HomeLarge Type Edition
HOME ARCHIVE SEARCH TABLE OF CONTENTS
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Services
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
PubMed
Right arrow PubMed Citation
The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 60:1071-1076 (2005)
© 2005 The Gerontological Society of America

Etiology and Clinical Course of Abdominal Pain in Senior Patients: A Prospective, Multicenter Study

Lawrence M. Lewis1,, Gerald A. Banet1, Michelle Blanda2, Fredric M. Hustey3, Stephen W. Meldon4 and Lowell W. Gerson2

1 Washington University, St. Louis, Missouri.
2 Northeastern Ohio Universities College of Medicine, Akron.
3 Cleveland Clinic Foundation, Ohio.
4 MetroHealth, Cleveland, Ohio.

Address correspondence to Lawrence M. Lewis, MD, Washington University School 8072, St. Louis, MO 63110. E-mail: lewisl{at}msnotes.wustl.edu


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Background. The authors describe the epidemiology and clinical course of older persons examined in emergency departments (EDs) for abdominal pain.

Methods. This was a prospective, multicenter, observational study of older persons (≥60 years) examined in participating EDs for nontraumatic abdominal pain. Medical records were reviewed for demographics, ED diagnoses, findings of radiographic imaging, disposition, operative procedures, length of hospitalization, and final diagnoses. Patients were interviewed at 2 weeks to determine clinical course, final diagnoses, and mortality status. The authors compared ED diagnoses with final diagnoses, reporting the percentage change in aggregate and for the 12 most common diagnoses.

Results. Of 360 patients (mean age, 73.2 ± 8.8 years; 66% women; 51% white) who met selection criteria, 209 (58%) were admitted to the hospital and 63 (18%) required surgery or an invasive procedure. For patients with complete follow-up information (n = 337), 37 (11%) had repeated ED visits and 23 (7%) were readmitted to the hospital. The case-fatality rate was 5%. Leading causes of abdominal pain were nonspecific (14.8%), urinary tract infection (8.6%), bowel obstruction (8%), gastroenteritis (6.8%), and diverticulitis (6.5%). The ED and final diagnoses matched 82% of the time. Older patients had higher mortality rates (odds ratio, 4.4; 95% confidence interval, 1.4–14) and lower diagnostic concordance rates (76% vs 87%; p =.01). Study limitations include inability to enroll all eligible persons and possible inaccuracies in participant-reported follow-up interviews.

Conclusions. Abdominal pain in older patients should be investigated thoroughly as, in this study, nearly 60% of patients were hospitalized, 20% underwent operative or invasive procedures, 10% had return ED visits, and 5% died within a 2-week follow-up period.

ABDOMINAL pain ranks as one of the most frequent reasons for trips to emergency departments (EDs) (1,2). This holds true for older patients, accounting for 3% to 4% of all ED visits in this age group (3). Several previous studies report that older persons with abdominal pain have twice the rate of surgery (4–7) and a six- to eightfold increase in mortality rates compared with younger adults (4,5,7). In addition, initial diagnostic accuracy decreases with increasing age (8).

Most previous studies that have evaluated the causes for and natural course of adult visits to the ED for abdominal pain have been single-center, retrospective chart reviews (9,10). More recently, two single-center ED-based case series have been published that report the causes of abdominal pain and outcomes of older patients (11,12). This is the first prospective, multicenter study to evaluate the causes of AP and outcomes of such patients. Its objectives were to identify the causes of abdominal pain in older persons, to determine ED diagnostic accuracy, and to describe resource utilization and clinical course among these patients. For the final objective, we included the following information: (a) rate of diagnostic imaging in the ED, (b) rate and length of hospitalization, (c) need for surgery or invasive procedures, and (d) rates of return ED visits, rehospitalization, or death at 2 weeks of follow-up.


