Diagnosis Of Non-specific Abdominal Pain Research Articles

Validation of the Appendicitis Inflammatory Response (AIR) score during pregnancy: A nested case-control study.

Appendicitis poses diagnostic challenges. A correct diagnosis is important during pregnancy to avoid unnecessary surgery on the one hand and delayed surgery on the other hand, as both may negatively affect pregnancy outcomes. Clinical scores for risk-stratified management of suspected appendicitis are well established in adults but have not been validated during pregnancy. This nested case-control study evaluated the diagnostic accuracy of the Appendicitis Inflammatory Response (AIR) score and imaging during pregnancy. By cross-linking national Swedish health registries from a defined geographical area, we identified a cohort of 154 women who underwent appendectomy for suspected appendicitis during pregnancy and a matched cohort of 232 pregnant women admitted for acute abdominal pain and suspected appendicitis but with a discharge diagnosis of nonspecific abdominal pain (NSAP). All variables were extracted from medical records. The diagnostic value of AIR score and imaging was estimated for patients with a final diagnosis of appendicitis compared with patients with negative appendectomy and NSAP patients. The final diagnoses for the operated patients were uncomplicated and complicated appendicitis in 49.4% and 26.6%, respectively, and negative appendectomy in 24.0%. Nearly half of all the patients underwent diagnostic imaging (41%), mainly by ultrasonography. The sensitivity and specificity of diagnostic imaging were 44.9% (95% CI 32.9%-57.4%) and 42.2% (95% CI 31.9%-53.1%), respectively. The area under the receiver operating characteristic curve of AIR score was 0.88 (95% CI 0.84-0.92) for all appendicitis and 0.90 (95% CI 0.84-0.95) for complicated appendicitis. The sensitivity for complicated appendicitis was 100% at a score of ≥4. The specificity for all appendicitis was 97% at a score of ≥9. The results of this study suggest that the AIR score may be a suitable diagnostic tool for risk stratification of pregnant women with abdominal pain and suspected appendicitis but further validation among pregnant women is needed.

Impact of emergency physician performed ultrasound in the evaluation of adult patients with acute abdominal pain: a prospective randomized bicentric trial

BackgroundAbdominal pain is common in patients visiting the emergency department (ED). The aim of this study was to assess the diagnostic contribution of point-of-care ultrasound (POCUS) in patients presenting to the ED with acute abdominal pain.MethodsWe designed an interventional randomized, controlled, open label, parallel-group, trial in two French EDs. We included adult patients presenting to the ED with acute abdominal pain. Exclusion criteria were a documented end-of-life, an immediate need of life-support therapy and pregnant or breast-feeding women. Patients were randomized in the experimental group (i.e., workup including POCUS) or control group (usual care). The primary objective of the study was to assess the added value of POCUS on diagnostic pathway in the ED, according to the diagnostic established a posteriori by an adjudication committee. The primary endpoint was the proportion of exact preliminary diagnosis between the 2 groups. The preliminary diagnosis made after clinical examination and biological results with POCUS (intervention arm) or without POCUS (usual care) was considered exact if it was similar to the adjudication committee diagnosis.ResultsBetween June 2021 11th and June 2022 23th, 256 patients were randomized, but five were not included in the primary analysis, leaving 125 patients in the POCUS group and 126 patients in the usual care group (130 women and 121 men, median [Q1-Q3] age: 42 [30;57]). There was no difference for exact diagnosis between the two groups (POCUS 70/125, 56% versus control 78/126 (62%), RD 1.23 [95% CI 0.74–2.04]). There was no difference in the accuracy for the diagnosis of non-specific abdominal pain nor number of biological or radiological exams. Diagnostic delays and length of stay in the ED were also similar.ConclusionsIn this trial, systematic POCUS did not improve the rate of diagnostic accuracy in unselected patients presenting to the ED with acute abdominal pain. However, as it was a safe procedure, further research should focus on patients with suspected etiologies where POCUS is particularly useful.Trial registration: This trial was registered on ClinicalTrials.gov on 2022/07/20 (https://clinicaltrials.gov/study/NCT04912206?id=NCT04912206&rank=1) (NCT04912206).

