a patient who developed acute appendicitis following blunt trauma to the abdomen sustained during a motor vehicle accident. Appendicitis must be considered as part of the differential diagnosis in any patient who presents to the ED with abdominal pain, including those whose pain begins after sustaining blunt trauma to the abdomen. Because appendicitis following trauma is uncommon, timely diagnosis requires a high index of suspicion., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Gastroparesis associated nausea, vomiting & abdominal pain (GP N/V/AP) are common presentations to the emergency department (ED). Treatment is often limited to antiemetic, prokinetic, opioid, & nonopioid agents. Haloperidol (HP) has been shown to have analgesic & antiemetic properties. We sought to evaluate HP in the ED as an alternative treatment of GP N/V/AP., Methods: Using an electronic medical record, 52 patients who presented to the ED w/GP N/V/AP secondary to diabetes mellitus and were treated w/HP were identified. Patients who received HP were compared to themselves w/the most recent previous encounter in which HP was not administered. ED length of stay (LOS), additional antiemetics/prokinetics administered, hospital LOS, and morphine equivalent doses of analgesia (ME) from each visit were recorded. Descriptive statistics, categorical (Chi Square Test or Z-Test for proportion) and continuous (Wilcoxon Signed Rank Test) comparisons were calculated. Statistical significance was considered for two tail p-values less than 0.05., Results: A statistically significant reduction in ME (Median 6.75 [IQR 7.93] v 10.75 [IQR12]: p=0.001) and reduced admissions for GP (5/52 v 14/52: p=0.02) when HP was administered was observed. There were no statistically significant differences in ED or hospital LOS, and additional antiemetics administered between encounters in which HP was administered and not administered. No complications were identified in patients who received HP., Conclusions: The rate of admission and ME was found to be significantly reduced in patients with GP secondary to diabetes mellitus who received HP. HP may represent an appropriate, effective, and safe alternative to traditional analgesia and antiemetic therapy in the ED management of GP associated N/V/AP., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Binge eating occurs in patients with eating disorders and can result in metabolic complications, leading to gastric rupture or necrosis. However, organ failure as acute renal failure is rarely observed. We report the case of an overeating episode resulting in massive gastric dilatation and acute renal failure with abdominal pressure and bilateral ureteral obstruction. The outcome was favorable with gastric aspiration and fasting., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Abdominal pain is common in children, but expeditious diagnosis of life- or organ-threatening diseases can be challenging. An evidence-based definition of tachycardia in children was established recently, but its diagnostic utility has not yet been studied., Objective: To test the hypothesis that abdominal pain with tachycardia may pose a higher likelihood of life- or organ-threatening diseases in children., Methods: A nested case-control study was conducted in a pediatric emergency department in 2013. Tachycardia was defined as a resting heart rate of more than 3 standard deviations above the average for that age. Life- or organ-threatening diseases were defined as "disorders that might result in permanent morbidity or mortality without appropriate intervention." A triage team recorded vital signs before emergency physicians attended patients. Patients with tachycardia (cases) and without tachycardia (controls) were systematically matched for age, sex, and month of visit. The groups were compared for the presence of life- or organ-threatening diseases., Results: There were 1683 visits for abdominal pain, 1512 of which had vital signs measured at rest. Eighty-three patients experienced tachycardia, while 1429 did not. Fifty-eight cases and 58 controls were matched. Life- or organ-threatening diseases were more common in the case group (19%) than the control group (5%, p=0.043). The relative risk of tachycardia to the presence of the diseases was 3.7 (95% confidence interval 1.2-12.0)., Conclusion: Tachycardia significantly increased the likelihood of life- or organ-threatening diseases. Tachycardia in children with abdominal pain should alert emergency physicians to the possibility of serious illness., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: Evaluate the diagnostic accuracy of the APPY1TM biomarker panel, previously described for use in pediatric patients, for identifying adult ED patients with abdominal pain who are at low risk of acute appendicitis., Methods: This study prospectively enrolled subjects >18years of age presenting to seven U.S. emergency departments with <72hours of abdominal pain suggesting possible acute appendicitis. The APPY1 panel was performed on blood samples drawn from each patient at the time of initial evaluation and results were correlated with the final diagnosis either positive or negative for acute appendicitis., Results: 431 patients were enrolled with 422 completing all aspects of the study. The APPY1 biomarker panel exhibited a sensitivity of 97.5% (95% CI, 91.3-99.3%), a negative predictive value of 98.4% (95% CI, 94.4-99.6%), a negative likelihood ratio of 0.07 (95% CI, 0.02-0.27), with a specificity of 36.5% (95% CI, 31.6-41.8%) for acute appendicitis. The panel correctly identified 125 of 342 (36.6%) patients who did not have appendicitis with 2 (2.5%) false negatives. The CT utilization rate in this population was 72.7% (307/422). Of 307 CT scans, 232 were done for patients who did not have appendicitis and 79 (34%) of these patients were correctly identified as negative with "low risk" biomarker panel results, representing 26% (79/307) of all CT scans performed., Conclusion: This biomarker panel exhibited high sensitivity and negative predictive value for acute appendicitis in this prospective adult cohort, thereby potentially reducing the dependence on CT for the evaluation of possible acute appendicitis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Aim: The aim of this study was to assess the diagnostic accuracy of the biomarker fibrinogen (FB), along with the more traditional markers white blood cell count (WBC), absolute neutrophil count (ANC), and C-reactive protein (CRP), to discriminate appendicitis from nonspecific abdominal pain (NSAP) in children., Methods: We prospectively evaluated all children aged 5 to 15 years admitted for suspected appendicitis at an academic pediatric emergency department during 2 years. Diagnostic accuracy of FB (prothrombin time-derived method), WBC, ANC, and CRP was assessed by the area under the curve (AUC) of the receiver operating characteristic curve., Results: A total of 275 patients were enrolled in the study (143 NSAP, 100 uncomplicated appendicitis, and 32 complicated appendicitis). WBC and ANC had a moderate diagnostic accuracy for appendicitis vs NSAP (WBC: AUC 0.79, ANC: AUC 0.79). FB and CPR had a poor diagnostic accuracy for appendicitis vs NSAP (FB: AUC 0.63, CRP: AUC 0.64) and a good diagnostic accuracy for complicated vs uncomplicated appendicitis (FB: AUC 0.86, CRP: AUC 0.90). All inflammatory markers had a good diagnostic accuracy for complicated appendicitis vs NSAP., Conclusions: WBC and ANC are useful inflammatory markers to discriminate appendicitis from NSAP. FB and CRP are not very useful to discriminate appendicitis from NSAP, but they discriminate properly complicated from uncomplicated appendicitis and NSAP, with a similar diagnostic accuracy. In a child with suspected appendicitis, a plasma FB level (prothrombin time-derived method) >520 mg/dL is associated to an increased likelihood of complicated appendicitis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background and Purpose of the Study: There is growing evidence to suggest the use of urinary 5-hydroxyindoleacetic acid (5-HIAA) test to help with the diagnosis of appendicitis. The aim of our study was to establish whether urinary 5-HIAA could be used as an effective diagnostic test for acute appendicitis., Design and Methods: A prospective double-blinded study was carried out from December 2014 to October 2015. Patients admitted to the emergency surgical ward of a teaching hospital with suspected appendicitis were included in the study. The diagnostic accuracy of the test was measured by receiver operating characteristic curve., Results: Ninety-seven patients were divided into 2 groups: acute appendicitis (n=38) and other diagnosis (n=59). The median value of urinary 5-HIAA was 24.19μmol/L (range, 5.39-138.27) for acute appendicitis vs 18.87μmol/L (range, 2.27-120.59) for other diagnosis group (P=.038). The sensitivity and specificity of urinary 5-HIAA at a cutoff value of 19μmol/L were 71% and 50%, respectively. Receiver operating characteristic analysis showed that the area under curve was 0.64 (confidence interval [CI], 0.513-0.737) for urinary 5-HIAA, which was lower than white blood cell count (0.69; CI, 0.574-0.797), neutrophil count (0.68; CI, 0.565-0.792), and C-reactive protein (0.76; CI, 0.657-0.857). There was no significant difference in the median values of 5-HIAA between different grades of severity of appendicitis (P=.704)., Conclusion: Urinary 5-HIAA is not an ideal test for the diagnosis of acute appendicitis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: The objective was to determine whether need for surgical consult contributes to delayed or reduced analgesic administration in older adults presenting to the emergency department with abdominal pain., Methods: Secondary data analyses from a prospective cohort study consisting of adults ≥65 years in age presenting to the emergency department with a chief concern of abdominal pain from November 1, 2012, through October 31, 2014, were performed. Measurements included administration of analgesics, time to administration, type given, and pain score reduction. Covariates for adjusted analyses included age, sex, race/ethnicity, and Emergency Severity Index., Results: A total of 3522 patients were included, of which 281 (8.7%) received any consult. Consult patients were less likely to receive any analgesic medication (53.0%) compared with nonconsult patients (62.5%) (relative risk = 0.80; 95% confidence interval, 0.70-0.91). However, among those patients receiving analgesic medications, there were no differences in likelihood of receiving an opioid, time to administration, or pain score reduction. When analyzing patients who received a surgical consult (n = 154, 4.4%), these associations were notably stronger. Surgical consult patients had a lower rate of analgesic administration (46.8%) compared with nonconsult patients (62.4%) (relative risk = 0.75; 95% confidence interval, 0.63- 0.89). Again, no differences were found in likelihood of receiving any opioid, time to administration, or pain score reduction., Conclusion: Need for abdominal surgical consult is associated with decreased administration of analgesics in older patients, possibly indicating a continued need to improve management in this setting. This difference, however, did not impact pain score reductions., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: The objective of the study is to prospectively validate the diagnostic accuracy of a biomarker panel consisting of white blood cell, C-reactive protein, and myeloid-related protein 8/14 levels in identifying pediatric patients with abdominal pain who are at low risk for appendicitis., Methods: This prospective observational study enrolled subjects aged 2 to 20 years presenting to 29 US emergency departments with abdominal pain suggesting possible acute appendicitis. Blood samples were analyzed for white blood cell, C-reactive protein, and myeloid-related protein 8/14 levels from which the composite biomarker panel results were calculated, then correlated with the final diagnosis either positive or negative for acute appendicitis., Results: A total of 2201 patients were enrolled, with 1887 completing all aspects of the study. Prevalence of appendicitis in this cohort was 25.3%. The biomarker panel exhibited a sensitivity of 97.1% (95% confidence interval [CI], 95.1%-98.2%), negative predictive value of 97.4% (95% CI, 95.8%-98.5%), negative likelihood ratio of 0.08 (95% CI, 0.05-0.13), with a specificity of 37.9% (95% CI, 35.4%-40.4%) for appendicitis. The panel correctly identified 534 (37.8%) of 1410 patients who did not have appendicitis with 14 false negatives (2.9%). Overall, 23.7% (132/557) of computed tomographic (CT) scans were done for patients with negative biomarker panel results, including 31.2% (131/420) of patients who had CT but did not have appendicitis., Conclusion: This biomarker panel exhibited high sensitivity and negative predictive value for acute appendicitis in this large prospective cohort. This panel may be useful in identifying pediatric patients who are at low risk for appendicitis and might be followed clinically, potentially reducing the dependence on CT in the evaluation for acute appendicitis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Retrograde menstruation is the backward movement of menstrual fluids. The underlying mechanisms remain unknown. The converse current itself is benign, but the result can be abdominal pain caused by peritoneal irritation and, eventually, endometriosis. The case was of a 25-year-old woman with lower abdominal pain accompanied by significant hemoperitoneum. Physical examination and inspection using abdominal ultrasonography and computed tomography failed to reveal a differential diagnosis. Detailed history taking revealed sexual activities during her menstrual period, which allowed for a diagnosis of retrograde menstruation. These findings emphasize the importance of extensive history taking.