   METHODS
Top
 Abstract
 Methods
Results
 Discussion
 References
 
Patient Selection
This prospective, observational study was performed at four Midwest academic teaching hospitals for 16 hours a day during a 6-week period in 2002. After a 6-week pilot study at 1 site, we developed an algorithm to guide the selection process and minimize variability (Figure 1). Patients 60 years or older with acute abdominal pain were eligible for enrollment. We defined acute abdominal pain as any type of abdominal discomfort that occurred within the previous 7 days. Patients with chronic abdominal pain were eligible only if there had been an acute change in the pattern of pain during the previous 7 days. We excluded patients if they had abdominal trauma, surgery, or other invasive abdominal procedures within the previous 30 days. Patients meeting selection criteria were approached for consent and permission for release of medical information. The institutional review boards of all participating facilities approved this study.



View larger version (33K):
[in this window]
[in a new window]
  		Figure 1. The algorithm used for patient selection

 
Data Collection
Trained assistants used standardized data collection forms to abstract patient demographics, use of diagnostic imaging, ED diagnosis, and discharge diagnosis (for patients who were admitted) from medical records. An independent reviewer confirmed the ED diagnosis most directly responsible for the abdominal pain for each patient. Trained interviewers questioned patients via telephone and using a scripted interview 2 weeks after ED or hospital discharge. We chose the 2-week follow-up period to improve recall and to try to exclude visits that were not related to the index visit. Patients were asked about additional testing, ED visits, hospital admission or readmission, and whether they were given a "cause" for their abdominal pain. The patient's "final" diagnosis was based on hospital discharge reports (when applicable) and any additional medical information obtained at the 2-week follow-up interview. Two-week follow-up data were unavailable for 23 patients, but these patients were included in all other analyses. For patients who were not admitted to the hospital, the final diagnosis differed from the ED diagnosis if additional testing made an alternative diagnosis more likely or if the clinical course was inconsistent with the ED diagnosis.

Clinical course included hospitalization or rehospitalization within the 2-week follow-up period, length of stay (LOS) longer than 3 days, operative procedures, return visits to an ED, or death. We chose an LOS of 3 days or longer to distinguish patients who were admitted to the hospital for a short-stay observation or simple rehydration from those who required specific and prolonged therapy. We thought this was particularly important because we used the outcome of admissions of 3 days or longer as a marker of serious disease. Operative procedures included surgery or invasive procedures used in place of surgery (e.g., computed tomography (CT)-guided abscess drainage or biopsy, or endoscopic retrograde cholangiopancreatography).

Because we did not capture all eligible patients, we reviewed our ED tracking and information system for all patients 60 years or older who came to the ED with abdominal pain during the study period. We compared age, race, sex, ED diagnosis, admission rate, imaging rate, rate of surgery or invasive procedure, and discharge diagnosis of nonenrolled patients with the data of those enrolled in the study to determine whether a selection bias or systematic differences existed between these groups.

Data Analyses
Each study site entered patient information into a database (Access, Microsoft Windows 2000; Redmond, WA), which was pooled for analysis. We used chi square analysis for dichotomous variables and the Student t test or analysis of variance for continuous variables, with p values ≤ 0.05 considered significant, to evaluate demographic and diagnostic imaging data. We report outcomes (admission, LOS ≥3 days, operative procedure, and death) for the entire population and specific demographic and clinical subpopulations, using frequencies and proportions with 95% confidence intervals (CIs).

We defined diagnostic agreement as the proportion of patients who had the same ED and final diagnoses. We calculated the percentage change between the ED and final diagnoses for all patients in aggregate and separately for each of the top 10 diagnostic categories. We used a chi square test to compare the concordance of ED diagnoses with final diagnoses, admission rates, and deaths for patients younger than 75 years with those of patients 75 years or older. We also used the chi square statistic to compare the rates of diagnostic imaging (plain films, CT, ultrasound) in patients younger than 75 years with those in patients 75 years or older. We calculated odds ratios for hospitalization, LOS ≥3 days, operative interventions, and deaths for age, race, and sex. We considered an odds ratio with a 95% CI that did not include 1 significant. We compared diagnostic imaging rates for the following patient subgroups using analysis of variance: those admitted for surgery or invasive procedures, those with an ED diagnosis of nonspecific abdominal pain, and all others. Statistical tests were conducted using Statistical Program for the Social Sciences, version 11.5 (SPSS, Chicago, IL).