A retrospective study of patients complaining of nontraumatic acute abdominal pain, admitted in the emergency department of an urban hospital in China

Abstract Background Nontraumatic acute abdominal pain (AAP) accounts for a large proportion of emergency department (ED) admissions. This study aimed to explore the underlying correlations among basic information, imaging examinations, and diagnoses. Methods A total of 7453 patients complaining of AAP, admitted to the ED of Zhongnan Hospital of Wuhan University, were enrolled in this retrospective study from January 1 to December 30, 2019. We collected the following information from the patients: sex, age, date of visit, pain location, nature of pain, level of severity, imaging (computed tomography, x-ray, and ultrasound), diagnosis, and outcomes (release from the hospital, transfer to another hospital, transfer to another department, observation room, hospitalization, or death). Results According to this study, AAP was more common in female than male. A total of 82.11% patients of AAP were in level 3 of severity, while 0.19% patients were in level 1. A total of 77.20% of the patients had undergone imaging. Swelling pain and colic are the 2 most common types of AAP. Nonspecific abdominal pain (NSAP) is the most common diagnosis. In the diagnosis of NSAP and gastroenteritis, female patients were more prevalent than male patients, but for renal colic, male patients were 3 times as many as female patients. Nonspecific abdominal pain, biliary colic, and cholecystitis are the 3 leading causes in patients 65 years or older. Nonspecific abdominal pain, renal colic, and gastroenteritis are the 3 leading causes of AAP in patients younger than 65 years. Conclusion With the help of imaging, clinicians can specify a diagnosis and perform corresponding treatment in most cases. However, making a precise diagnosis of AAP within a short period is still challenging. Further research should be conducted to seek safer and more effective techniques to streamline clinicians’ work.

78 A Lockdown Dilemma; Ingestion of Magnetic Beads Presenting as Right Iliac Fossa Pain and Sub-Acute Small Bowel Obstruction

Abstract A 13-year-old girl presented with a three-day history of migratory right iliac fossa pain. Observations and inflammatory markers were normal, and an ultrasound scan was inconclusive. A provisional diagnosis of non-specific abdominal pain or early appendicitis was made, and she was discharged with safety netting advice. She represented six days later with ongoing abdominal pain now associated with multiple episodes of vomiting; hence, the decision was made to proceed to diagnostic laparoscopy rather than a magnetic resonance scan for further assessment as recommended by the radiology department. Intra-operative findings revealed 200mls of serous fluid in the pelvis, normal-looking appendix, dilated stomach, and a tangle of small bowel loops. Blunt and careful dissection revealed fistulous tracts that magnetized the laparoscopic instruments. A mini-laparotomy was performed with the extraction of fourteen magnetic beads and the repair of nine enterotomies. Foreign body ingestion is a known cause of abdominal pain, which in some cases might mimic or even be the cause of acute appendicitis. This case highlights the importance of careful history taking in children presenting with acute abdominal pain of doubtful aetiology.

A Diagnostic Score (DS) in the Difficult Diagnosis of Non-specific Abdominal Pain (NSAP).

The diagnostic scores (DSs) for patients with non-specific abdominal pain (NSAP) have been rarely evaluated. In the NSAP study group there were 614 patients (268 females and 346 males) versus 719 patients in the non-NSAP group including 368 females and 351 males. The clinical symptoms (n=22), signs and tests (n=14) and laboratory analyses (n=3) were recorded in each patient. Meta-analytical techniques were used to detect the summary sensitivity (Se) and specificity (Sp) estimates for each data set (symptoms, signs and tests as well as DS models). In receiver operating characteristic (ROC) analysis, the area under curve (AUC) values for i) symptoms ii) signs and tests and iii) DS were as following: i) AUC=0.542 (95% CI=0.512-0.572); ii) AUC=0.625 (95% CI=0.550-0.700), and iii) AUC=0.874 (95% CI=0.850-0.898). The differences between these AUC values are as following: between i and ii, p=0.097; between i and iii, p<0.0001 and between ii and iii, p<0.0001. This is the first study to provide evidence that DS may help in the difficult diagnosis of NSAP.