Although traditionally regarded as a specific pediatric disease, abdominal migraine may also be observed in adults. Unfortunately, however, this condition is frequently overlooked in the differential diagnosis of abdominal pain in the emergency department (ED). A 30-year-old woman presented to our ED complaining of abdominal pain and vomiting, lasting for 12 hours. The pain was periumbilical, continuous, and not associated with fever or diarrhea. The physical examination and the results of conventional blood tests were normal. The patient was treated with intravenous ketoprofen, metoclopramide, and ranitidine, obtaining a prompt relief of symptoms. She had a history of similar episodes in the last 15 years, with several ED visits, blood test examinations, ultrasonography of the abdomen, and upper gastrointestinal endoscopies. Celiac disease, porphyry, sickle cell disease, and inflammatory bowel disease were all excluded. In July 2012, she became pregnant, and she delivered a healthy baby on April 2013. Until November 2014, she has remained asymptomatic. Based on the clinical characteristics of the abdominal pain episodes, the exclusion of any alternative diagnosis, and the relief of symptoms during and after pregnancy, a final diagnosis of abdominal migraine could be established. A skilled emergency physician should always consider abdominal migraine in the differential diagnosis of patients admitted to the ED with abdominal pain, especially when the attacks are recurrent and no alternative diagnosis can be clearly established.

