When in the ER with abdominal pain, adjust your expectations

Abdominal pain is the bane of many emergency physicians.

Recently, I wrote how CT scans are on the rise in the ER.  Much of those scans look for potential causes of abdominal pain.

In an essay from TIME, Zachary Meisel discusses why abdominal pain, in his words, is the doctor’s “booby prize.”  And when you consider that there are 7 million visits annually by people who report abdominal pain, that’s a lot of proverbial prizes.

One reason is the myriad of causes that lead bring a patient to the hospital clutching his abdomen.  It can range from something as relatively benign as viral gastroenteritis, where a patient be safely discharged home, to any number of “acute” abdominal problems necessitating surgery.

But more important, we need to consider how limited doctors actually are in the ER.

Consider the ubiquitous CT scan, which is being ordered with increasing regularity:

The pros: CT scans are readily available, able to look at every organ in the abdomen and pelvis, and very good for ruling out many of the immediately life-threatening causes of belly pain. CT scans can also reduce the need for exploratory surgery. The cons: Often, CTs can’t diagnose the actual cause of ER patients’ abdominal pain. Worse, CTs deliver significant doses of radiation to a patient’s abdomen and pelvis (equivalent to between 100 and 250 chest X-rays). Over a lifetime, patients who receive two or three abdominal CT scans are exposed to more radiation than many Hiroshima survivors.

Add that to the fact that patients expect a definitive diagnosis when visiting the hospital — one that doctors can’t always give when it comes to abdominal pain.

Worse, according to Dr. Meisel, “a recent survey of patients who went to the ER with belly complaints found that those who received extensive testing — including CT scans and blood work — were more likely to feel confident with their care than those who didn’t,” and that, “over 70% of the same sample vastly underestimated the risk of the cumulative radiation exposure for the CT scans, and many of them did not recall accurately if they had ever received this test before.”

Like many areas of medicine, the diagnosis of abdominal pain is inexact. The tools at the doctors’ disposal aren’t accurate enough to give an expedient, definitive diagnosis. Worse, they can be harmful by exposing patients to potentially unnecessary radiation.

Until we have better tests, patients need to adjust their expectations. Physicians can play a role by explaining the limits of their diagnostic skills in the emergency setting, and educating patients that more scans do not necessarily equate to better medicine.

The media can also help, but publishing more commentaries by physicians like Dr. Meisel, who gives a realistic look at the vast number of variables that doctors face when treating patients with abdominal pain.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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