Clinical outcome after surgical resection of small bowel cancer

Background: Small bowel cancer (SBC) is rare, however there is recent trend toward increased incidence.Methods: Retrospective evaluation of the clinical presentation, diagnosis, management and clinical outcome of adult patients with primary SBC who were admitted at Sohag University Hospital during 2014-2019.Results: Twenty-one patients with SBC were enrolled (14 males and 7 females) with median age of 56 (range 32-83) years. Small bowel mass was identified preoperatively in 13 patients (62%). Thirteen patients (62%) presented with abdominal emergencies after failure of prompt diagnosis of non-specific abdominal pain of variable durations (median: 4, range: 2-11 weeks). Apart from duodenal tumors, histopathological diagnosis for jejunal and ileal tumors was not achieved preoperatively. Tumor types were gastrointestinal stromal tumors, GISTs (9, 43%), lymphoma (8, 38%) and adenocarcinoma (4, 19%). Patients with jejunal and ileal masses were managed by resection and primary anastomosis. Duodenal tumors required local resection in 2 and pancreatico-duodenectomy in 4 patients. Increased risk of aggressive behavior in GISTs, advanced stage and incomplete resection in lymphomas and adenocarcinomas were associated with higher recurrence rates and diminished survival. Follow-up ranged from 5 to 48 months, with survival rate of 76% (16 patients alive).Conclusions: The diagnosis of SBC is difficult and delayed. Appropriate surgical management, even during emergency, could achieve prolonged survival.

The rate of short-term revisits after diagnosis of non-specific abdominal pain is similar for surgeons and emergency physicians - results from a single tertiary hospital emergency department

BackgroundAcute abdominal pain can be a diagnostic challenge even for experienced surgeons. Delayed diagnosis can lead to higher morbidity, mortality and increased costs. While readmission rate has been used to evaluate quality of surgical care, studies addressing the issue in emergency departments (ED) are rare. The role of emergency physicians in the care of patients with abdominal pain is increasing in many European countries, including Finland. It is not known whether this has an effect on the number of readmissions.Here we evaluate whether the increasing role of emergency physicians in examining patients presenting with abdominal pain has affected the rate of short-term revisits among patients with non-specific abdominal pain (NSAP).MethodsWe identified consecutive ED patients receiving a diagnosis of NSAP 1.1. 2015–31.12.2016 in the ED of Tampere University Hospital. Those revisiting the ED within 48 h were selected for further analysis. Data were obtained from electronic medical records. We compared the outcomes of those initially examined by surgeons and by emergency physicians.ResultsDuring the study period, 173,630 patients visited our ED, of whom 6.1% (n = 10,609) were discharged with a diagnosis of NSAP. Only 3.0% of patients revisited the ED, 0.7% required hospitalization and 0.06% immediate surgery. The short-term revisit rates among those originally examined by surgeons and by emergency physicians were similar, 2.8 and 3.2% respectively (p = 0.193).ConclusionsThe rate of short-term revisits in patients with NSAP was altogether low. The increasing role of emergency physicians in the care of acute abdominal patients did not affect the revisit rate.

Nonspecific abdominal pain: A follow-up survey.

Little data have been published on the outcome of patients discharged from the emergency department (ED) after being diagnosed with nonspecific abdominal pain (NSAP). This study aimed to investigate short-term follow-up of patients discharged with a diagnosis of NSAP from the ED. This prospective, observational study was conducted in the University-based ED and enrolled all consecutive adult patients who were diagnosed as NSAP out of patients presented with abdominal pain (AP). The main outcome measure was the presence of recurrent AP resulting in referral to the ED and specific diagnoses within the first 3- and 90-day postdischarge. On the 3rd and 90th days, all patients discharged with NSAP from the ED were asked questions, and their response entered into a questionnaire. A total of 684 patients presented with AP, of which 299 (46%) had a diagnosis of NSAP within the 4-month period. Fifty cases (16%) could not be included due to inability to access. Eighty-one out of 249 patients (32.5%) complained of recurrent AP within the first 3 days. Twenty-two cases (8.8%) were readmitted to ED once again in the meantime, and ten received specific diagnoses including three with acute abdomen. Within 90 days, additional nine patients out of 20 (45%) with recurrent AP received specific diagnoses including two with acute abdomen. Certain specific underlying entities can be missed in patients considered to have NSAP and discharged from the ED. Adherence to timely follow-up and repeated examinations are of vital importance in these patients.

