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Diagnostic pitfalls and accuracy of diagnosis in acute abdominal pain
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
2006 (English)In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, Vol. 41, no 10, 1126-1131 p.Article in journal (Refereed) Published
Abstract [en]

Objective. To identify the differential diagnostic difficulties in acute abdominal pain at the emergency department and during hospitalization. Material and methods. Patients with abdominal pain lasting for up to 7 days were registered during 1997-2000 and re-evaluated one year after discharge (n=2851). Results. Diagnoses with low sensitivity at the emergency department but markedly increased sensitivity at discharge were non-specific abdominal pain with a sensitivity value at the emergency department of 0.43, appendicitis 0.80, gallstones 0.68, constipation 0.74 and peptic ulcer 0.26. Corresponding K-values were 0.48, 0.74, 0.84, 0.88 and 0.93, respectively. Malignancy, gynaecological complaints, dyspepsia, urinary tract infection and diverticulitis displayed fairly good concordance between the preliminary and discharge judgements, but the predictive diagnostic value was still low at discharge. Sensitivity values at discharge were 0.40, 0.75, 0.73, 0.77 and 0.83, respectively. Among 479 surgically treated patients, 104 initially received a diagnosis usually not requiring surgery and had a median delay until operation of 22 h (95% CI 30-50 h), compared with 8 h (12-18 h) for referrals. Conclusions. Non-specific abdominal pain is the main differential diagnostic problem in the emergency department also for diagnoses requiring surgery. Constipation is a diagnostic pitfall and when making this diagnosis a careful re-evaluation is necessary.

Place, publisher, year, edition, pages
2006. Vol. 41, no 10, 1126-1131 p.
Keyword [en]
acute abdominal pain, decision-making, diagnosis, sensitivity, specificity, validity
National Category
Medical and Health Sciences
URN: urn:nbn:se:uu:diva-94906DOI: 10.1080/00365520600587485ISI: 000240662200002PubMedID: 16990196OAI: oai:DiVA.org:uu-94906DiVA: diva2:168924
Available from: 2006-09-22 Created: 2006-09-22 Last updated: 2011-06-10Bibliographically approved
In thesis
1. Acute Abdominal Pain
Open this publication in new window or tab >>Acute Abdominal Pain
2006 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The aim was to identify diagnostic difficulties for acute abdominal pain at the emergency department and during hospital stay. A total of 3349 patients admitted to Mora Hospital with acute abdominal pain of up to seven days duration, were registered prospectively for history and clinical signs according to a structured schedule. The preliminary diagnosis from the attending physician at the emergency department, any investigations or surgery and final diagnosis were registered at a follow-up after at least one year.

There were no differences in diagnostic performance between physicians with 0.5 to 5 years of medical experience. The information collected and a careful examination of the patient was more important than formal competence. The main differential diagnostic problem was non-specific abdominal pain; this was the same for diagnoses requiring surgery. Patients originally diagnosed as not needing surgery had a median delay before operation of 22 hours (mean 40 hours, with 95% confidence interval of 30-50 hours), compared to 8 hours (mean 15 hours, 95% confidence interval of 12-28 hours) for patients with the same final follow-up diagnosis as the preliminary diagnosis. Constipation was a diagnostic pitfall, as 9% of the patients considered constipated required surgery for potentially life threatening reasons and 8% were later found to have an abdominal malignancy. Both the preliminary diagnosis and the discharge diagnosis were less reliable for elderly patients than for younger patients. Elderly patients often had specific organ disease and arrived at the emergency department after a longer history of abdominal pain.

This study confirms that assessment of suspected appendicitis can still be based on clinical judgements combined with laboratory tests. Classical clinical findings indicating localised inflammation, such as isolated pain in the right iliac fossa, rebound tenderness, right-sided rectal tenderness, pain migration to the right iliac fossa, local guarding and aggravation of pain when moving, were reliable for predicting acute appendicitis. A CT scan can be saved for the more equivocal cases of acute abdominal pain. A generous strategy regarding CT scan among elderly patients with acute abdominal pain, even in the absence of pronounced signs of an inflammatory intra-abdominal process, is recommended.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2006. 72 p.
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 174
Surgery, acute abdominal pain, diagnostic pitfalls, decision-making, competence, sensitivity, specificity, high age, acute appendicitis, Kirurgi
urn:nbn:se:uu:diva-7161 (URN)91-554-6664-8 (ISBN)
Public defence
2006-10-13, Enghoffsalen, Thoraxcentrum, ingång 50, Akademiska sjukhuset, Uppsala, 13:15
Available from: 2006-09-22 Created: 2006-09-22 Last updated: 2011-06-10Bibliographically approved

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Laurell, HelenaGunnarsson, Ulf
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