By Stacey Kusterbeck
Chronic abdominal pain is a common presenting complaint in EDs. “Despite the frequency with which ED clinicians confront recurrent abdominal pain, virtually zero research exists upon which to guide evidence-based protocols,” says Christopher Carpenter, MD, MSC, FACEP, FAAEM, AGSF, professor of emergency medicine at Washington University in St. Louis.
Researchers have yet to define “low-risk” abdominal pain or “recurrent” abdominal pain in reproducibly measurable ways. In a recent paper, Carpenter and colleagues argued that will not change until lawmakers create a fully funded NIH Institute of Emergency Care.1
“Lacking such an institute, the possibility of similarly weak recommendations in a decade is very likely,” Carpenter says. “Without guidelines, patients could get unnecessary testing, not receive tests they need, or get misdiagnoses.”
For example, the American College of Emergency Physicians’ clinical policy on appendicitis starts from the assumption the patient has appendicitis.2 But when the patient arrives with abdominal pain or vomiting, ED providers do not know the patient has appendicitis.
Similarly, the American College of Radiology’s Appropriateness Criteria start from the perspective of a diagnosis (e.g., appendicitis or cholecystitis). But when the patient arrives at the ED, providers know only symptoms, not a diagnosis. “The lack of clinical practice guidelines is associated with practice variability — between physicians and across healthcare systems — in the diagnostic approach to abdominal pain,” Carpenter says.
The second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-2) authors sought to close that knowledge gap by focusing on the syndromic presentation of recurrent, low-risk abdominal pain rather than from the vantage point of a diagnosis.3 “The approach is intended for adults who presented to the ED with multiple similar symptoms of abdominal pain over months to years,” notes Carpenter, one of the authors.
According to the recommendations, if the patient underwent a CT scan of the abdomen and pelvis in the previous year, there is insufficient evidence to determine which patients need a repeat CT scan and which patients can avoid it.
The authors also recommended screening for depression or anxiety. Undifferentiated abdominal pain with no clear etiology represents almost 30% of ED visits for abdominal pain.4 Psychological factors may exacerbate or precipitate abdominal pain. “Active screening for depression or anxiety may provide a trigger for mental health services referrals and reduce ED returns for the same chief complaint of abdominal pain for a subset of our patients,” Carpenter says.
REFERENCES
1. Carpenter CR, E Silva LOJ, Upadhye S, et al. A candle in the dark: The role of indirect evidence in emergency medicine clinical practice guidelines. Acad Emerg Med 2022;29:674-677.
2. Howell JM, Eddy OL, Lukens TW, et al. Clinical policy: Critical issues in the evaluation and management of emergency department patients with suspected appendicitis. Ann Emerg Med 2010;55:71-116.
3. Broder JS, Oliveira J E Silva L, et al. Guidelines for reasonable and appropriate care in the emergency department 2 (GRACE-2): Low-risk, recurrent abdominal pain in the emergency department. Acad Emerg Med 2022;29:526-560.
4. Oliveira J E Silva L, Prakken SD, Meltzer AC, et al. Depression and anxiety screening in emergency department patients with recurrent abdominal pain: An evidence synthesis for a clinical practice guideline. Acad Emerg Med 2022;29:615-629.
Without clear guidelines, patients could undergo unnecessary testing (or not receive tests they need), which could lead to misdiagnoses — or worse.
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