Background: Pain is common at an emergency department (ED). Two common scales used to rate intensity are the visual analog scale (VAS) and the numeric rating scale (NRS), but it remains unknown which is superior to use in the ED., Aim: The aim of the study is to compare correlations between values on the VAS and the NRS in patients visiting the ED as well as to assess the patients' preference of scale., Methods: Patients who visited the ED due to chest pain, abdominal pain, or an orthopedic condition during autumn 2012 were enrolled onto a cross-sectional study with a consecutive sample. Patients rated their pain using the VAS and NRS scales. They answered an open-ended oral questionnaire regarding their preference and their estimation of the sufficiency of the scales. Data were analyzed with significance test., Results: In all, 217 patients (70% of eligible, 94% of invited) participated. The pain scores generated from the NRS and the VAS were found to strongly correlate (mean difference, 0.41; 95% confidence interval, 0.29-0.53). Most patients found the NRS easier to use than the VAS (61% and 22%, respectively; P < .001). Furthermore, a majority reported that the NRS reflected/described their pain better than the VAS (53% and 26%, respectively; P < .01)., Conclusion: Because values on the NRS correspond well to values on the VAS, values rated with different scales over time might be comparable. Because a majority of the patients found the NRS scale simpler to use and preferred it over the VAS, it might be more appropriate to use in the ED., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: There has been a rise in advanced diagnostic imaging (ADI) use in the emergency department (ED). Increased utilization may contribute to longer length of stay (LOS), but prior reports have not considered improved methods for modeling skewed LOS data., Methods: The 2010 National Hospital Ambulatory Medical Care Survey data were analyzed by 5 common ED chief complaints. Generalized linear model (GLM) was compared to quantile and ordinary least squares (OLS) regression to evaluate the association between ADI and ED LOS. Receipt of computed tomography or magnetic resonance imaging was the primary exposure. Emergency department LOS was the primary outcome., Results: Of the 33,685 ED visits analyzed, 17% involved ADI. The median LOS for patients without ADI was 138 minutes compared to 252 minutes for those who received ADI. Overall, GLM offered the most unbiased estimates, although it provided similar adjusted point estimates to OLS for the marginal change in LOS associated with ADI. The effect of imaging differed by LOS quantile, especially for patients with abdominal pain, fever, and back symptoms., Conclusions: Generalized linear model offered an improved modeling approach compared to OLS and quantile regression. Consideration of such techniques may facilitate a more complete view of the effect of ADI on ED LOS., (Published by Elsevier Inc.)