Role of CT in the Diagnosis of Nonspecific Abdominal Pain: A Multicenter Analysis.

The objective of our study was to determine whether specific patient and physician factors-known before CT-are associated with a diagnosis of nonspecific abdominal pain (NSAP) after CT in the emergency department (ED). We analyzed data originally collected in a prospective multicenter study. In the parent study, we identified ED patients referred to CT for evaluation of abdominal pain. We surveyed their physicians before and after CT to identify changes in leading diagnoses, diagnostic confidence, and admission decisions. In the current study, we conducted a multiple regression analysis to identify whether the following were associated with a post-CT diagnosis of NSAP: patient age; patient sex; physicians' years of experience; physicians' pre-CT diagnostic confidence; and physicians' pre-CT admission decision if CT had not been available. We analyzed patients with and those without a pre-CT diagnosis of NSAP separately. For the sensitivity analysis, we excluded patients with different physicians before and after CT. In total, 544 patients were included: 10% (52/544) with a pre-CT diagnosis of NSAP and 90% (492/544) with a pre-CT diagnosis other than NSAP. The leading diagnoses changed after CT in a large proportion of patients with a pre-CT diagnosis of NSAP (38%, 20/52). In regression analysis, we found that physicians' pre-CT diagnostic confidence was inversely associated with a post-CT diagnosis of NSAP in patients with a pre-CT diagnosis other than NSAP (p = 0.0001). No other associations were significant in both primary and sensitivity analyses. With the exception of physicians' pre-CT diagnostic confidence, the factors evaluated were not associated with a post-CT diagnosis of NSAP.

Same Day Upper and Lower Endoscopy Results in Patients Presenting with Nonspecific Abdominal Pain

Objective: The aim of this study was to evaluate the upper gastrointestinal endoscopy and colonoscopy results in patients who presented with abdominal pain and received a diagnosis of nonspecific abdominal pain following the examination and tests. Methods: We included a total of 52 patients who presented at the emergency service between 01.01.2011 and 01.01.2012 with symptoms of abdominal pain and received a diagnosis of nonspecific abdominal pain following normal examination, routine blood and urine tests and ultrasound analysis. All patients underwent upper gastrointestinal endoscopy and colonoscopy on the same day. The results were evaluated and diagnoses made according to the endoscopy and pathology findings. Results: There were 23 (44.2%) males and 29 (55.8%) females. The mean age was 54.5 ± 15.3 (23-86) years. A pathology was present on upper endoscopy in 47 (90.4%) patients and lower endoscopy in 27 (51.9%) patients. Comparison of the pathology rates for upper endoscopy and colonoscopy showed a significantly higher rate for upper endoscopy. The most common findings were chronic gastritis with upper endoscopy 13 males (25%) and 17 (32.7%) females, hemorrhoids with colonoscopy 10 males (19.2%) and 12 (23.1%) females. A pathology was present on both examinations in 25 (48%) patients. Cancer was found in 7 (13.5%) patients (6 gastric, 1 colon cancer). Helicobacter pylori was (+) in 53.8% of the cases. Discussion and Conclusion: Same day upper and lower endoscopy in patients with nonspecific abdominal pain provided important results. However, we feel upper endoscopy should have priority when it is not possible to perform both investigations. Key words: Abdominal pain, Endoscopy, Gastrit,

Achieving the Triple Aim Through Informed Consent for Computed Tomography.

Achieving the Triple Aim Through Informed Consent for Computed Tomography.

Long-term follow-up of patients diagnosed with nonspecific abdominal pain (NSAP): identification of pathology as a possible cause for NSAP