   RESULTS
Top
 Abstract
 Methods
 Results
Discussion
 References
 
During the study period, 477 patients were screened. Study coordinators were unavailable for 76 (16%) patients, and 7 (1.5%) patients refused to give consent. Of 394 consenting patients (83% of those screened), 34 were excluded: 15 (3.8%) had recent abdominal surgery or trauma and 19 (4.8%) had chronic pain. This left 360 (75%) patients with demographic, ED, and hospital data; however, follow-up data were missing for 23 (4.8%) of these patients. Thus, 337 (71%) of the original patient sample had complete data, including information on their outcomes at 2 weeks.

Demographic Data
Two thirds (n = 236) of the cohort were women and 51% (n = 185) were white (Table 1). Minority patients were significantly younger than the white patients (71.4 ± 8.8 years vs 74.6 ± 8.8 years; p <.001). The suburban site recruited more white (86% vs 47%; p <.001) and older patients compared with the 3 urban centers (76.7 years vs 72.4 years; p <.001). There were no significant differences in mean age (71.3 ± 8.9 years vs 73.1 ± 8.9 years; p =.10), sex, race, cause of abdominal pain, admission rate, rate of surgery, or in-hospital mortality rates among eligible patients who were enrolled and those who were not enrolled.


View this table:
[in this window]
[in a new window]
  		Table 1. Demographic Characteristics of Nonenrolled and Enrolled Patients With Abdominal Pain (N = 443).

 
Causes of Abdominal Pain
Table 2 shows the leading causes of the abdominal pain, based on ED and final diagnoses. The most common final diagnoses were nonspecific abdominal pain, 14.8%; urinary tract infection, 8.6%; bowel obstruction, 8%; gastroenteritis, 6.8%; diverticulitis, 6.5%; and gallbladder disease, 6.2%. Two less common but still important causes of abdominal pain were ischemic bowel and appendicitis, which accounted for 1.2% and 0.6% of final diagnoses, respectively. Twenty-six of 39 patients (67%) admitted with nonspecific abdominal pain had more specific diagnoses at discharge: diverticulitis in 4 patients and gallbladder disease, bowel obstruction, cancer/mass, and peptic ulcer disease/gastroesophageal reflux disease in 3 patients each. Only 1 of these 39 patients was admitted for surgery, and the remaining 38 were admitted to the medical service. Thirteen (33%) of the patients admitted to the hospital without a specific diagnosis in the ED required either surgery (n = 2) or specific medical therapy (n = 11) during their admission.


View this table:
[in this window]
[in a new window]
  		Table 2. Diagnoses for Patients With Abdominal Pain With Percentage Change Between Emergency Department and Final Diagnoses (N = 337).

 
Diagnostic Agreement
Overall agreement of ED diagnoses with final diagnoses was 82% (95% CI, 77% to 86%). The ED diagnosis was discordant with the final diagnosis in 62 patients. Sixty (97%) of these patients were admitted on their index visit; 13 (22%) had return ED visits within the follow-up period, with 5 (8%) requiring rehospitalization.

Diagnostic agreement differed by causes of abdominal pain, as can be seen by the percentage change among the 10 most common diagnoses in Table 2. Patients with gallbladder disease had the highest rate of diagnostic discordance, followed by those with cancer, nonspecific abdominal pain, diverticulitis, and cardiac disease. Patients younger than 75 years were more likely to have an ED diagnosis concordant with the final diagnosis than were those 75 years or older (87% vs 76%; p =.01).