Abdominal apoplexy was reported by Barber in 1909, and the occurrence rate of the apoplexy is known to be quite rare, but the mortality is high if untreated. We report an unusual case of abdominal apoplexy due to spontaneous rupture of gastric artery. A male patient in his fifth decade with recently diagnosed liver cirrhosis history arrived to the emergency department with severe abdominal pain, which led to abdominal computer tomography indicating spontaneous rupture of gastric artery. Celiac angiogram and embolization were conducted, and exploratory laparotomy was followed. The outcome of the patient was poor, and he died on the second day of admission. As in our case, the mortality can be high, so prompt restoration of circulation volume and early diagnosis should be made in similar cases.

Objectives: To identify a biomarker panel with sufficient sensitivity and negative predictive value to identify children with abdominal pain at low risk for acute appendicitis in order to avoid unnecessary imaging., Methods: We prospectively enrolled 503 subjects aged two to 20 years with <72 hours of abdominal pain consistent with appendicitis. Blood samples from each patient were analyzed for CBC, differential, and 5 candidate proteins. Biomarker values were evaluated using principal component, recursive partitioning and logistic regression to select the combination that best discriminated between those subjects with and without disease., Results: The prevalence of acute appendicitis was 28.6%. A mathematical combination of three inflammation-related markers in a panel comprised of white blood cell count (WBC), C-reactive protein (CRP), and myeloid-related protein 8/14 complex (MRP 8/14) provided the best discrimination. This panel exhibited a sensitivity of 96.5% (95% CI, 92-99%), a negative predictive value of 96.9% (95% CI, 93-99%), a negative likelihood ratio of 0.08 (95% CI, 0.03- 0.19), and a specificity of 43.2% (95% CI, 38-48%) for acute appendicitis. Sixty of 185 CT scans (32.4%) were done for patients with negative biomarker panel results which, if deferred, would have reduced CT utilization at initial presentation by one third at the cost of missing five of 144 (3.5%) patients with appendicitis., Conclusion: This panel may be useful in identifying pediatric patients with signs and symptoms suggestive of acute appendicitis who are at low risk and can be followed clinically, potentially sparing them exposure to the ionizing radiation of CT., (© 2013.)

Ruptured celiac artery aneurysm is a rare cause for epigastric pain and is usually detected incidentally. Atypical presentation with postemetic epigastralgia and pleural effusion usually leads physicians to make the diagnosis of Boerhaave syndrome. Herein, we report a 32-year-old woman who was diagnosed with Boerhaave syndrome initially after presenting with acute postemetic epigastralgia and predominant left side pleural effusion. Diagnostic left thoracentesis yielded bloody fluid with similar amylase level to serum. The chest computed tomographic scan showed no evidence of esophageal rupture. However, a ruptured celiac artery aneurysm with retroperitoneal hematoma extending to the posterior mediastinum and bilateral pleural space was found incidentally. Although ruptured celiac artery aneurysm is an uncommon cause for postemetic epigastralgia, acute vascular events such as the previously stated cause should be the first impression rather than Boerhaave syndrome if the patient also presents with isolated pleural effusion containing unelevated amylase.

Colonoscopy is a common procedure used for screening, diagnosis, and treatment of gastrointestinal disease. Life-threatening complications are uncommon (28/10 000 procedures) but include perforation, hemorrhage, diverticulitis, and postpolypectomy syndrome. Although previously reported, the association between appendicitis and colonoscopy is not widely known. This case report highlights the underlying pathophysiology, clinical presentation, and diagnosis of postcolonoscopy appendicitis. A 52-year-old man presented to the emergency department with abdominal pain 8 hours after an uncomplicated routine screening colonoscopy. He initially reported mild generalized abdominal discomfort which 3 hours after the procedure intensified and localized to the periumbilical region. Computed tomography of the abdomen with oral and intravenous contrast revealed appendicitis as the cause of his abdominal pain. He underwent laparoscopic appendectomy and recovered uneventfully. Colonoscopy is a common procedure that rarely has life-threatening complications. Although establishing causality is difficult, there is an association between colonoscopy and appendicitis, which may be underreported with literature-based estimates as high as 3.8 appendicitis cases per 10 000 procedures. Timely diagnosis of postcolonoscopy appendicitis may prove challenging given limited knowledge of this association between colonoscopy and appendicitis and similarity of presentation with other more well-known complications. This case report demonstrates that a recent history of colonoscopy should not preclude consideration of a traditionally broad differential diagnosis for abdominal pain, including appendicitis.