Nonspecific abdominal pain (NSAP) accounts for 40 % of all general surgical admissions. Data suggest that conditions such as irritable bowel syndrome and gynaecological pathologies can be misdiagnosed as NSAP. Delayed diagnosis and management can cause increased morbidity. Our aim was to follow-up a cohort of patients with an initial diagnosis of NSAP to determine their eventual diagnosis. Hospital episode statistic (HES) data were reviewed to identify 100 acute surgical admissions coded as NSAP at discharge between January and December 2008. Medical records were systematically reviewed over a 3-year follow-up period to identify further investigations, operations and any eventual diagnoses in patients who fulfilled NSAP criteria. General practitioners were contacted to evaluate any further GP surgery visits and hospital referrals for this cohort of patients. A total of 59 were incorrectly coded as NSAP; only 41 fulfilled the criteria of NSAP at discharge from the initial acute admission. The majority of patients correctly diagnosed as NSAP were female (71 %) individuals. Median age across both genders was 25.7 years (interquartile range 19.4–37.7 years). At three yearly follow-up, 54 % of patients appropriately labelled as NSAP were diagnosed with a specific pathology. This study highlights that around half of patients correctly labelled with NSAP were subsequently diagnosed with a specific pathology. Our results suggest that patients diagnosed with NSAP should be followed up to avoid additional morbidity from misdiagnosis. Furthermore, the current coding system for NSAP needs to be modified.

Nonspecific abdominal pain is a safe diagnosis

AimThe aim of this study is to assess if a clinical diagnosis of nonspecific abdominal pain (NSAP) is safe and if patients with this initial diagnosis are likely to require further investigation or surgical intervention. Methods3323 patients admitted with NSAP from July 1990 to September 2012 utilizing a prospective database of all surgical admissions were included. Readmission over the period of the study and specifically within 30days of their initial presentation was identified together with any invasive investigation or surgical intervention. Main results319 children (9.6%) were subsequently readmitted with abdominal pain at some point during the study period. Of these, 78 (2.3%) were readmitted within 30days. 118 (3.5%) children subsequently had an operation or invasive investigation some point following their initial admission. Of these 33 (0.6%) had the procedure within 3months of the initial admission. 13 patients had an appendicectomy within 3months of the initial presentation. Of these histology confirmed appendicitis in 8 patients. This gives an overall incidence of “missed” appendicitis of 0.2 % (8/3323). ConclusionThis study confirms that a clinical diagnosis of nonspecific abdominal pain (NSAP) is safe in a pediatric population and the risk of “missing” appendicitis is only 0.2%. Patients and/or parents can be confidently reassured that the risk of missing organic pathology is very low.

Are Neutrophil CD64 Expression and Interleukin-6 Early Useful Markers for Diagnosis of Acute Appendicitis?

The aim of the study is to evaluate the diagnostic value of interleukin-6 (IL-6) level and neutrophil cluster of differentiation 64 (CD64) expression in diagnosis of acute appendicitis (AA). A prospective controlled trail was performed. Children who were hospitalized with a diagnosis of right lower quadrant pain were our cohort. Serum samples for white blood cell, C-reactive protein (CRP), leukocyte CD64 expression, and IL-6 were obtained from the patients just after their admission. Operation was performed if appendicitis seemed probable, others were observed actively. Patients who had noncomplicated appendicitis were Group 1, patients who had complicated appendicitis were Group 2, and patients who had discharged after observation without operation with a diagnosis of nonspecific abdominal pain and had negative appendectomy without another surgical disease were Group 3. In this study, 49 patients were enrolled. CRP and CD64 levels were found higher in Group 2. IL-6 levels were found to be lower in Group 3 than Groups 1 and 2. There was a difference between Group 2 and the other groups about CD64 levels. The CRP level and expression of leukocyte CD64 level did not effectively predict the diagnosis of noncomplicated appendicitis, but it predicted well the patients with complicated appendicitis. However, IL-6 levels are statistically significantly different between Group 3 and Groups 1 and 2. According to this result, IL-6 levels predicted well the patient with appendicitis. Applying additional diagnostic methods such as IL-6 levels seems to be helpful in reducing the numbers of false-positive diagnosis of AA.

Abdominalschmerzen ohne anatomisch - pathologisches Korrelat - wie weiter?

Abdominal pain without any identifiable cause represents a frequent phenomenon in clinical practice and a challenge for the physician. Prior to establishing the diagnosis of non-specific abdominal pain it is crucial to exclude a variety of potential causes. The differential diagnosis is long and includes functional problems but also extra-intestinal pathologies including thoracic, neurogenic, and metabolic causes as well as intoxications. Moreover, an intra-abdominal pathology, particularly a malignancy, must be ruled out systematically prior to labeling a patient as having "non specific" abdominal pain.

Acute appendicitis – is there still a place for active observation?