Diagnostic Imaging
The overall rate of diagnostic imaging was 39% for plain radiographs, 38% for CT, and 11% for ultrasound. The use of plain radiographs differed significantly by patient age and sex (Table 3). We also found a significant difference in rates of CT use between nonenrolled and enrolled patients (23% vs 38%; p =.01). There were significant differences in the rate of utilization and the sensitivity for each of the imaging methods by patient subgroup: surgical/invasive, nonspecific abdominal pain, and all others. The CT results were diagnostic in 70 of 105 patients who had a specific cause of pain (67%; 95% CI, 57% to 75%) compared with plain films, which were diagnostic in 42 of 114 patients (37%; 95% CI, 28% to 46%). Computed tomography was much more likely to be diagnostic in the 63 patients with diseases requiring surgery (obstruction, gallbladder disease, diverticulitis) (78%; 95% CI, 57% to 91%) than in the 235 patients with medical conditions (urinary tract infection, gastroenteritis, pancreatitis; 41%; 95% CI, 30% to 53%) or in the 62 patients with nonspecific abdominal pain (3%; 95% CI, 0.2% to 19%).


View this table:
[in this window]
[in a new window]
  		Table 3. Emergency Department Radiologic Utilization by Age, Race, Sex, and Patient Subtype.

 
Clinical Course
Of the 360 patients with complete follow-up information, 209 (58%) were admitted to the hospital (Table 4). The mean LOS was 6.1 ± 6.2 days, ranging from 1 to 34 days. One hundred forty-five (74%) of the admitted patients stayed at least 3 days, whereas 31 (16%) were admitted for 1 day or less. Thirty-three patients (10% overall and 17% of those admitted to the hospital) had operative procedures. An additional 25 admitted patients (13%) had invasive procedures, as defined in Methods. Seventeen of the 194 (8.8%) admitted patients for whom we have 2-week follow-up information returned to the ED within the follow-up period, compared with 20 of 143 discharged patients (14%). Of the 17 patients admitted on their index visit who returned to the ED within 2 weeks, 12 were readmitted and 2 required surgery (1 planned). A total of 23 patients (6.8%) were either admitted or readmitted within the 2-week period after their index visits. Seventeen patients (5%) died within the 2-week follow-up period. However, none of the patients discharged home from the ED on their index visit died. Overall, 164 patients (43%) had LOS ≥3 days, required operative procedures, or died within the 2-week follow-up period.


View this table:
[in this window]
[in a new window]
  		Table 4. Disposition and Outcomes of Geriatric Emergency Department Patients With Abdominal Pain.

 
We found no significant differences in outcomes by sex or race (Table 5). Patients 75 years or older were more likely to be admitted than were younger patients (odds ratio, 1.7; 95% CI, 1.08 to 2.62). Mortality rates differed significantly for those 75 years or older compared with those 60 to 74 years old (odds ratio, 4.4; 95% CI, 1.4 to 14).


View this table:
[in this window]
[in a new window]
  		Table 5. Association of Age, Race, and Sex With Adverse Outcomes.

 

   DISCUSSION
Top
 Abstract
 Methods
 Results
 Discussion
References
 
Previous studies have shown that older patients who come to the ED with abdominal pain are more likely to have serious conditions and require hospitalization than are their younger counterparts (4,5,9,13). Our findings support the serious nature of abdominal pain in older persons, because more than 40% of patients were hospitalized for 3 or more days, had operative procedures, or died within the 2-week follow-up period. Furthermore, even among these older participants, we noted age-related differences in outcomes. Patients 75 years or older were more likely to be admitted to the hospital than were their younger counterparts. Our data also suggest decreased diagnostic accuracy in our oldest patients (≥75 years), reflecting findings of previous investigators (8,14).