Study Objective: The aims of the study were to prospectively evaluate the Alvarado and Samuel (pediatric appendicitis score [PAS]) appendicitis scoring systems in children and determine performance based on sex., Methods: Children with abdominal pain concerning for appendicitis were recruited. Nine parameters evaluated by the scores were documented before imaging/surgery consultation. Test characteristics were calculated on all patients and by sex., Results: Two hundred eighty-seven patients enrolled; median age was 9.8 years; and 155 (54%) were diagnosed with pathologic examination-confirmed appendicitis. Patients with appendicitis had mean PAS of 7.6, and those without had mean of 5.6 (P < .001). Patients with appendicitis had a mean Alvarado of 7.2, and those without had a mean of 5.2 (P < .001). In appendicitis patients, PAS cutoff of 6 or greater would give 137 correct diagnoses; sensitivity, 88%; specificity, 50%; and positive predictive value (PPV), 67%. An Alvarado cutoff of 7 or greater would give 118 correct diagnoses; sensitivity, 76%; specificity, 72%; and PPV, 76%. Both performed better in males than females., Conclusion: Regardless of sex, neither PAS nor Alvarado has adequate predictive values for sole use to diagnose appendicitis., (Copyright © 2011 Elsevier Inc. All rights reserved.)

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., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: This study aimed to evaluate the utility of C-reactive protein (CRP), procalcitonin (PCT), D-lactate, and white blood cell (WBC) count as an aid to distinguish appendicitis from other diagnoses., Methods: This prospective, observational study was conducted at an urban tertiary academic pediatric emergency department (ED). Subjects aged 1 to 18 years presenting with abdominal pain suspicious for acute appendicitis were enrolled. Data included history, physical examination, laboratory data (complete blood count, CRP, D-lactate, PCT [semiquantitative]), laboratory results, x-rays, surgical consultation notes, histopathology, and admission data. Stepwise logistic regression analysis was performed to identify independent risk factors., Results: Two hundred nine subjects (59% male, 41% female) were enrolled over 6 months. One hundred fifteen subjects were histologically diagnosed with appendicitis; 94 subjects did not have appendicitis and were used as controls. Mean values of WBC, CRP, PCT, and absolute neutrophil count in subjects with definitive appendicitis were significantly higher than in subjects with no definitive appendicitis. D-Lactate levels were noncorrelative. Significant independent risk factors identified for definitive appendicitis included WBC count more than 12 cells × 1000/mm(3) (adjusted odds ratio [AOR], 6.54), CRP level greater than 3 mg/dL (AOR, 3.44), presence of hopping pain (AOR, 2.69), and presence of pain with walking (AOR, 2.56). Odds ratio for definitive appendicitis and its 95% confidence interval was found to be 7.75 for subjects with both WBC more than 12 cells × 1000/mm(3) and CRP greater than 3 mg/dL., Conclusions: C-reactive protein with WBC is useful in distinguishing appendicitis from other diagnoses in pediatric subjects presenting to the ED. White blood cell count greater than >12 cells × 1000/mm(3) and CRP greater than 3 mg/dL increases the likelihood of appendicitis. D-Lactate is not a useful laboratory adjunct., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Objective: The digital rectal examination (DRE) is commonly recommended in the evaluation of individuals with undifferentiated abdominal pain (UAP) despite negligible evidence. We aimed to determine its clinical utility., Methods: We prospectively enrolled 893 UAP subjects in an observational, convenience sample study at our urban, academic emergency department. Exclusion criteria were age younger than 18 years, vaginal or rectal bleeding, pregnancy, and primarily flank pain or vaginal complaint. Data forms were completed before laboratory testing, imaging, or other diagnostic maneuvers; and structured telephone and chart follow-up was performed. Physicians were asked to document DRE findings contemporaneously as well as their perception of the DRE's diagnostic impact. Final diagnosis in each case was compared with DRE result., Results: Five hundred thirty-eight of 893 (60%) subjects had a DRE performed at the discretion of the examining physician. The DRE was classified as "not useful" in 494 of 538 (92%). In the remaining 44 subjects, physicians reported having their differential diagnosis influenced by the DRE. Seventeen of 538 (3%; 0.95 confidence interval, 1.9%-5.0%) were diagnostically helped, and 12 of 538 (2%; 0.95 confidence interval, 1.3%-3.9%) were diagnostically harmed. Eleven of 538 (2%) were lost to final follow-up. Sensitivity analysis indicates that unless all 11 had diagnostically helpful DREs, the DRE was statistically as likely to be harmful as helpful., Conclusion: Differential diagnosis was unaffected in most subjects undergoing DRE, and it appears as likely to be harmful as helpful in predicting final diagnosis. Given the discomfort and minimal predictive value of the DRE in this setting, highly selective use seems reasonable.

Congenital small bowel malrotation is an uncommon cause of ischemic bowel. There are only a few case reports highlighting this condition in gravid patients. We report a 33-year-old primigravida at 27 weeks who presented to the emergency department with diffuse abdominal pain. Although initially stable, she experienced a rapid calamitous decline. On laparatomy she was diagnosed with congenital small bowel malrotation. Intraabdominal catastrophes must always be considered as a possible etiology of nonobstetrical abdominal pain in pregnant women.