We read the study of Akbar et al. with interest and have also noted the increasing enthusiasm for diagnostic laparoscopy in recent years amongst our colleagues. In a similar fashion to the authors, in clear-cut cases of appendicitis on initial presentation we leave the surgical approach (open or laparoscopic) to the discretion of the operating surgeon, but as a consultant firm we have generally employed the ‘active observation’1 approach (without computerised tomography) for the management of patients with suspected appendicitis with equivocal signs and symptoms, rather than performing diagnostic laparoscopy. Aware of our traditional approach in the face of the increasing use of diagnostic laparoscopy, we conducted a 9-month retrospective audit of patients admitted with suspected appendicitis under the care of the lead author (DJA) to assess our outcomes. In total, 38 patients underwent appendicectomy, performed via both open and laparoscopic approaches, resulting in a 5% negative appendicectomy rate (two patients). No additional or alternative diagnoses were made at the time of surgery, and no patients discharged with a diagnosis of non-specific abdominal pain were re-admitted with appendicitis. Bearing in mind reported re-admission rates of 33% in patients undergoing a negative appendicectomy,2 as well as the small but real risks of diagnostic laparoscopy, such as major vascular injury or significant port-site bleeding,3 we are happy to continue our approach to managing patients with suspected appendicitis without laparoscopy used solely as a diagnostic tool.

Lethal cause of abdominal pain: a diagnosis not to be missed

A 77-year-old woman was brought to the accident and emergency department with a 11-day history of abdominal pain. She was in shock and required resuscitation. She had attended the accident and emergency a few days before and had been discharged home with a diagnosis of non-specific abdominal pain. The previous abdominal X-ray is shown in Figure 1. Her past medical history included bilateral below knee amputation for peripheral vascular disease, pacemaker for heart block and hypertension. On examination, post-resuscitation, she was confused and apyrexial with a heart rate of 100 beats/minute and a blood pressure of 110/70 mmHg. Her abdomen was diffusely distended with minimal tenderness in the epigastrium and supra-umbilical region. There was no rigidity or guarding. Bowel sounds were normal. Digital rectal examination showed soft faeces. Blood test showed a haemoglobin of 6.6 g/dl (down from 11 g/dl during her previous accident and emergency visit). There was slight impairment of renal function with a urea of 11 mg/dl and creatinine of 160 mg/dl. The rest of the blood tests were within normal limits. Arterial blood gases showed metabolic acidosis with a pH of 7.2 and lactate of 3 mmol/litre. A computed tomography scan of the abdomen was performed. 1. What is the differential diagnosis? 2. What can you find in the abdominal X-ray? 3. What can you find in the computed tomography scan? 4. What is the treatment? 5. What is the prognosis of this patient? The differential diagnoses in this case are peritonitis from hollow viscus perforation, ischaemic bowel and leaking abdominal aortic aneurysm. The abdominal X-ray (Figure 1) shows minimal dilatation of the right and transverse colon and a tortuous calcified aorta. However the upper aortic calcification is not obvious. Computed tomography scan shows an abdominal aortic aneurysm which commences immediately distal to the origin of the right renal artery with not involving the bifurcation. There is leakage from this aneurysm (Figure 2b arrow) which has a maximum diameter of 5 cm. There is a periaortic haematoma which extends anteriorly to displace the loops of bowel anteriorly (Figure 2b). There is free fluid in the peritoneal cavity (Figure 2a). The right kidney is well perfused but the left kidney shows no evidence of perfusion (Figure 2c). There are some calculi in the left pelvis. In this patient, palliation was felt to be the most appropriate treatment option (her case was discussed with the on-call vascular surgeons). The patient died a few hours after her hospital admission. In a relatively fitter patient, open surgery is the treatment of choice.

Irritable bowel syndrome in patients discharged from surgical wards with non-specific abdominal pain.