Our rate of surgery (18% for patients admitted to the hospital and 10% overall) is lower than previously reported (9,10,12) and may reflect our selection criteria, which would include, for example, patients with a primary problem of vomiting, as long as they had associated abdominal pain. This increased our sensitivity for bowel obstruction, but it also increased the number of patients with gastroenteritis. In addition, our lower surgery rate may have resulted from the advancement of procedures such as CT-guided drainage or biopsy and endoscopic retrograde cholangiopancreatography. As noted in Results, these procedures occurred in 13% of admitted patients, accounting for 43% of all invasive or operative procedures. When we included these procedures, our operative procedure rate increased to 30%, which is similar to the 24% that Kizer and Vassar (15) reported. Our 2-week mortality rate of 4.7% [similar to the 2-month mortality rate of 5.3% reported by Marco and colleagues (12)] and recidivism rate (return ED visit or hospitalization) of 11% further support the serious nature of this problem in an older population.

Leading specific causes of abdominal pain included urinary tract infection (8.6%), bowel obstruction (8%), gastroenteritis (6.8%), diverticulitis (6.5%), and gallbladder disease (6.2%). Our numbers for cardiac, gallbladder, and urinary tract diseases are similar to those reported by Marco and colleagues (12) but differ somewhat from earlier studies that reported higher rates for gallbladder disease (10,15,16).

A nonabdominal cause (usually thoracic in location and aortic, cardiac, or pulmonary in cause) was considered the likely reason for pain in approximately 5% of our patients. Review articles make the point of considering intrathoracic processes in patients with abdominal pain, particularly in older patients, but we could find only two studies that reported these numbers, both with results consistent with our own (12,17).

In our study, the ED diagnosis matched the final 2-week diagnosis approximately 80% of the time, a significant improvement over previous studies, which have reported agreement between ED and final diagnoses to range from 45% to 68% (8,14,15,18). Similar to the studies by de Dombal (8) and Adams and colleagues (14), we observed a decrease in agreement between the ED and final diagnoses for older patients (≥75 years), although not to the same degree. Correctly diagnosing conditions in patients in the ED significantly reduces both disease- and treatment-related morbidity (15,19,20).

The diagnosis of nonspecific abdominal pain is essentially one of exclusion, with no diagnostic criterion standard, yet it accounts for the largest single diagnostic category for patients with abdominal pain both in the ED and after hospitalization. Although it almost certainly consists of several conditions (none of which meet more specific diagnostic thresholds), it is a well accepted diagnosis in practice and is included prominently in the literature concerning abdominal pain, where it is also called "undifferentiated abdominal pain." The studies with which we compared our results regarding congruence all had a category for nonspecific or undifferentiated abdominal pain, with rates varying from 10% to more than 40% (21,22).

Although an earlier review reported a lower rate (<10%) of nonspecific abdominal pain, further analysis of this study showed that the more specific diagnoses given to an additional 27% of patients were not supported by their history, examination, or laboratory findings (16). Because misdiagnosis is thought to be potentially more dangerous than having no specific diagnosis (by causing premature closure of diagnostic testing and decision making), practitioners embraced the idea of using a diagnosis of nonspecific or undifferentiated abdominal pain when no other diagnosis could be reasonably confirmed.

Several potential variables may be responsible for reducing our percentage of nonspecific abdominal pain to 21%, including training and experience of the emergency physicians and the increased use of CT imaging. The CT scans were diagnostic significantly more often than were plain films in patients with a specific cause for their abdominal pain. However, it is important to note that the patients in our study who could not be given a specific diagnosis had similar rates of diagnostic imaging, including CT. This supports the concept that clinicians use CT both to confirm and to rule out disease and that a diagnosis of nonspecific abdominal pain is not necessarily due to insufficient investigation.

Although CT was diagnostic in a significantly higher percentage of patients with diseases requiring surgery than in those with specific medical conditions or nonspecific abdominal pain, it may have been as useful in these other populations. A normal finding on a CT may allow physicians to feel more comfortable in not identifying a specific cause for the abdominal pain. A recent study looking at the use of CT in patients with abdominal pain suggests that it allows physicians to discharge patients who might otherwise be admitted for observation (23). Others have found that it alters decisions regarding both admission and discharge almost equally (24).