Objective: We sought to determine the impact of 3 validated scales of physician risk behavior on imaging use in emergency department (ED) patients with abdominal pain., Methods: We performed a prospective cohort study of nonpregnant ED patients with acute, nontraumatic abdominal pain and then administered 3 instruments (a risk-taking subscale of the Jackson Personality Index, the stress from uncertainty scale, and a malpractice fear scale) to attending physicians who had evaluated these patients and made decisions regarding abdominal imaging. Outcomes were the use of abdominal pelvic computed tomography (CT) and any imaging use (CT, ultrasound, or abdominal plain film). Hierarchical logistic regression was used to determine the effect of risk scales on abdominal imaging use., Results: Of 838 patients with acute abdominal pain, 487 (58%) received imaging studies; 395 (47%) received an CT, 111 (13%) ultrasound, and 122 (15%) an abdominal plain film. Both CT and any imaging use were lower among the physicians who were least risk-averse as measured by the risk-taking subscale (highest quartiles vs 3 lower quartiles). In adjusted analysis, probability of CT in the least risk-averse group was 35% (95% confidence interval [CI], 28%-44%) compared to 50% (95% CI, 45%-54%) among more risk-averse physicians, and the probability of any imaging was 53% (95% CI, 44%-61%) compared to 64% (95% CI, 61%-68%). Malpractice fear and stress due to uncertainty were not predictive of imaging use., Conclusion: Self-reported physician risk-taking behavior predicts the use of imaging in ED patients with abdominal pain, whereas malpractice fear and stress due to uncertainty do not.

A 50-year-old woman presented to our emergency department complaining of recurrent epigastric stabbing pain on eating of 1 month duration. She had a history of morbid obesity treated 13 years before with laparoscopic vertical banded gastroplasty (VBG). Diagnosis was made by radiology, after upper gastrointestinal series and abdominal unenhanced computed tomography. These demonstrated intragastric band migration, with outlet stenosis of narrowed stomach. Vertical banded gastroplasty is a miniinvasive approach that gives the benefits of shorter hospital stay, less postoperative pain, and quicker functional recovery. However, many complications are known and require recognition to be appropriately treated. In our case, the history and clinical presentation led to a high suspicion of intraabdominal pathology due to postoperative complication. Radiologic upper gastrointestinal investigation and computed tomography findings were then decisive to detect the intragastric band migration.

Introduction: We hypothesized that emergency physician-performed endovaginal ultrasound (EVUS) would change diagnostic decision making in nonpregnant women with right lower quadrant (RLQ) pain., Methods: A prospective cohort of female patients was enrolled at an urban emergency department (ED). Inclusion criteria were RLQ pain, hemodynamic stability, and a strong suspicion for appendicitis or right adnexal pathology. Treating physicians were queried regarding pre- and post-ED EVUS probability of disease, differential diagnoses, consultation, and management. Positive findings included large cysts or multitissue densities, tubal dilation, uterine enlargement/mass, and extensive peritoneal fluid., Results: With a positive ED EVUS, mean physician probability increased for gynecologic (24%) and decreased for both surgical (14%) and medical (20%) disease. With a negative ED EVUS, mean physician probability increased for surgical disease (5.3%) and decreased for gynecologic disease (18.6%)., Conclusion: Emergency department EVUS changes physician diagnostic decision making in nonpregnant women with undifferentiated RLQ pain.

Objective: The purpose of this study was to identify a clinical guideline for the evaluation of nonspecific abdominal pain (NSAP) using history, physical examination, laboratory analysis, acute abdominal series (AAS) radiographs, and nonenhanced helical computed tomography (NHCT) clinical predictor variables (CPVs)., Setting: The setting of this study was at an urban emergency department (ED) with 70,000 yearly visits., Methods: This is an institutional review board-approved, prospective, observational study. The primary outcome variable was urgent intervention (UI), defined as a diagnosis requiring surgical or medical treatment to prevent death or major morbidity. Subjects underwent prompted history, physical, laboratory studies, AAS, and NHCT and were followed up to 6 months for ultimate diagnosis and outcome. CPVs were subjected to classification and regression tree analysis., Results: One hundred sixty-five subjects were analyzed. Thirteen percent of subjects required UI within 24 hours of presentation; an additional 34% underwent elective interventions that mitigated morbidity or mortality. Four guideline models were generated. Model 1 consisted of history and physical, with a sensitivity of 25%, a specificity of 92%, a positive likelihood ratio of 3.17, and a negative likelihood ratio of 0.81. Model 2 consisted of model 1 with laboratory, with a sensitivity of 39%, a specificity of 88%, a positive likelihood ratio of 3.25, and a negative likelihood ratio of 0.69. Model 3 consisted of model 2 with AAS, with a sensitivity of 56%, a specificity of 81%, a positive likelihood ratio of 2.94, and a negative likelihood ratio of 0.54. Model 4 comprised all inputs, including NHCT, with a sensitivity of 92%, a specificity of 90%, a positive likelihood ratio of 9.2, and a negative likelihood ratio of 0.089. NHCT was the single most accurate CPV for UI., Conclusions: No clinical guideline was identified exclusive of NHCT that possessed adequate sensitivity for exclusion of UI. NHCT is a rational choice for decision support in the evaluation of NSAP and is likely the single most useful diagnostic adjunct available to augment the clinical evaluation.