A questionnaire was used to discover the prevalence of seven recognized symptoms of irritable bowel syndrome (IBS) in 96 patients who had been discharged from hospital 1-2 years previously with the diagnosis of non-specific abdominal pain. Compared with 1897 controls from a population survey in the same city, the patients were more likely to have these symptoms; the differences were statistically significant in most cases. The frequency of recurrent abdominal pain with features suggesting an intestinal origin was increased fivefold in male and fourfold in female patients (P < 0.001). Criteria for the diagnosis of IBS were present in 37 per cent of women and 19 per cent of men, versus 5 and 2 per cent respectively in controls (P < 0.001). Approximately half the patients remembered having symptoms of IBS at the time of admission and 70 per cent had had other attacks of abdominal pain. At the time of admission, the hospital notes mentioned the possibility of IBS in only 6 per cent of cases. Most patients would have welcomed an explanation for the pain at the time of their hospital admission.

Large Gastric Trichobezoar in a Normal Healthy Woman: Case Report and Review of Pertinent Literature

This report presents a unique case of a gastric trichobezoar in a relatively healthy, young female with no history of psychological or psychiatric disorders. Furthermore, unlike previously reported cases, this patient had no history of gastric surgery. The mode of presentation and the difficulties in diagnosis are discussed. The different modalities of treatment, both surgical and nonsurgical, are evaluated and discussed. The diagnosis of a trichobezoar in a healthy patient requires a high index of suspicion, as it can present with nonspecific symptomatology. It should be included in the differential diagnosis of nonspecific abdominal pain.

Computed tomography scan use in the emergency department evaluation of patients with nonspecific abdominal pain is increasing despite decreased patient acuity

Study objectives: Computed tomography (CT) scanner use has become increasingly common in US emergency departments (EDs). We undertake a study to investigate the change in frequency of the use of ED CT scans in patients with abdominal pain. We also investigated the relationship between CT scan use and changes in patient acuity.Methods: Data were obtained from the 1996 to 2000 National Hospital Ambulatory Medical Care Survey (NHAMCS), a national probability sample survey conducted by the National Center for Health Statistics, Centers for Disease Control and Prevention. All visits that were coded as nonspecific abdominal pain (International Classification of Diseases, Ninth Revision code 789) were identified. Data were collected for the use of blood tests. Indicators of patient severity (triage category and hospital admission rates) were also collected, and demographic data were obtained. Continuous variables were summarized by mean and SDs. Proportions were compared with a χ2 test; an a priori significance level of P value less than .05 was selected. Descriptive analyses were performed with statistical software (Microsoft Excel 2000 version 9.0; Microsoft Corporation, Redmond, WA). The data used for this study are openly accessible to the public and excluded all patient identifiers. The study was therefore exempt from institutional board review approval.Results: We analyzed 115,011 visits that represented 496.4 million visits to US EDs during the 5-year study period. Data were weighted in accordance with NHAMCS guidelines for statistical analysis. Three thousand five hundred sixty-four patients with a final ED diagnosis of nonspecific abdominal pain were identified, representing 15,767,037 weighted patient visits nationally. There was a slight increase in the percentage of patients with nonspecific abdominal pain (2.7% in 1996, 3.3% in 2000, χ2=13.7, P=.001). The rate of CT scan use increased from 1.7% to 10.2% (χ2=40.4, P=.001). The hospital admission rate decreased from 15.6% (350,588 admissions) in 1996 to 14.9% (573,784 admissions) in 2000 (χ2=0.13, P=NS). There was a decrease in the triage acuity of patients with abdominal pain presenting to the ED. The presenting acuity of patients as categorized by a triage level one (to be seen within ≤15 minutes) decreased significantly from 22.4% to 10.8% (χ2=36.4, P=.001). There was a 10-fold increase in the rate of CT use in admitted patients (3.3% in 1996, increasing to 37.4% in 2000). The use of a CBC count increased from 56% to 65% (χ2=5.0, P=.05). Overall, the growth in CT scanning was higher than for the growth in the use of a CBC count or hospital admission rate, which suggests that despite a decreasing patient acuity, the rate of CT scan use is increasing. Projections based on 5 years of data suggest that if current growth continues, by 2010 more than 30% of all ED patients with a final diagnosis of nonspecific abdominal pain will undergo a CT scan while in the ED.Conclusion: The use of CT scanning in patients with nonspecific abdominal pain is increasing rapidly. This increase cannot be explained by increasing patient acuity and has not changed the admission rate. These trends need to be factored into ED design. Further studies involving patients most likely to benefit from a CT may result in large cost savings and may ease ED congestion.