So is nonspecific abdominal pain likely to portend a benign prognosis? Lukens and associates (11) found that most patients (88%) who had been discharged from the ED with a diagnosis of undifferentiated abdominal pain improved within 2 to 3 weeks. However, they included only 25 patients older than 60 years in their study and yet had an overall readmission rate of 4.6%. More than one half of our 70 patients in whom the ED evaluation failed to provide a specific diagnosis were admitted for further evaluation. One third of these patients required specific medical or surgical therapy during their hospitalization, whereas another one third left the hospital within 24 hours without receiving a more specific diagnosis or further therapy. How can we better differentiate between those requiring specific therapy and those with benign self-limited disease?

The physicians in our study may have used a conservative approach, admitting most of our older patients without a specific diagnosis to capture those who required therapy. This strategy resulted in admitting 31 (16%) patients for 1 day or less. Physicians also used diagnostic imaging liberally, obtaining CT scans in nearly 40% of these patients. Despite these strategies, 20 of the 143 (14%) patients initially discharged returned to an ED within 2 weeks, with 11 (8%) of these being admitted. Importantly, none of these patients required emergency surgery.

Our study does have limitations. We did not enroll all eligible patients. However, a comparison between nonenrolled and enrolled patients did not reveal any systematic differences in demographic or clinical characteristics with the exception of lower CT use for nonenrolled patients. The 2-week follow-up interview helped identify patients with persisting problems. However, we may have missed those with serious but more indolent processes. In addition, patient-reported information may not be completely accurate.

Conclusions
Physicians of older patients should know that despite improved diagnostic technology, a significant rate of inconclusive or incorrect diagnoses exists in older patients evaluated in an ED for abdominal pain. Many of these patients have serious conditions. Further study is required to help define both a higher risk population of patients who require admission and treatment and a lower risk population of patients who can be safely discharged. Such a strategy should provide a safe, cost-effective approach for evaluating abdominal pain in older patients.


   Acknowledgments
 
The authors thank the following persons for their considerable assistance with this study and manuscript: Phillip Asaro, MD, Christopher Carpenter, MD, Davinder Hayreh, MA, Shane O'Neill, MD, Dag Shapshak, MD, and Emanuel Trigenis, MD.

Dr. Meldon is supported in part by an AGS/Hartford Jahnigen Career Development Scholar Award.

Supported in part by a grant from the American Geriatric Society and the Society for Academic Emergency Medicine.