Objective: The physical examination of the abdomen is crucial to emergency department (ED) management of patients with abdominal pain. We sought to determine the interrater variation between attending and resident physicians in detecting abdominal exam findings., Methods: Research enrollers surveyed attending and resident physicians on abdominal exam findings in the ED in patients with abdominal pain. Strength of agreement was calculated using the kappa statistic., Results: A convenience sample of 122 surveys was completed. Calculated kappa results are in parentheses. There was almost perfect agreement on the presence of masses and substantial agreement on the need for imaging studies. There was moderate agreement on guarding, distension, tenderness, and need for laboratory tests and surgical consultation. For 88 (72%) patients with tenderness, substantial agreement was calculated for epigastric tenderness, moderate agreement on right upper quadrant, supraumbilical, suprapubic, left lower quadrant, right lower quadrant tenderness, and fair agreement on left upper quadrant tenderness. Sixty-one (50%) patients received pain medicine in the ED. Among those, there was fair agreement on a presence of a surgical abdomen. Upper level resident physicians noted a higher level of agreement with the attending physician for tenderness than junior resident physicians., Conclusions: There was moderate agreement between resident and attending physicians for most of the findings in patients with abdominal pain. Recognition that selected findings are more variable than others should encourage careful confirmation of resident physicians' assessments in teaching settings.

The objectives of this study were to determine the prevalence of use of abdominal computed tomography (CT) in older ED patients with acute nontraumatic abdominal pain, describe the most common diagnostic CT findings, and determine the proportion of diagnostic CT results. This was a prospective, observational, multicenter study of 337 patients 60 years or older. History was obtained prospectively; charts were reviewed for radiographic findings, dispositions, diagnoses, and clinical course, and patients were followed up at 2 weeks for additional information. The prevalence of use of abdominal CT was 37%. The most common diagnostic findings were diverticulitis (18%), bowel obstruction (18%), nephrolithiasis (10%), and gallbladder disease (10%). Eight percent of patients had findings suggestive of neoplasm. Overall, 57% of CT results were diagnostic (95% confidence interval [CI], 49%-66%), 75% (95% CI, 63%-84%) for patients requiring acute medical or surgical intervention, and 85% (95% CI, 62%-97%) for patients requiring acute surgical intervention. CT use is highly prevalent in older ED patients with acute abdominal pain. CT results are often diagnostic, especially for patients with emergent conditions.

The objective of the study was to assess the validity and reliability of the visual analog scale (VAS) in the measurement of acute abdominal pain, and to identify the minimum clinically significant difference in VAS scores among patients with acute abdominal pain. The study was undertaken in preparation for a randomized clinical trial of opioid use in acute abdominal pain. A prospective, observational cohort study of a convenience sample of patients presenting to 2 urban EDs with the chief complaint of acute abdominal pain was conducted. At time 0 and 1 minute later each subject indicated pain severity on a 100mm VAS. This was repeated every 30 minutes for 2 hours. Patients were also asked to contrast their current pain severity with their pain in the preceding 30 minutes using one of 5 graded verbal descriptors: "much less pain," "little less pain," "the same pain," "little more pain," and "much more pain." Validity was assessed by performing an analysis of variance for linear trend on the association between the 5 categorical pain descriptors and change in VAS scores. Reliability was assessed using the intra-class correlation coefficient (ICC) between VAS scores taken 1 minute apart, supplemented by a Bland-Altman analysis. The minimum clinically significant difference in pain was defined as the mean difference between sequential VAS scores obtained 30 minutes apart when the patient noted a "little less" or "little more" pain. Differences in VAS scores increased linearly as pain descriptors escalated from "much less" to "much more" pain (P <.001). Reliability was high, ICC = 0.99 [95%CI 0.989 to 0.992] for 0 and 1 minute VAS scores. The minimum clinically significant difference in acute abdominal pain was 16 mm (95% CI 13, 18 mm). VAS measures of acute abdominal pain are valid and reliable. The 95% CI surrounding the minimum clinically significant difference of approximately 16 mm overlaps with the 95% CI of minimum clinically significant difference of approximately 13 mm reported previously in traumatic and other types of acute pain. We conclude that the VAS is a methodologically sound instrument for quantitative assessment of acute abdominal pain and for detecting clinically important changes in such pain., (Copyright 2002, Elsevier Science (USA). All rights reserved.))

Reports citing excellent sensitivity, specificity, and predictive accuracy of focused appendiceal computed tomography (CT) and showing an overall reduction in resource use and nontherapeutic laparotomies have led to increasing use of that imaging modality. Diagnostic algorithms have begun to incorporate appendiceal CT for patients presenting to the emergency department with right lower quadrant pain. We present a series of 4 cases in which use of appendiceal CT ultimately led to increased cost, resource use, and complexity in patient care. The results of these cases support an argument against unbridled use of appendiceal CT scanning and reinforce the need for clinical evaluation by the operating surgeon before routine performance of appendiceal CT scan.

