Abdominal pain
Abdominal pain is a complaint frequently encountered in the outpatient environment. Numerous etiologies, both chronic and acute, are amenable to outpatient evaluation. Yet, some causes of abdominal pain require immediate, targeted, and organized evaluation because of related morbidity and mortality. The differential diagnosis of a patient with acute abdominal pain is extensive, requiring the clinician to not only be aware of the underlying pathophysiology of the pain, but also of the clinical presentation, course, and initial treatment of more dangerous causes.
A directed history, physical examination, and adjunctive testing approach will enable those patients with suspicious presentations to be recognized, initially treated, and properly referred for further care.
High risk for and subtle presentation of serious pathologic conditions in elderly patients presenting with abdominal pain mandate cautious, expeditious examinations and vigorous therapy. The elderly patient presenting with abdominal pain demands more time and resources than all other emergency department ED presentations.
Symptoms of abdominal pain
Their hospital stay is 20% longer than in younger patients who present with the same complaint, they need to be admitted virtually half the time, and they need surgical consultation one-third of the time. Unlike most other patient complaints, the elderly patient with abdominal pain necessitates more than the question of being sick or not sick and a disposition for admission or discharge from the ED physician. Not recognizing an acute surgical illness in the ED can result in increased mortality, even if a patient is hospitalized for observation. Of the older patients who have abdominal pain and are sent home, almost one-third of them return to the ED with ongoing symptoms.
Pain in the abdomen is expected to be a frequent complaint and an indication for consultation for primary care. It occurs almost in every individual once in his/her lifetime regardless of age, gender, and social status. Pain in the abdomen may be caused by a wide range of conditions ranging from predominantly minor and self-limiting gastroenteritis to acute and lethal conditions abdominal aortic aneurysm. For the majority of patients presenting with abdominal pain, the GP is the principal contact individual and the gatekeeper to the health care system.
Organize health care
GPs organize health care by triaging uncomplicated abdominal pain self-limiting, requiring only symptomatic treatment and potentially serious disease requiring further investigation and aggressive therapy. Decisions are made based on history and clinical examination by weighing risks and disease likelihood. For rational judgment and counseling, GPs require setting-specific knowledge regarding the prevalence pre-test probability, the suspected underlying etiology work-up probability, and the prognosis of abdominal pain. Nonetheless, the individual evidence regarding such information is limited, and conclusions drawn from single studies are not automatically applicable to the field of general practice. To the best of our knowledge, systematic reviews of recent evidence regarding risks and chances of abdominal pain are not yet available.
We systematically reviewed symptom-assessing studies of prevalence, etiology, frequencies, and prognosis of abdominal pain as a primary or secondary complaint as presented to GPs in primary care settings.
Abdominal pain is the leading chief complaint among emergency department ED patients. It accounts for 8% of the 100 million annual ED visits. A few patients presenting with abdominal pain undergo a catastrophic event, including a ruptured abdominal aortic aneurysm.
The majority of abdominal pain patients have a small issue, including dyspepsia. In total, 20% to 25% of patients with abdominal pain are discovered to have a serious disease necessitating admission to an acute care hospital.20 The leading surgical emergency is appendicitis. Since Fitz’s description in 1886 of the surgical management of appendicitis,16 early operations and diagnoses have been shown to avoid appendicitis perforation. This prevents acute complications like the formation of abscesses and sepsis and delayed complications like scar tissue formation with recurrent episodes of intestinal obstruction and infertility.
Diagnosis of abdominal pain
Those patients who don’t get admitted typically are treated, discharged from the ED, and do fine. Lukens et al25 have reported that only 3% of the patients with abdominal pain discharged from the ED get admitted in the next 3 weeks. Within primary care, a mean of 1.32 visits must be made to thoroughly complete these patients’ work-up, with one-half discovered following examination to have nonspecific abdominal pain as the diagnosis. The abdominal pain work-up ordered more ancillary use than did all other studied ambulatory complaints, according to Gold and Azevedo17.
Diagnosis and management of abdominal pain is a challenge for several reasons: first, the definitive diagnosis is frequently unclear, with an unconfirmed or uncertain diagnosis made in more than 40% of patients.8 Inability to confirm a diagnosis leads to additional testing and, frequently, follow-up visits to the primary care physician or the ED despite favorable long-term prognoses; second, the responsibility for making a diagnosis and the extensive differential of presenting symptoms frequently compels the ED to replicate many of the tests or expand the differential diagnosis of those who present with recurrent pain.
The challenge of ascertaining the cause of abdominal pain leads to huge numbers of negative work-up, unnecessary interventions, added expense, and drain on patient and hospital resources second, the doctor is usually in the dilemma of when to label the patient as safe for discharge and terminate the work-up in a timely fashion in the presence of a negative work-up or an indeterminate diagnosis.
Pain relief may even aid diagnosis. Personal opinions regarding this issue rest predominantly on experience and anecdotal experience since, up to now, there has not been a controlled study to put the matter at rest.
Zoltie and Cust undertook a prospective, randomized, double-blind, placebo-controlled, trial comparing the effect of sublingual buprenorphine with placebo.
They found no disparity in the diagnosis and treatment of either group of patients and concluded that early relief of pain was safe. There is a basic flaw in this study in that only 42% of patients received adequate analgesia in the treatment group versus 52% in the placebo group. Also, sublingual buprenorphine is not routinely prescribed for patients with acute abdominal pain. No conclusions can be drawn from this study.
Theme of our hospital
Our purpose in doing this study was to measure the effectiveness of
papaveretum early to patients with acute abdominal pain and to examine its influence on subsequent diagnosis and management choices.
Patients and methods
Patients admitted as emergency patients with acute abdominal pain sufficiently severe to require opiate analgesia were approached for participation in the study. Individuals below the age of 16 years and individuals with suspected leaking abdominal aortic aneurysms were excluded from participating in the study. Ethical approval was acquired from the Coventry research and ethical committee. All participants of the study provided valid consent.
Treatment of our patients
Patients were initially assessed by the admitting house officer, and their abdominal tenderness and pain were assessed on a linear analog scale. The scale varied from 0 for no pain to 10 cm for the worst possible pain. The house officer also noted the sites of tenderness and his or her clinical diagnosis. If analgesia was considered suitable patients were invited to take part in the study.
The purpose and aims of the study were described by the house officer and supported by a study information sheet, which was kept with each patient. Where consent was declined reasons for decline were recorded. Opening a sealed envelope, the house officer randomly allocated consenting patients to receive a blinded intramuscular injection of a maximum of 1 ml of fluid with either papaveretum 20 mg or saline.
The trial was designed to have 50 patients in each group receiving treatment. The amount of liquid that was administered depended on the house officer’s estimate of what dose of papaveretum the individual patient needed. Patients were followed up approximately one hour later by a surgical registrar, who reproduced the linear analog scores of pain and tenderness. He also scored the comfort of the patient and his confidence as a percentage of his diagnosis and management choice to operate or observe. The registrar also documented whether he believed the patient to be in the treatment or control group and whether the diagnosis or management decision was in any respect compromised by involving the patient in the study.