Complaints of abdominal pain from patients seeking treatment in hospital emergency rooms nationally rose 31.8 percent from 1999-2008, but about one-half of those patients were discharged without a diagnosis, according to data from the U.S. Centers For Disease Control and Prevention.
In fact, the CDC reports that abdominal pain and chest pain continue to be the most common ailments for a visit to the ER for patients aged 15 years and over. Statistics show that about 7 million people aged 18 and older visit the ER each year with complaints of abdominal pain.
In Connecticut, emergency room doctors concur that abdominal pain is among the top ailments treated and among the most difficult to diagnosis.
“It is like finding a needle in a haystack, in which you think ‘Please let them not be the 50 percent where I can’t tell them what is wrong,’ ” said Dr. Jeff A. Finkelstein, director of Hartford Hospital’s emergency department. The hospital’s ER reported treating 1,674 cases of abdominal pain during the months of April and May.
Because the abdominal area contains multiple organs: the stomach, small and large intestines, pancreas, liver and gallbladder, “abdominal pain is very challenging to find the specific cause in a short time frame,” said Finkelstein.
Part of the challenge for emergency room doctors is that they are treating patients with no prior knowledge of their medical history. There are also many diagnostic possibilities, including appendicitis which requires surgery; acute gastritis [inflammation of the stomach,] inflammation of the gallbladder, bowel obstructions, and diverticulitis [formation of pouches in the colon wall that are inflamed or infected].
Stomach ailments can also be caused by excess gas, bloating, cramping, problems pushing food through the intestine, infections, bacteria and ulcers.
“There are so many different things to investigate and a battery of tests for narrowing down a diagnosis,’’ said Dr. Christopher M. Davison, Greenwich Hospital’s medical director.
Doctors conduct multiple tests and lab work that can take up to four to five hours. “It’s tricky because there are so many diagnostic possibilities, which require a detailed physical exam, with appropriate tests, and a possible consultation later on,’’ said Dr. Michael R. Saxe, chairman of the emergency medicine department at Middlesex Hospital.
Medical history is critical in reaching a diagnosis. “After the patient interview where you can examine their medical history, you should be able to have a differential diagnosis,” said Dr. Kilbourn Gordon III, Bridgeport Hospital’s director of urgent care.
Advanced medical imaging has become a valuable tool in diagnosing abdominal pain. The use of advanced medical imaging, MRI and ultrasound increased 122.6 percent for emergency room visits related to abdominal pain and 367.6 percent for visits related to chest pain from 1999 to 2008, according to data from the CDC.
“The technology of CT scans has dramatically increased in all emergency departments and provides tremendous amounts of diagnostic information,” said Saxe.
The advantage of ultrasound and CT scans is “You may find they have a tumor, or Crohn’s disease [inflammatory bowel disease]; it picks up diseases otherwise non-apparent,” said Dr. Michael Carius, chairman of Norwalk Hospital’s department of emergency medicine.
“You feel confident your patient is not suffering from anything serious after a CT scan because without it you could be flying blind,” Waterbury Hospital Medical Emergency Department Director Dr. David A. Goldwag said.
Abdominal pain can be persistent and particularly worrisome among older patients.
“I was at a hospital and someone came back with the same problem three times,” said Finkelstein. A third such visit involves a much more in-depth evaluation. Doctors compare the lab tests to see what has changed and ask if the patient followed the plan of care.
“Elderly people are more likely to have something potentially wrong, especially patients aged 75 and older,” said Dr. Danyal Ibrahim, director of emergency medicine at St. Francis Hospital and Medical Center in Hartford.
Saxe observed “patients over 65 have a 50 percent chance of staying overnight, while patients under 40 have a 25 percent chance.”
Lack of primary care, an aging population and poor diet are among the reasons for the continued increase in patients with abdominal pain, doctors said.
“The American diet has deteriorated. Combined with an aging population, this all has an effect,” said Goldwag.
Gillian Bromfeld is a C-HIT intern and a senior at the University of Connecticut.