   Footnotes
 
Decision Editor: John E. Morley, MB, BCh

Received February 17, 2004

Accepted June 3, 2004


   References
Top
 Abstract
 Methods
 Results
 Discussion
 References
 

  1. Powers RD, Guertler AT. Abdominal pain in the ED: stability and change over 20 years. Am J Emerg Med. 1995;13:301-303.[Medline]
  2. McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2001 emergency department summary. Adv Data. 2003;335:1-29.
  3. Wofford JL, Schwartz E, Timerding BL, et al. Emergency department utilization by the elderly: analysis of the National Hospital Ambulatory Medical Care Survey. Acad Emerg Med. 1996;3:694-699.[Medline]
  4. Staniland JR, Ditchburn J, De Dombal FT. Clinical presentation of acute abdomen: study of 600 patients. BMJ. 1972;3:393-398.
  5. Lowenstein SR, Crescenzi CA, Kern DC, Steel K. Care of the elderly in the emergency department. Ann Emerg Med. 1986;15:528-535.[Medline]
  6. Clavien PA, Junod P, Chapuis G. A prospective study of 776 cases of acute non-traumatic abdominal pain. Acute appendicitis and its diagnosis. Schweiz Med Wochenschr. 1987;117:1205-1212.[Medline]
  7. Franz MG, Norman J, Fabri PJ. Increased morbidity of appendicitis with advancing age. Am Surg. 1995;61:40-44.[Medline]
  8. de Dombal FT. The OMGE acute abdominal pain survey. Progress report, 1986. Scand J Gastroenterol Suppl. 1988;144:35-42.[Medline]
  9. Brewer BJ, Golden GT, Hitch DC, Rudolf LE, Wangensteen SL. Abdominal pain. An analysis of 1,000 consecutive cases in a University Hospital emergency room. Am J Surg. 1976;131:219-223.[Medline]
  10. Bugliosi TF, Meloy TD, Vukov LF. Acute abdominal pain in the elderly. Ann Emerg Med. 1990;19:1383-1386.[Medline]
  11. Lukens TW, Emerman C, Effron D. The natural history and clinical findings in undifferentiated abdominal pain. Ann Emerg Med. 1993;22:690-696.[Medline]
  12. Marco CA, Schoenfeld CN, Keyl PM, Menkes ED, Doehring MC. Abdominal pain in geriatric emergency patients: variables associated with adverse outcomes. Acad Emerg Med. 1998;5:1163-1168.[Medline]
  13. Sherlock DJ. Acute appendicitis in the over-sixty age group. Br J Surg. 1985;72:245-246.[Medline]
  14. Adams ID, Chan M, Clifford PC, et al. Computer aided diagnosis of acute abdominal pain: a multicentre study. BMJ. 1986;293:800-804.
  15. Kizer KW, Vassar MJ. Emergency department diagnosis of abdominal disorders in the elderly. Am J Emerg Med. 1998;16:357-362.[Medline]
  16. Sandhu GS, Redmond AD, Prescott MV. Non-specific abdominal pain: a safe diagnosis? J R Coll Surg Edinb. 1995;40:109-111.[Medline]
  17. Irvin TT. Abdominal pain: a surgical audit of 1190 emergency admissions. Br J Surg. 1989;76:1121-1125.[Medline]
  18. Simmen HP, Decurtins M, Rotzer A, et al. Emergency room patients with abdominal pain unrelated to trauma: prospective analysis in a surgical university hospital. Hepatogastroenterology. 1991;38:279-282.[Medline]
  19. van Geloven AAW, Biesheuvel TH, Luitse JSK, Hoitsma HFW, Obertop H. Hospital admissions of patients aged over 80 with acute abdominal complaints. Eur J Surg. 2000;166:866-871.[Medline]
  20. Arenal JJ, Bengoechea-Beeby M. Mortality associated with emergency abdominal surgery in the elderly. Can J Surg. 2003;46:111-116.[Medline]
  21. Fenyo G. Acute abdominal disease in the elderly: experience from two series in Stockholm. Am J Surg. 1982;143:751-754.[Medline]
  22. Smyth E, Stonebridge PA, Freeland P, Macleod DA. Prognosis of elderly patients with non-specific abdominal pain. J Accid Emerg Med. 1996;13:44-45.[Abstract/Free Full Text]
  23. Rosen MP, Sands DZ, Longmaid HE, III, et al. Impact of abdominal CT on the management of patients presenting to the emergency department with acute abdominal pain. AJR. 2000;174:1391-1396.[Abstract/Free Full Text]
  24. Nagurney JT, Brown DFM, Chang Y, et al. Use of diagnostic testing in the emergency department for patients presenting with non-traumatic abdominal pain. J Emerg Med. 2003;25:363-371.[Medline]



This article has been cited by other articles:


Home page
 Emerg. Med. J.Home page
A Lindelius, S Torngren, A Sonden, H Pettersson, and J Adami
Impact of surgeon-performed ultrasound on diagnosis of abdominal pain
Emerg. Med. J., August 1, 2008; 25(8): 486 - 491.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Services
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
PubMed
Right arrow PubMed Citation

HOME ARCHIVE SEARCH TABLE OF CONTENTS