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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  • Dani E

    I work as a registered nurse doing telephone triage, with nearly a decade experience in ER. I always try to explain the responsibility of the emergency room physician is to rule out serious/ life threatening issues at that moment, and that is why it is important for PCP follow up. Many people have an unrealistic expectation of an ER visit, especially when it comes to abdominal pain.

  • http://www.thenerdynurse.com The Nerdy Nurse

    Education is really key to this issue.

    As a nurse, I wasn’t even aware of the fact that a patient receives that much more radiation from a CT scan, and that just a few are more radiation than nuclear bomb survivor.

    That is pretty powerful information that the frequent flyers may want to know for them to not be demanding a CT scan every time the walk in the door.

  • Mark

    Patients get so mad when the ED doctor says to them, “Well, I can’t be sure what is causing your symptoms, but I’ve ruled out anything emegently serious. Here is xx for you sx, and please follow up with your PCP”. Livid, livid, livid. Threats to sue.

    • pj

      Mark , as a PCP in that situation, I often tell pts, “Since Doctors didn’t manufacture or design the human body, and we can’t predict the future, we don’t always know where (your problem) comes from, or if it will get better or worse.”

      That’s a shame your expertise is not respected.

  • Maria

    Maybe patients are livid because everyone know a few people who were carelessly dismissed and suffered the consequences.

    A friend of mine, nine months pregnant, went to the ER for the sudden onset of searing, mind-boggling pain. She was laughed at, lots of “welcome to the club” and derision.

    I suppose they didn’t care that she had suffered a ruptured uterus, the baby died, uterus was removed in the following emergency surgery, in which they also, accidentally, severed her urethra (oops!)…

    So it’s stories like these that may make patients just a tad distrustful when they feel absolutely awful and doctors won’t believe them.

  • t petrusick

    A couple of points if you can not see a normal appendix it soes not mean you do not have appendicits.
    As a Pediatrician I see my share of ER follow up abdominal pain visits as well as first encounters . A simple sed rate or crp is helpful in indicating need for close followup of further evaluation. ER docs seldom do these tests.

  • http://www.bsurgmed.wordpress.com Thomas Pane, M.D.

    Nice article. The abdomen tends to be a “black box” for many nonsurgeon evaluators, and the stakes can be very high if a serious diagnosis is missed. Ultrasound can stand in for CT in some but not all workups. I think it is good that we now understand that CT scans do carry real risk. We can use that knowledge to come up with evaluation guidelines that limit the number of unneeded scans, while still avoiding missed diagnoses.

  • Guest

    I’m an ER doc.
    I’m starting to see patients who have had 50, 60 or even 100 CT scans because they are the hospital’s frequent fliers and every time you register to be seen in the ER it is likely you will be seen by a physician who is concerned (rightly so) about being sued.
    I’ve also seen several of these patients develop strange cancers, ie biliary cancer at a young age.
    I think we’ll start hearing about a new phenomenom, “Defensive Medicine Associated cancer”, in the coming years. And the lawyers will pounce like they always do. Then us doctors will really be stuck.

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