Whereas controversy surrounds emergency department (ED) analgesia administration to patients with undifferentiated abdominal pain, few studies have addressed the level of patient-physician agreement on abdominal pain severity and need for opioid analgesia. This prospective study was undertaken to assess concordance between emergency physicians and patients on abdominal pain severity. Study subjects were a convenience sample of 30 adults seen in an urban university-affiliated tertiary care ED (annual census 65,000) who had undifferentiated abdominal pain meeting an initial severity threshold of 5 on a 10 cm visual analog scale (VAS) marked by the patient. Patients' and physicians' VAS scores, obtained in blinded fashion at presentation (t0) and at one (t1) and two (t2) hours into the ED stay, were compared with t test (VAS scores) and sign-rank (percent change in VAS scores) analyses. In addition, patients and physicians were asked at each assessment time, in blinded fashion, "Is the pain severe enough to warrant morphine?" The kappa statistic was used to characterize the degree of agreement between physician and patient assessments as to whether opioids were indicated. At t0, t1, and t2, patients' mean VAS scores (7.5, 6.7, and 5.1) were significantly (P < .05) higher than the corresponding physicians' VAS scores (5.3, 4.7, and 3.9). Though VAS scores for physicians started lower than those of patients, the percentage changes in scores from one assessment to the next were similar by Wilcoxon sign-rank testing (P > .50 for time intervals t0 - t1 and t1 - t2). Overall, patients and physicians agreed on the question of whether pain was sufficient to warrant opioids in 71 of 90 (78.9%) assessments; the corresponding kappa statistic of .57 indicated moderate agreement (P < .0001). These results, indicating that patients and physicians usually agree on whether opioids are warranted for abdominal pain, have important implications for further research on ED analgesia in this population.

The authors report the case of a 6-year-old boy with a spinal cord arteriovenous malformation (AVM) who presented with acute flank pain and a delayed onset of paraplegia. An early diagnosis of a spinal cord AVM was made difficult by the absence of neurological findings on initial evaluation. Included is a description of his clinical course, and the presentation of spinal AVMs to the emergency physician is discussed.

While most conscious patients with severe intraabdominal injuries (IAI) will usually present with either abdominal pain or tenderness, there is a small group of awake and alert patients in whom the physical examination will be falsely negative because of the presence of associated extraabdominal ("distracting") injuries. We sought to define the types of extraabdominal injuries that could lead to a false negative physical examination for potentially severe IAI in adult victims of blunt trauma. This study was prospectively performed on consecutive blunt trauma patients over a 14-month period in our level I trauma center. Inclusion criteria were as follows: (1) Glasgow Coma Scale score of 15; (2) age 18 years or older; and (3) computed tomography (CT) of the abdomen or diagnostic peritoneal lavage (DPL) performed regardless of initial physical examination findings. Patients were questioned specifically about the presence of abdominal pain and the initial abdominal examination was documented in addition to other extraabdominal injuries. Abdominal injuries were considered to be present based upon either abdominal CT findings or a positive DPL. Patients with and without abdominal pain or tenderness were compared for the presence of IAI. A total of 350 patients were enrolled. There were 142 patients with neither abdominal pain nor tenderness (group 1) and 208 patients with either or both (group 2). Ten of the 142 patients (7.0%) in group 1 had IAI compared with 44 of the 208 patients (21.2%) in group 2 (P = .0003). Presence of pain and/or tenderness had a sensitivity of 82%, a specificity of 45%, a positive predictive value of 21%, and negative predictive value of 93%. All 10 patients in group 1, and 36 of the 44 group 2 patients, had associated extraabdominal injuries. Although the presence of abdominal pain or tenderness was associated with a significantly higher incidence of IAI, the lack of these findings did not preclude IAI.

The purpose of this study was to determine the impact on patient care and the cost effectiveness of testing for chlamydial infection in the emergency department. All patients tested for chlamydial infection in three emergency departments between October 1, 1993 and January 31, 1994 were retrospectively reviewed for charges and adequacy of therapy. In one hospital, the effectiveness of a call-back system to enhance proper therapy of inadequately treated patients was evaluated. Of 2,416 test results, 249 were positive, and 197 of these charts were available for review. All 16 male patients were treated appropriately at the initial visit; 105 of 181 female patients were inadequately treated at the initial visit. The charge to identify each patient inadequately treated was $981.22 ($103,000 for 105). Of the 28 inadequately treated patients receiving a follow-up call, 20 sought treatment. The high cost of testing patients cannot be justified without an adequate surveillance system to enhance proper follow-up treatment.

Henoch-Schoenlein purpura (HSP) is a common vasculitic disorder of childhood. Patients with this disorder typically present with palpable purpura or petechia associated with one or more of the following signs and symptoms: abdominal pain, arthritis/arthralgias, and nephritis. The diagnosis may be difficult to make, however, when a patient presents with isolated symptoms such as abdominal pain without the typical rash. A high index of suspicion must be maintained to diagnose HSP in this setting and to avoid unnecessary interventions. This report describes two unusual patients with the presenting complaint of abdominal pain who had delayed onset of the purpuric rash, making the diagnosis of HSP difficult.

Recent studies have suggested that the results of complete blood counts (CBCs) are neither sensitive nor specific in diagnosing abdominal pain, but no study has attempted to determine whether CBC results actually influence the management of ED patients. This study attempted to determine whether CBC results in women with lower abdominal pain affect ED disposition or diagnosis. One hundred women between the ages of 15 and 45 with lower abdominal pain presenting to a community hospital ED with an annual census of 45,000 were enrolled in this prospective study. Before review of the CBC results but after review of all other studies, the ED physician recorded a presumptive diagnosis and indicated whether consultation and/or admission were warranted. After the results of the CBC were reviewed, these factors were reassessed. Patient management or ED diagnosis was affected in two cases (2%; 95% confidence interval 0% to 7%), one resulting in appropriate discharge and one resulting in unnecessary admission. It was concluded that in young women with abdominal pain CBC results rarely affect clinical decision-making.

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.